Policy for the Insertion and Maintenance of Urinary and Supra Pubic Catheters in adults

Transcription

1 Policy for the Insertion and Maintenance of Urinary and Supra Pubic Catheters in adults Document Summary To ensure staff fully understand how to insert and maintain urinary catheters in adults. DOCUMENT NUMBER POL/001/042/027 DATE RATIFIED April 2014 DATE IMPLEMENTED April 2014 NEXT REVIEW DATE April 2017 ACCOUNTABLE DIRECTOR POLICY AUTHOR Director of Operations/Executive Nurse and Director of Infection Prevention and Control Head of Infection Prevention and Public health Important Note: The Intranet version of this document is the only version that is maintained. Any printed copies should therefore be viewed as uncontrolled and, as such, may not necessarily contain the latest updates and amendments.

2 TABLE OF CONTENTS 1 SCOPE Introduction Statement of Intent Definitions Duties, Roles and Responsibilities Insertion and maintenance of urinary catheters in adults DECISION TO CATHERTERISRE SELECTION OF A CATHETER DEVICE PATIENT PREPARATION EQUIPMENT AND PREPARATION INSERTION PROCEDURE ONGOING CATHETER CARE/MAINTENANCE Training Monitoring compliance with this policy References/ Bibliography Related Trust Policy/Procedures Appendix 1: Urethral Catheterisation April 2014 Page 2 of 22 Our Ref: POL/001/042

3 1 SCOPE The purpose of this policy is to provide a structure that will support healthcare professionals working within Cumbria Partnership Foundation Trust regarding the Insertion and maintenance of urethral and Supra Pubic catheterisation. The policy applies to any member of staff who has successfully completed the Trust approved workshop on catheterisation and e-learning training. It is anticipated that as part of this process an identified mentor will ensure supervision until both the mentor and member of staff feel competent to perform the task without supervision. 2 INTRODUCTION Urethral Catheterisation is when either an intermittent (in and out catheter) or a Foley catheter (one with a balloon) is inserted into the bladder through the urethra using aseptic technique for the purpose of evacuating or instilling fluids. Due to the relatively high risk of infection, a urinary catheter should only be used when there is no other alternative method of emptying the bladder. As directed by Carl Rowbotham, consultant Urologist MBHT In males the first catheterisation should be performed or observed by a GP if there is any indication of complications such as:- 1. previous difficult catheterisation changes 2. previous treatment for urethral stricture 3. history of visible haematuria 4. previous failure to catheterise by same level clinician (risk of trauma) 5. artificial urinary sphincter 6. radical prostatectomy for Ca prostate (? stricture) 7. positive urine dip and systemic infection(fever/rigor/temp 38) If a patient has anticoagulant or anti platelet agents-(risk of trauma or decompression bleeding) observation required following catheterisation If a patient has antibiotic cover for inspections or treatments or history of rheumatic fever then antibiotic therapy required for catheterisation Male patients should only have the standard size utilisied. (Nursing Times 2008) Other risks of using a urinary catheter include: injury to the urethra caused by rough insertion of the catheter narrowing of the urethra due to scar tissue caused by the insertion of the catheter injury to the bladder caused by incorrect insertion of the catheter bladder stones, although these usually only develop after years of catheterisation (NHS Choices April 2014 Page 3 of 22 Our Ref: POL/001/042

