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Infection Prevention and Control
Adult Urinary Catheterisation Policy INSERTION AND MANAGEMENT IN A RESIDENTIAL SETTING
1 of 13 - Infection Prevention and Control Adult Urinary Catheterisation Policy
Infection Prevention and Control
Adult Urinary Catheterisation Policy INSERTION AND MANAGEMENT IN A RESIDENTIAL SETTING
Contents
Page
Introduction
3
Definition
3
Responsibilities
4
Related policies and protocols
4
Education of staff, carers and service users
5
Assessing the need for a catheter
5
Clinical indications for catheterisation
6
Choosing a catheter
6
Length of catheter
7
Size of catheter
7
Balloon size of catheter
7
Type of catheter
7
Insertion
8
Use of lubrication gels
9
Drainage systems
9
Documentation
10
Catheter care and maintenance
10
Catheter bag emptying
11
Urine sampling
11
Quality improvement systems
11
Bibliography
12
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Infection Prevention and Control
Adult Urinary Catheterisation Policy INSERTION AND MANAGEMENT IN A RESIDENTIAL SETTING Urinary catheterisation is an invasive procedure and as such should be considered as a last resort when dealing with urinary incontinence (RCN 2012) In the community setting long term catheterisation is mainly used in elderly service users and service users with a neurological condition (NICE 2012) Epic 3 guidelines (Loveday et al 2013) identified urinary tract infections (UTI) associated with catheterisation as the most common infection acquired as a result of healthcare. The longer a catheter is in situ the higher the risk of an infection becomes, due to microorganisms ability to bypass natural host mechanisms, such as the urethra and micturition, and gain entry to the bladder. Further contributing facts include method and duration of catheterisation, and the quality of catheter care. The purpose of this policy is to support organisations and individuals in reducing the risk of urinary tract infections associated with insertion and maintenance of indwelling urinary devices. This policy covers insertion and ongoing care of indwelling urinary catheters, as well as suprapubic and intermittent catheterisation for both male and female service users. Implementation of the policy will also demonstrate compliance with the Health and Social Care Act 2014 – Code of Practice for the Prevention and Control of Healthcare Associated Infections, (DH 2015). Criterion 9 (of the Code of Practice) covers (in part) use and care of invasive devices and specifies that provider organisations must have and adhere to policies, designed for the individual’s care that will help to prevent and control infection.
Definitions Catheterisation - Urinary catheterisation is a procedure used to drain the bladder and collect urine, through a flexible tube called a catheter Short term indwelling urethral / urinary catheter - A urinary catheter which is inserted into the bladder, via the urethra, and remains in place for a period of time of less than 28 days Supra-pubic catheter/ catheterisation -Supra-pubic catheterisation creates a tunnel from the abdominal wall to the bladder. Urine can then be drained directly from the bladder, via a supra-pubic catheter, into a collection bag
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Infection Prevention and Control
Adult Urinary Catheterisation Policy INSERTION AND MANAGEMENT IN A RESIDENTIAL SETTING Intermittent catheterisation - A urinary catheter is periodically passed through the urethra into the bladder for the purpose of emptying it of urine. This procedure is often performed by the service user themselves and requires a high level of personal hygiene especially hand hygiene Catheter Valve – is a tap-like device that fits into the end of a urethral or suprapubic catheter and allows urine to be stored in the bladder and emptied straight into the toilet or bag.
Responsibilities Registered nurses are accountable for their own practice and must work within legislation and abide by the Nursing Midwifery Council (NMC) Code: Professional standards of practice and behaviour for nurses and midwives (2015) All qualified healthcare practitioners, care assistants and support staff must adhere to legislation, protocols and guidelines relevant to their role and field of practice (Skills for Health) All qualified healthcare practitioners, care assistants and support staff must work within their sphere of competence and know when to seek advice if faced with situations beyond their competence (Skills for Health).
