Long-term urinary catheters: prevention and control of healthcare-associated infections in primary and community care

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1 Long-term urinary catheters: prevention and control of healthcare-associated infections in primary and community care A NICE pathway brings together all NICE guidance, quality standards and materials to support implementation on a specific topic area. The pathways are interactive and designed to be used online. This pdf version gives you a single pathway diagram and uses numbering to link the boxes in the diagram to the associated recommendations. To view the online version of this pathway visit: Pathway last updated: 17 August To see details of any updates to this pathway since its launch, visit: About this Pathway. For information on the NICE guidance used to create this path, see: Sources. All rights reserved NICEPathways

2 Page 2 of 11

3 1 Patient with a long-term urinary catheter No additional information 2 Education of patients, their carers and healthcare workers Educate patients and carers about and train them in techniques of hand decontamination, insertion of intermittent catheters where applicable, and catheter management before discharge from hospital. Community and primary healthcare workers must be trained in catheter insertion, including suprapubic catheter replacement and catheter maintenance. Ensure that follow-up training and ongoing support of patients and carers are available for the duration of long-term catheterisation. 3 Assessing the need for catheterisation Use indwelling urinary catheters only after alternative methods of management have been considered. Review the patient's clinical need for catheterisation regularly and remove the urinary catheter as soon as possible. Document catheter insertion, changes and care. Quality standards The following quality statement is relevant to this part of the pathway. 4. urinary catheters Page 3 of 11

4 4 Catheter drainage options Following assessment, select the best approach to catheterisation that takes account of clinical need, anticipated duration of catheterisation, patient preference and risk of infection. Use intermittent catheterisation in preference to an indwelling catheter if it is clinically appropriate and a practical option for the patient. Offer a choice of either single-use hydrophilic or gel reservoir catheters for intermittent selfcatheterisation. Select the type and gauge of an indwelling urinary catheter based on an assessment of the patient's individual characteristics, including: age any allergy or sensitivity to catheter materials gender history of symptomatic urinary tract infection patient preference and comfort previous catheter history reason for catheterisation. In general, inflate the catheter balloon with 10 ml of sterile water in adults and 3 5 ml in children. In patients for whom it is appropriate, a catheter valve may be used as an alternative to a drainage bag. Quality standards The following quality statement is relevant to this part of the pathway. 4. urinary catheters Page 4 of 11

5 5 Catheter insertion All catheterisations carried out by healthcare workers should be aseptic procedures. After training, healthcare workers should be assessed for their competence to carry out these types of procedures. Intermittent self-catheterisation is a clean procedure. A lubricant for single-patient use is required for non-lubricated catheters. For urethral catheterisation, clean the meatus before insertion of the catheter, in accordance with local guidelines/policy. Use an appropriate lubricant from a single-use container during catheter insertion to minimise urethral trauma and infection. Quality standards The following quality statement is relevant to this part of the pathway. 4. urinary catheters 6 Catheter maintenance Connect indwelling catheters to a sterile closed urinary drainage system or catheter valve. Healthcare workers should ensure that the connection between the catheter and the urinary drainage system is not broken except for good clinical reasons (for example changing the bag in line with the manufacturer's recommendations). Healthcare workers must decontaminate their hands and wear a new pair of clean, non-sterile gloves before manipulating a patient's catheter, and must decontaminate their hands after removing gloves. Patients managing their own catheters, and their carers, must be educated about the need for hand decontamination before and after manipulation of the catheter, in accordance with the standard principles in this pathway. Page 5 of 11