4 Supra Pubic Catheter is one that is inserted directly into the bladder via the abdomen just superior to the pubic bone. Indications for this procedure are when urethral catheterisation is contraindicated and it is not possible to relieve urinary retention by any other means. Supra pubic catheterisation may also be indicated as a long term solution to bladder drainage in patients with neurological conditions and spinal cord injury. The initial insertion of Supra Pubic catheters is usually performed within the Acute Care setting. This policy refers to the subsequent catheter changes. Long-term indwelling catheters (both urethral and suprapubic) carries a significant risk of symptomatic urinary tract infection. 3 STATEMENT OF INTENT The purpose of this policy is to prevent potential risks associated with catheterisation. 4 DEFINITIONS Aseptic no Touch Technique (ANTT) -, a method of treatment that ensures no skin to skin contact with the patient without the barrier of gloves etc. Catheter-associated urinary tract infection (CAUTI). Charriere size (ch) urinary catheter size (divide by 3 will give diameter in millimetres) Cumbria Partnership Foundation Trust - CPFT 5 DUTIES, ROLES AND RESPONSIBILITIES Duties Policy Implementation Policy Audits and monitoring Adequately resourced Oversee the policy Policy review Staff training on this policy Incident reporting Compliance with advice and DH guidance Staff responsibilities Work within the policy Trust Board Chief Executive Director of Infection Prevention & Control Managers and Matrons x x x x x x x x All Prescriber s and staff x x x x x x x x x Infection Prevention and Control Committee x x x x Infectio n Preventi on & Control Team x x x x x Occupational Health April 2014 Page 4 of 22 Our Ref: POL/001/042

5 6 INSERTION AND MAINTENANCE OF CATHETERS IN ADULTS 6.1 Decision to catheterise When discussing catheterisation as a treatment option, intermittent catheterisation should always be considered for incomplete emptying as the first option, rather than indwelling catheterisation, providing this is a safe and acceptable alternative for the individual and carer(s). Never catheterise or consider continued catheter usage for nursing convenience. A full assessment of the individual and their needs should be carried out before catheterisation. This includes identifying underlying cause(s) for their bladderemptying problem and exploration of the factors that may contraindicate catheterisation Indications for catheterisation within CPFT Monitoring renal function hourly during critical illness Acute urinary retention Chronic urinary retention, only if symptomatic and/or with renal compromise To assist in the healing of open sacral or perineal wounds in incontinent patients Where it is viewed on balance as better for the patient to use a catheter, such as end-of-life care, disability, unfit for surgery, staff must remember that the risks associated with catheter usage are of a serious nature that increasingly may become difficult to justify. Particular care is necessary in women, the elderly and those with impaired immunity. Neurological disease Patients with intractable urinary incontinence when all other management approaches have failed Contra-indications for catheterisation within CPFT Mental health or cognitive status of the patient, which may raise questions regarding the patients ability to give informed consent and safety. There is evidence suggesting that confused patients may attempt to forcibly remove the catheter, which can lead to urethral trauma and potentially septicaemia. Carer availability in order to manage / undertake the catheter care for the patient. Where a patient is unable to communicate in English every effort will be made to find an interpreter. Tissue viability and preserving skin integrity. Catheterisation can increase the risk of pressure ulcer development, as there is a tendency to reduce patient interactions such as toileting or pad changing. April 2014 Page 5 of 22 Our Ref: POL/001/042

6 Patients with known or suspected urethral injury or false passages. Patients with urethral stricture however these may be managed by the use of a larger charriere intermittent catheter. Gender reassignment patients or patients who have had extensive genital surgery would not be catheterised by a nurse without a GP or urologist present. 6.2 Selection of a catheter device Catheter selection should be determined by: Reason for catheterisation How long the catheter will remain in-situ (this will help determine material choice) Diameter size and length (to facilitate adequate drainage and promote patient comfort and dignity) Any allergy or sensitivity to the catheter materials Gender History of symptomatic urine infection Previous catheter history Patient preference and comfort Re-assessment of the initial choice of catheter used should be carried out on a regular basis. A brief description of commonly used catheters is given below (not all catheters are licenced for Supra Pubic use see manufactures instructions) Catheter type Indication Advantages Disadvantages Nelaton intermittent catheter Body image Less chance of infection PTFE coated latex Hydrogel coated latex Hydrogel coated silicone Silicone elastomer coated latex One use only (insert drain bladder remove) Medium term 7-28 days Long term Up to 12 weeks Long term Up to12 weeks Long term up to12 weeks Reduced tissue damage and more resistant to encrustation More compatible with body tissue, less trauma, low surface friction Suitable for patients with latex allergy Smooth internal and external surfaces, may reduce potential for Requires person to be able to perform procedure or have family/carer or nurse to perform Unsuitable if latex allergy Unsuitable if latex allergy Rigid Cuff formation on balloon deflation may make removal difficult Unsuitable if latex allergy April 2014 Page 6 of 22 Our Ref: POL/001/042