Related Policies and Protocols Local policies and protocols should include, but not be restricted to: Hand hygiene policy Asepsis policy Consent policy Waste management policy Standard precautions Insertion of female indwelling urethral catheter Insertion of male indwelling urethral catheter Insertion of female supra-pubic catheter Insertion of male supra-pubic catheter
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Infection Prevention and Control
Adult Urinary Catheterisation Policy INSERTION AND MANAGEMENT IN A RESIDENTIAL SETTING
Education of Staff, Carers and Service Users All healthcare professionals undertaking these procedures must have attended recognised training courses in female catheterisation, male catheterisation, supra pubic catheterisation and intermittent catheterisation and be assessed as competent for each individual procedure (Nice 2003) Health care workers, social care staff, service users and their carers should be educated on infection prevention and control aspects of catheter management alongside good hand hygiene practices. This education must include: • Cleaning around catheter sites • Emptying urinary drainage bags and taking urine samples • Attaching a night bag to the closed drainage system • Changing leg bags
Assessing the need for a Catheter The need for an indwelling catheter should only be considered once the use of all alternative methods of management has been considered. The service user’s needs must be assessed prior to catheterisation for: • Latex allergy • Length of catheter (standard, female) • Type of sterile drainage bag and sampling port (urometer; 2-L bag; leg bag) or catheter valve; and • Comfort and dignity (Epic 3 2013) An indwelling catheter should not be used in the following circumstances: • Catheterise or continue catheter usage for convenience •
Catheterisation should not be presented or promoted as an easy, best option to regain continence
When assessing the suitability of the service user for an indwelling catheter consideration must be given to the individual’s cognitive abilities and ensure the final decision to catheterise has more benefits to the client than disadvantages. Where possible this decision should be made in consultation with the service user and multi-disciplinary team. Once the decision is made to catheterise a client, ensure there are clear stated reasons recorded in client’s notes and constantly review the need for continued catheter usage (RCN 2012).
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Infection Prevention and Control
Adult Urinary Catheterisation Policy INSERTION AND MANAGEMENT IN A RESIDENTIAL SETTING
Clinical Indications for Catheterisation The following are clinical indications for urethral catheterisation: • acute urinary retention •
chronic urinary retention, only if symptomatic and/or with renal compromise
•
monitoring renal function hourly during critical illness
•
monitoring /recording/draining residual urine volumes (wherever possible, a bladder scanner is the preferred option to measure residual urine volumes)
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during and after surgery, for a variety of reasons
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allowing bladder irrigation/lavage in specific circumstances
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allowing instillation of medications, e.g. chemotherapy
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bypassing an obstruction
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enabling bladder function tests, e.g. urodynamics
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facilitating continence and maintain skin integrity (when all conservative treatment methods have failed)
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Obtaining a sterile urine specimen.
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To minimise distress or discomfort during end-of-life care
Choosing a Catheter When choosing a suitable catheter and drainage system consideration needs to be given to the clinical need of the client, length of time the catheter is to remain in situ, the clients lifestyle, gender and mobility. The terms FOLEY and NELATON catheters are generic terms. Foley catheters are all indwelling catheters and means they have a balloon to retain them in the bladder. Whilst all intermittent catheters are NELATON catheters and they have no self-retaining balloon and are self-lubricating.
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Infection Prevention and Control
Adult Urinary Catheterisation Policy INSERTION AND MANAGEMENT IN A RESIDENTIAL SETTING
Length of Catheter • Male (Standard length) 41-43cm • Female 21-26cm In women who are obese or have reduced mobility and require a wheelchair a standard length urethral catheter may be considered to prevent discomfort. Standard length catheter is also used for suprapubic catheterisations. A female length catheter must not be used for a male service user as this can cause severe trauma to the prostatic urethra.
Size of catheter •
Male 12-16Ch
•
Female 10-14Ch
•
Suprapubic 16Ch
The outer diameter of the catheter is the size and is measured in the Charriere scale (Ch. 1Ch = 1/3 mm.) Always select the smallest size catheter. Larger size catheters may cause pain, discomfort, trauma and bypassing of urine around the catheter. (Robinson 2006)
Balloon size of catheter The balloon of the catheter should be inflated to the size stated by the manufacturer. This is usually 10ml of sterile water (NICE 2006) Tap water should not be used as this may introduce bacteria to the bladder and the use of normal saline should be avoided as this may cause crystal formation in the inflation channel. Do not exceed the recommended volume of water as there is danger of irritation of bladder, spasm & necrosis. Underinflation results in balloon distortion and there is a risk that the catheter may become dislodged from the bladder.