6 Urine samples must be obtained from a sampling port using an aseptic technique. Position urinary drainage bags below the level of the bladder, and make sure they are not in contact with the floor. Use a link system to facilitate overnight drainage, to keep the original system intact. Empty the urinary drainage bag frequently enough to maintain urine flow and prevent reflux, and change it when clinically indicated. Wash the meatus daily with soap and water. To minimise the risk of blockages, encrustations and catheter-associated infections for patients with a long-term indwelling urinary catheter: develop a patient-specific care regimen consider approaches such as reviewing the frequency of planned catheter changes and increasing fluid intake document catheter blockages. Bladder instillations or washouts must not be used to prevent catheter-associated infections. Change catheters only when clinically necessary or according to the manufacturer's current recommendations. When changing catheters in patients with a long-term indwelling urinary catheter: do not offer antibiotic prophylaxis routinely consider antibiotic prophylaxis 1 for patients who: have a history of symptomatic urinary tract infection after catheter change or experience trauma during catheterisation (trauma is defined as frank haematuria after catheterisation or two or more attempts of catheterisation). NICE has produced a pathway on antimicrobial stewardship. Quality standards The following quality statement is relevant to this part of the pathway. 4. urinary catheters Page 6 of 11

7 Resources The following implementation tool is relevant to this part of the pathway. Infection control: clinical audit tool (catheter maintenance) 1 At the time of publication of the pathway (March 2012), no antibiotics have a UK marketing authorisation for this indication. Informed consent should be obtained and documented. Page 7 of 11

8 Glossary Aseptic technique An aseptic technique ensures that only uncontaminated equipment and fluids come into contact with susceptible body sites. It should be used during any clinical procedure that bypasses the body's natural defences. Using the principles of asepsis minimises the spread of organisms from one person to another. Clean surgery Surgery involving an incision in which no inflammation is encountered, without a break in sterile technique, and during which the respiratory tract, alimentary or genitourinary tracts are not entered. Clean-contaminated surgery Surgery involving an incision through which the respiratory, alimentary, or genitourinary tract is entered under controlled conditions but with no contamination encountered. Contaminated surgery Surgery involving an incision in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered. Open traumatic wounds that are more than hours old also fall into this category. Debridement The excision or wide removal of all dead (necrotic) and damaged tissue, that may develop in a surgical wound. Direct patient care 'Hands on' or face-to-face contact with patients. Any physical aspect of the healthcare of a patient, including treatments, self-care and administration of medication. Page 8 of 11

9 Dirty or infected wound An incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered (for example, emergency surgery for faecal peritonitis), and for traumatic wounds where treatment is delayed, there is faecal contamination, or devitalised tissue is present. Hand decontamination The use of handrub or handwashing to reduce the number of bacteria on the hands. In this pathway this term is interchangeable with 'hand hygiene'. Handrub A preparation applied to the hands to reduce the number of viable microorganisms. This guidance refers to handrubs compliant with British standards (BS EN1500; standard for efficacy of hygienic handrubs using a reference of 60% isopropyl alcohol). Healing by primary intention Occurs when a wound has been sutured after an operation and heals to leave a minimal, cosmetically acceptable scar. Healing by secondary intention Occurs when a wound is deliberately left open at the end of an operation because of excessive bacterial contamination, particularly by anaerobes or when there is a risk of devitalised tissue, which leads to infection and delayed healing. It may be sutured within a few days (delayed primary closure), or much later when the wound is clean and granulating (secondary closure), or left to complete healing naturally without the intervention of suturing. Healthcare workers People employed by the health service, social services, a local authority or an agency to provide care for a sick, disabled or elderly person. Healthcare waste Any waste produced by, and as a consequence of, healthcare activities. Page 9 of 11

10 Interactive dressing Modern (post-1980) dressing materials. Designed to promote the wound healing process through the creation and maintenance of a local, warm, moist environment underneath the chosen dressing, when left in place for a period indicated through a continuous assessment process. Perfusion Blood flow through tissues or organs. If not optimal, it can increase the risk of infectious complications (particularly surgical site infections). Personal protective equipment Equipment that is intended to be worn or held by a person to protect them from risks to their health and safety while at work. Examples include gloves, aprons, and eye and face protection. Sources Infection control (2012) NICE guideline CG139 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Page 10 of 11

11 Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT Page 11 of 11

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