7 Silicone catheters Long term up to 12 weeks encrustation Suitable for patients with latex allergy. More rigid than latex. Minimal mucosal irritation. Larger internal bore in relation to Charriere size. D shaped lumen which may induce formation of encrustation. Silicone permits gas diffusion therefore balloons may deflate and allow the catheter to fall out prematurely. Nitrofurazone silicone Silver alloy coated hydrogel Long term up to 12 weeks Up to 28 days Indicated for CAUTI including E coli and MRSA Prevents bacteria bonding onto to the catheter surface. 6.3 Patient Preparation Consent Catheterisation is an invasive procedure with associated serious risks, therefore obtaining documented valid consent is vital to the procedure. In gaining consent the patient expects that it is in their best interest and safety. In the process of gaining consent to catheterise a patient it is best practice to provide supportive written information in a format that they understand. Explaining the procedure and providing the reason for catheterisation to the patient will help reduce patient anxiety and embarrassment and help the patient to report any problems that may occur while the catheter is in-situ. Relaxing the patient by offering reassurance and support will help for smoother insertion of the catheter and assist in avoiding unnecessary discomfort and the potential of urethral trauma during the insertion. When consenting to catheterisation the patient understands the rational, the alternatives and the consequences of not being catheterised. Patient consent is also required for a chaperone or other supervising healthcare worker. A patient s signature alone is evidence of consent but not proof that they have understood the procedure. The patient needs to understand that the catheter will be removed as soon as possible to minimise the risk of infection. For long term catheters (up to 3 months) the risks of bypassing, discomfort, blockage, infection, multi-resistant infection, bleeding and in men, painful erections needs to be discussed. It is a necessity that verbal consent and agreement is reached and the relevant information recorded in the patients medical and/or nursing notes. It implies an understanding of the event and the associated potential complications/problems. (Consent policy - POL/001/010) (RCN 2011 Informed consent in Health and Social Care Research) April 2014 Page 7 of 22 Our Ref: POL/001/042

8 6.4 Equipment and Preparation Catheterisation is a sterile procedure as it involves instrumentation of a sterile tract. It is imperative that the healthcare professional has a good understanding of the principles of the ANTT as this will help to reduce the risk of urinary tract infection. See appendix 1 Equipment needed Sterile dressing pack containing disposable plastic apron, gauze and dressing sheets 1 pair of sterile gloves for insertion and 1 pair clean gloves for washing area Selection of appropriate catheters. (It is advisable to take a spare catheter in addition to the one you want) Sterile single use anaesthetic lubricating jelly (1-2 tubes) Red topped urine specimen container (if required) Soap and water for cleaning skin Alcohol based hand rub 10 ml sterile water if not using prefilled or complete sets Syringes and needle (to draw up sterile water and inflate balloon, syringe to deflate balloon). A closed urinary drainage system, e.g., a night bag, leg bag or catheter valve A catheter drainage bag stand, if required Support mechanisms Waste bag and sharps container The use of a single use anaesthetic lubricating gel is well recognised for catheterisation. However, it is essential to ask the patient if they have any sensitivity to lignocaine, Chlorhexidine or latex before commencing the procedure. At least 11 ml (male) or 6ml (female) of the gel is instilled directly into the urethra until this volume reaches the sphincter/bladder neck region. It is recommended that the practitioner waits 5 minutes after instilling the gel, before starting the catheterisation but it is important to follow manufacturer s guidance. By inserting the single use anaesthetic gel, the friction between the catheter and the mucosal layer will reduce and lead to a smooth insertion of the catheter into the bladder. A maximised anaesthetic effect will help the patient to relax and the insertion of the catheter should be easier. 6.5 Insertion Procedure Action Rationale Urethral Supra Pubic 1. Prior to the procedure explain the process to the To ensure the patient understands the April 2014 Page 8 of 22 Our Ref: POL/001/042