Type of catheter The catheter material will determine the amount of time the catheter can remain in situ. Selection of catheter type must be based on an assessment of the service user’s needs prior to catheterisation (see section: Assessing the need for a catheter Epic 3, 2013). The catheter material selected should be chosen for comfort, ease of insertion and removal, with minimal risk of complications (NICE 2003). i
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Infection Prevention and Control
Adult Urinary Catheterisation Policy INSERTION AND MANAGEMENT IN A RESIDENTIAL SETTING
Catheter
Use
Single Use Coated
In/out catheter used for intermi7ent self-‐catheterisa9on
PVC (Plas9c)
Specialist urology procedures 2 weeks
PTFE (Teflon coated latex)
Short term less than 28 days
Hydrogel coated (e.g. Biocath)
Long term 12 weeks
All (pure 100%) silicone (If service user has a Long term 12 weeks known latex allergy)
Note: these are maximum recommendations for use of catheter prior to routine change – ensure manufacturer’s recommendations are followed.
Insertion of a Catheter An assessment must be performed regarding the best approach to catheterisation, taking into account clinical needs, anticipated duration, service user preference and risk of infection. The principles of general asepsis, use of personal protective equipment and effective hand decontamination must be adhered to. Catheterisation is an aseptic procedure and should only be undertaken by healthcare workers trained and competent in this procedure. (Epic 3 2013) Intermittent catheterisation is a clean procedure when carried out as a selfcatheterisation, however when undertaken by a third party it must be carried out as an aseptic procedure. A lubricant from a sterile single use container should be used to minimise urethral discomfort and the risk of infection where non-lubricated catheters are used. Prior to inserting a urethral catheter the meatus (skin around the entrance of the urethra) must be cleaned using sterile normal saline solution.
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Infection Prevention and Control
Adult Urinary Catheterisation Policy INSERTION AND MANAGEMENT IN A RESIDENTIAL SETTING
Use of lubrication /anaesthetic gels The use of a sterile lubrication/anaesthetic gel can reduce the risks of trauma on insertion. Trauma can increase the potential for infection (Epic 3 2013) Sterile single use lubrication/anaesthetic gels should be used prior to urethral catheterisation to avoid trauma and stricture formation. (NICE Guidelines 2003) During change of a suprapubic catheter sterile lubricant /anaesthetic gel should be used to allow for a smoother passage of the catheter and to minimise trauma.
Drainage systems The catheter once inserted needs to be connected to a sterile closed drainage system with a sampling port. It is important to consider individual service user’s needs and involve them when selecting an appropriate drainage system. Issues to consider: • Hands must be decontaminated and a new pair of clean non-sterile gloves worn before manipulating each service user’s catheter or drainage system • Decontaminate hands immediately following glove use • Connection between the catheter and the sterile drainage bag should not be broken unless clinically indicated. More frequent disconnections will break the closed system and increase the risk of infection • Change bags in line with manufacturer’s recommendations • Ambulant service users normally prefer leg bags. These are available in 350, 500 and 750ml volumes • A catheter valve is not suitable for incontinent/neurological service users and those with memory problems • Consider the type of tap on a drainage bag as some service users may have impaired manual dexterity and be unable to operate the tap • Service users with long term catheters may need to use a day bag by day and attach a night bag at night. This must be connected to the day bag so as not to break the closed system between the day bag and catheter • Bags are single use medical devices and must be used once. Night bags must not be emptied and re-used even on the same service user • The bag must be hung on a stand to prevent it from touching the floor
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Infection Prevention and Control
Adult Urinary Catheterisation Policy INSERTION AND MANAGEMENT IN A RESIDENTIAL SETTING
Documentation Once a urinary catheter has been inserted and secured the following must be documented in the service user’s records / care plan: • Reason for catheterisation/change of catheter • Clinical indications for continuing catheterisation • Date for removal or review by an appropriate clinician overseeing the service user’s care • Type of catheter • Size of catheter • Balloon size and amount of water in balloon • Date and time • Signature of person completing procedure No service user should be discharged or transferred with a short – term indwelling urethral catheter without a plan documenting the above points. Many NHS and non-NHS healthcare organisations utilize a service user Urinary Catheter Passport for service users with catheters. This is held by the service user and does not replace standard documentation for catheter care record keeping but facilitates collaborative working between healthcare professionals in primary and secondary care.
