VOL: 97, ISSUE: 20, PAGE NO: 70
Kathy Getliffe, PhD, MSc, RGN, DN, PGCEA, is professor of nursing at the University of SouthamptonRecently published Department of Health guidelines for preventing infections associated with the insertion and maintenance of short to medium-term indwelling urethral catheters in acute care (Pratt et al, 2001) form part of the first phase of national evidence-based guidelines commissioned by the DoH in 1998. The guidelines take the form of broad statements or principles of good practice that all practitioners can use and which should be incorporated into more detailed local procedural protocols. They can also be used as a benchmark for quality improvement and to assess clinical effectiveness.
Recently published Department of Health guidelines for preventing infections associated with the insertion and maintenance of short to medium-term indwelling urethral catheters in acute care (Pratt et al, 2001) form part of the first phase of national evidence-based guidelines commissioned by the DoH in 1998. The guidelines take the form of broad statements or principles of good practice that all practitioners can use and which should be incorporated into more detailed local procedural protocols. They can also be used as a benchmark for quality improvement and to assess clinical effectiveness.
The guidelines were developed by a nurse-led, multiprofessional team, which included specialist and generalist clinical practitioners, epidemiologists, researchers and other representatives. The process was based on a systematic review of published literature in the subject area, supplemented by existing professional, national and international guidelines, using a validated appraisal instrument. This was followed by extensive consultation, including focus groups, specialist panel discussion and web-based discussion groups, to ensure acceptability, credibility and practicability.
As with many aspects of health care, there is little robust evidence available to inform guideline development. Few rigorously conducted experimental studies were identified, not least because of the ethical issues involved, and consequently a range of other evidence was included.
An important aspect of the guidelines is that the evidence used is categorised so that readers are aware of its type and quality:
- Category 1 Generally consistent findings in evidence derived from a majority of acceptable studies;
- Category 2 Evidence based on a single acceptable study or a weak or inconsistent finding in multiple acceptable studies;
- Category 3 Limited scientific evidence that does not meet all the criteria of 'acceptable studies' or studies that are not of good quality or directly applicable. This includes published expert opinion derived from systematically retrieved and appraised professional national and international guidelines.
It is notable that out of a total of 18 recommendations in the DoH guidelines, the evidence supporting all but three of them is classed as category 3. This should not be interpreted as being of less clinical value than categories 1 or 2; indeed, the guidelines state that all recommendations are equally endorsed and none is regarded as optional. However, it does emphasise the limitations of existing research and the important role that national guidelines can play in drawing together the best available evidence.
Guideline structure and key issues
Guideline recommendations are grouped into a series of four distinct interventions and the key issues associated with each are considered briefly below. Each intervention comprises:
- A headline statement that describes the key issue being addressed;
- A synthesis of the related evidence;
- The guideline recommendation(s) with a corresponding evidence grade;
- A bibliography listing the evidence cited.
Assessing the need for catheterisation
Catheterising patients places them in significant danger of acquiring a urinary tract infection, and the longer the catheter is in place the greater the risk. Recommendations therefore relate to using indwelling urethral catheters only after considering alternative methods of management, removing the catheter as soon as possible and documenting catheter insertion and care. Although there is always a balance to be struck between concise guidance and subject breadth, mention could have been made of other related risks, including stricture formation.
Selection of catheter type
The question here is whether there is evidence that one catheter is better than another. Limited research evidence and evidence from best practice indicates that the incidence of catheter-associated infection in the short-term is not influenced by any particular type of catheter material, with the exception of silver alloy catheters, which are not currently available in the UK.
Many practitioners have strong preferences for one type of catheter over another and the recommendations allow the choice of catheter material to be dependent on clinical experience, patient assessment and anticipated duration of catheterisation.
Aseptic catheter insertion
Catheterisation is recognised as a skilled aseptic procedure that requires appropriate training and competence. The recommendations advise cleaning of the urethral meatus but offer no direct guidance on the solution to be used, although expert opinion is cited as indicating that there is no advantage in using antiseptic solutions. It is also recommended that an appropriate lubricant from a single-use container should be used to minimise urethral trauma and infection. There is perhaps a missed opportunity here to consider anaesthetic gels - more commonly used for men, they can also be used to reduce discomfort in women.
This large section includes two subsections with the headline statements of 'leave the closed system alone' and 'appropriate maintenance minimises infections'. Its 10 separate recommendations include the only three supported by category 1 and 2 evidence:
- Do not add antiseptic or antimicrobial solutions to urinary drainage bags;
- Routine personal hygiene is all that is needed to maintain meatal hygiene;
- Bladder irrigation, instillation and washout do not prevent catheter-associated infection.
The terms bladder irrigation, instillation and washout are defined in the guideline glossary, but the evidence cited relates specifically to their failure to prevent infection. The guidelines acknowledge that irrigation may be indicated during urological surgery or to manage catheter obstruction, but make no mention of the appropriateness (or otherwise) of instillations or washouts under other circumstances. This reflects the focus on acute care and short-term catheterisation. However, some recognition that certain patients may go on to require medium or long-term catheter care, which may require alternative protocols - bag changing, for instance - would have been beneficial.
Overall, the guidelines should be welcomed for their emphasis on key points for practice. These key points should be incorporated into all local operational protocols. Limitations in the available evidence mean that the recommendations are often based on expert opinion yet the authors have shown a largely robust approach to the systematic retrieval and appraisal of this information.
It is interesting that much of the available literature dates back 10 years or more and that a major source is textbook material rather than primary studies - this is the reality rather than a criticism.
Although the focus of the guidelines is on preventing catheter-associated infection in acute care, further mention could have been made of the related risks of stricture formation, of recognising when short-term care becomes medium or long-term care and other aspects of catheter care, including patient information and education.
The guidelines are expected to be updated next summer, but in the meantime there is a clear need for further research to confirm and/or guide best practice.