9 patient. Give reassurance to the patient throughout the procedure. 2. (a) Undertake procedure on the patient s bed or in clinical treatment area using screens/curtains to promote and maintain dignity. If the procedure is carried out in the patient s home ensure privacy and dignity maintained at all times. (b) Assist the patient into the supine position. (c) Do not expose the patient at this stage of the procedure. 3. Prepare the surface for equipment. 4. In hospital, clinic or nursing/residential home, take the trolley to the patient s bedside. 5. Decontaminate hands using either liquid soap and water or sanitizer. 6. Put on disposable plastic apron. 7. Open the outer cover of the catheterisation pack and slide the pack onto the top shelf of the trolley or suitable surface within patient home. Don clean gloves. 8. Using ANTT open the supplementary items onto the sterile field of the catheterisation pack. 9. Remove cover that is maintaining the patient s privacy and position a disposable pad/towel under the patient s buttocks and thighs. 10. Maintaining the patient s dignity position absorbent pad or towel below the Supra Pubic site. procedure. To ensure patient s privacy and dignity is maintained. To ensure the external genitalia is accessible. To maintain patient s dignity and comfort. The top shelf acts as a clean working surface. To reduce risk of infection. To reduce risk of cross infection. To prepare equipment. To reduce the risk of cross infection. To ensure urine does not leak onto the bed. To ensure urine does not leak onto the bed. April 2014 Page 9 of 22 Our Ref: POL/001/042

10 11. In female, separate labia, locate external urethral opening and clean with soap and water. In male, lift the penis and retract the foreskin if present using a gauze swab and clean the glans penis with soap and water. 12. Clean around the Supra Pubic site with sterile normal saline 13. Remove gloves, wash hands/gel put on sterile gloves and continue to use ANTT. 14. Place dressing / protective towel (sterile) in position. 15. If catheter change required Explain procedure to patient and deflate the balloon, remove catheter slowly. Discard in appropriate clinical waste. 16. If removing Supra pubic catheter explain procedure to patient and deflate the balloon. Remove catheter slowly by gripping with thumb and fore finger next to the abdomen so once slowly removed you will know the depth and angle required to replace. 17. Following manufacturer s instructions, slowly instil anaesthetic lubricating gel into the urethra (approx. 11mls male, 6mls female). Remove the nozzle from the urethra and in male with thumb and fore finger use firm strokes to ensure gel pushed throughout the urethra. Wait 5 minutes to ensure a maximised anaesthetic effect. To reduce the risk of introducing infection. Lifting the penis straightens the penile urethra and facilitates catheterisation. To reduce the risk of introducing infection. To reduce the risk of cross infection. To create a protective field. To reduce anxiety, allow for relaxation of muscles and reduce trauma. To reduce anxiety, allow for relaxation of muscles and reduce trauma. Adequate lubrication helps to prevent urethral trauma. Use of anaesthetic minimises the discomfort experienced by the patient and can aid success of the procedure. April 2014 Page 10 of 22 Our Ref: POL/001/042