Catheter care and maintenance To reduce the risk of infection, blockage encrustation the following recommendation have been made by NICE (2012) following a systematic review: • Healthcare workers must decontaminate their hands and wear a new pair of clean non sterile gloves before manipulating the catheter or bag, and must decontaminate their hands after removal of gloves • Service users and carers must be advised to wash their hands before and after manipulating the catheter or drainage bag. • The service user’s need for a indwelling catheter needs to be reviewed regularly and the catheter removed as soon as possible • Indwelling catheters should be connected to a sterile closed urinary drainage system or catheter valve • Maintain a closed urinary drainage system by avoiding breaking the connection between catheter and drainage bag unless clinical indicated • A link system should be used to facilitate overnight drainage • Washing the urethral meatus with un-perfumed soap and water daily. Vigorous cleansing may increase the risk of infection
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Infection Prevention and Control
Adult Urinary Catheterisation Policy INSERTION AND MANAGEMENT IN A RESIDENTIAL SETTING • • •
Catheters and drainage bags must be positioned below the level of the bladder and not touching the floor to prevent backflow of the urine into the bladder and reduce the risk of infection A strap or adhesive anchor should be used to anchor the catheter to the leg to prevent urethral and bladder neck trauma Urine samples must be obtained from a sampling port using an aseptic non touch technique
Catheter Bag Emptying • • • • • • •
This procedure carries a risk of healthcare associated infection therefore a nontouch clean technique is required Where possible educate and encourage the service user to empty their own drainage bag Effective hand hygiene technique is necessary before and after each intervention Staff should wear a disposable plastic apron and non-sterile single use gloves The drainage bag should be emptied when ¾ full The outlet port should be swabbed with a 70% isopropyl alcohol swab before and after opening Use a separate, clean container for each service user (ideally disposable) and avoid contact between the urinary drainage tap and the container when emptying the drainage bag
Urine Sampling – see separate protocol • • • • •
Always use drainage bags with an integral sampling port to facilitate collection of urine samples for analysis Urine samples must only be taken from the sampling port using an aseptic technique Do not disconnect the bag from the catheter to obtain urine samples Samples should never be taken direct from the catheter or catheter bag even if the bag has just been changed Before obtaining a catheter sample of urine the port should be cleaned with an isopropyl alcohol 70% impregnated swab and allowed to dry.
Quality Improvement Systems Use quality improvement systems to support the appropriate use and management of short term urethral catheters and ensure their timely removal including: • Protocols for catheter insertion • Use of bladder ultrasound scanners to assess and manage urinary retention
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Adult Urinary Catheterisation Policy INSERTION AND MANAGEMENT IN A RESIDENTIAL SETTING
• • • •
Reminders to review the continuing use or prompt the removal of catheters Audit and feedback of compliance with practice guidelines Continuing professional education. Use of Urinary Catheter Passports held by service users
Bibliography Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, Browne J, Prieto J, Wilcox M. (2013) Epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England NICE (2003) Guideline 139 Infection. Prevention and control of healthcare associated infections in primary and community care London NICE NICE (2012) Guideline 139 Infection. Prevention and control of healthcare associated infections in primary and community care London NICE Pomfret I (2006) Which urinary system is for you? Charter Continence Care 4 p12 Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SRLJ, McDougall C, Wilcox MH (2007) Epic 2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England Robinson J (2006) Selecting a urinary catheter and drainage system British journal of Nursing 15(19) pp1045-1050 Royal College of Nursing (2012) Catheter Care RCN guidance for nurses London RCN Saving Lives: High Impact Intervention No 6 Urinary Catheter Care Bundle Skills for life: Competences/National Occupational Standards www.skillsforhealth.org.uk The Royal Marsden Hospital Manual of Clinical Nursing Procedures (eighth edition) London Blackwell publishing
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Infection Prevention and Control Gordon House, Station Road Mill Hill, London NW2 2JU Telephone 020 8906 2777 Fax: 020 8906 2233 www.infectionpreventionsolutions.co.uk
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