11 18. Tear open at the tip of the catheter, the plastic cover surrounding it. Gently insert the catheter 2-3 cms at a time. To prevent contamination of the catheter. To minimise patient discomfort and reduce incidence of trauma. (a) Advance the catheter to the bifurcation. In Supra Pubic catheterisation there is a risk that the catheter tip may have passed into the urethra. In women it is recommended that a visual check be performed. (b) Slowly inflate the balloon according to the manufacturer s direction, having ensured that the catheter is positioned correctly. If any pain or resistance discontinue. (c) Withdraw the catheter to feel the bladder wall/neck and attach the drainage bag/valve if not already connected. (d) Secure the catheter using a support strap, leg support sleeve or G strap. Ensure that the catheter does not become taught when the patient is mobilising or when the penis becomes erect (urethral). 19. In male, ensure that the glans penis is cleansed after the procedure and reposition the foreskin if present. 20. Help the patient into a comfortable position. Ensure that the patient s skin and bed are both clean and dry. Advancing the catheter ensures that it is correctly positioned in the bladder. (British Association of Urological Guidelines 2010) Inadvertent inflation of the balloon in the urethra causes pain and urethral trauma. Withdrawing the catheter ensures the balloon sits correctly ensuring optimal urine drainage. To maintain patient comfort and to reduce the risk of urethral and bladder neck trauma. Retraction and constriction of the foreskin behind the glans penis resulting in paraphimosis may occur if this is not done. If the area is wet or moist, secondary infection and skin irritation may occur. April 2014 Page 11 of 22 Our Ref: POL/001/042

12 21. Measure the amount of urine emptied if in retention. 22. Take a urine specimen for laboratory examination if required. 23. Dispose of equipment in a plastic clinical waste bag and seal the bag. Clean area/trolley and decontaminate hands in the appropriate manner. In the community waste can go down the domestic waste stream otherwise clinical waste bin. Any sharps must be disposed of in sharps box. 24. Record information in relevant documents, this should include : Reasons for catheterisation Residual volume Date and time of catheterisation Catheter type length and size Amount of water instilled into the balloon batch number and manufacturer Drainage system used Problems negotiated during the procedure Review date of change of catheter 25. Record patient experience and any problems. 26. Drainage bag to be positioned above the floor but below the level of the To be aware of bladder capacity for patients with previous occurrences of urinary retention. To monitor renal function and fluid balance. To rule out urinary tract infection. To prevent environmental contamination. To provide a point of reference or comparison in the event of later queries. To provide a point of reference or comparison in the event of later queries. To prevent reflux or contamination. April 2014 Page 12 of 22 Our Ref: POL/001/042

13 bladder. 27. Samples of urine should only be taken if valid reason for example if infection suspected. It must be taken aseptically via the catheter sampling port after cleaning with an isopropyl alcohol 70% impregnated swab and allowed to dry thoroughly To prevent cross infection, and erroneous results. ALERT NPSA 2009/RR0002 There is a significant risk of trauma if a female catheter is used on a male patient. Store male and female catheters separately. 6.6 Ongoing catheter care/maintenance Patients and carers must be educated about and trained in techniques of hand decontamination and catheter management. Follow up training and ongoing support of patients and carers within the community setting should be management by healthcare workers including catheter changes. The key drivers influencing catheter care are given below:- There must be a clear rationale for ongoing usage of a catheter (short term catheters should be reviewed as a minimum on a monthly basis) Cleanliness o Do not clean the periurethral area with antiseptics to prevent catheter associated UTI while the catheter is in place. Routine hygiene (e.g. cleansing of the meatus during daily bathing/showering) is appropriate. o Bladder installations and washouts must not be used to prevent catheter-associated infection o Antibiotic prophylaxis when changing catheters should only be used for patients with a catheter-associated urinary tract infection, including MRSA in urine. Please note antibiotic therapy must be commenced 24 hours prior to changing a urinary catheter when the patient has a CAUTI. Drainage system o Catheters are connected using a closed drainage system. Urine drainage bags are emptied regularly (usually when two-thirds full) and positioned above floor and below the level of the bladder (except if a belly-bag). This will maintain urine flow and prevent reflux or blockage by occlusion from the bladder mucosa. Leg worn drainage bags are changed every 5 to 7 days, night drainage bags April 2014 Page 13 of 22 Our Ref: POL/001/042

14 are single use only. A catheter-valve should always be considered in situations when the bladder can provide safe urinary storage, changed every 5 to 7 days. o When changing the leg/belly bag or valve a non touch technique must be used. o A clean container is used for each individual at the time of bag emptying; avoid splashing and prevent contact between drainage tap and non sterile collecting container. Gloves are worn to empty drainage bags, drainage taps should be cleaned after emptying. o Hand washing/decontamination before and after each individual. Carers and patients managing their own catheters must wash their hands before and after manipulation of the catheter. o Leg bags may also be emptied directly into the toilet o A link system should be used to facilitate overnight drainage, to keep the original system intact Catheter maintenance solutions Urinary catheter maintenance solutions are pre-packaged sterile solutions ready for administration. These solutions act mechanically in order to maintain urinary drainage, reduce blockage/encrustation and sustain urinary catheter life where appropriate. A urinary catheter maintenance solution must not be used to prevent catheter-associated infection. The principle indication for the use of a urinary catheter maintenance solution is to prevent long term catheter encrustation and blockage, establishing the need to use the solution requires the following assessment:- First time blockage should be investigated by determining the cause:- Check the positioning of catheter, bags and tubing. Assess fluid intake and bowel pattern On removing the catheter inspect for crystals. When a catheter has evidence of phosphate deposition and is associated with urine ph>7 (alkaline) then regular ph monitoring is helpful to assess responses to treatment and fluid intake. It is also important to document the findings. This will give a rationale for use of an appropriate urinary catheter maintenance solution. Cystocopy should be undertaken if repeated catheter blockages occur with no visible cause. Cautions to use of urinary catheter maintenance solution If the patient found the procedure painful or distressing previously Recent radiotherapy to the lower urinary tract Known history of carcinoma to the lower urinary tract Recent surgery to or involving the lower urinary tract Recent insertion of a prosthesis April 2014 Page 14 of 22 Our Ref: POL/001/042

15 Immunocompromised patient Known bladder over activity making administration and retention difficult The patient has a known history of haematuria The patient has a known history of fistula to the lower urinary tract If the patient has evidence of active urinary tract infection or has known urinary bacterial colonisation an assessment of the risk of bacteraemia should be carried out in conjunction those directly involved in the patient s care. Maintenance Solutions should not be used in spinal injured patients because of the risk of autonomic dysreflexia. All solutions increase the shedding of epithelial cells into the bladder therefore it may be more appropriate to manage the blockages with more frequent catheter changes. + Catheter removal o Long term catheters are usually replaced every 12 weeks, the precise duration will depend on patient factors o Clamping indwelling catheters prior to removal is not necessary o Antibiotic therapy is not indicated to cover catheter removal Problem Solving Catheter problem Possible reasons Possible solutions Urine not draining into bag Incorrectly sited catheter; it may be in the urethra and not fully in the bladder Deflate retaining balloon and gently reposition Incorrect position of drainage bag above the level of the bladder can prevent good flow of urine Check tubing and ensure drainage bag is below level of bladder Drainage tubing may be kinked Haematuria Bypassing of urine around catheter Catheter may be blocked by debris Trauma post-catheterisation Infection Prostatic enlargement Calculi Carcinoma May indicate presence of infection Gentle flush of catheter with sterile water or saline solution Observe output and document severity of haematuria. Seek medical advice if haematuria persists Encourage fluid intake Obtain a catheter specimen of urine using the sampling port April 2014 Page 15 of 22 Our Ref: POL/001/042

16 Pain or discomfort Catheter retaining balloon will not deflate Bladder spasm/instability Constipation Incorrect positioning of drainage system Balloon overinflated The eyelets of the bladder may be occluded by urothelium due to hydrostatic suction May be indication of infection Valve port and balloon inflation channel may be compressed Faulty valve mechanism Consider use of anti-cholinergic medication Increase fluid and dietary fibre intake Check drainage bag is in correct position, i.e. below level of bladder Check volume, if overinflated remove water Raise the drainage bag above the level of the bladder for seconds only Obtain a catheter specimen of urine using the sampling port Check no external compression problems Valve port should always be aspirated slowly. If done forcefully the valve mechanism will collapse Deflation can sometimes be achieved by injecting an additional small volume of sterile water then slowly aspirating again If attempts fail, medical advice must be sought. Cutting the catheter along its length is not a safe practice and may result in retraction of the catheter into the bladder. Other comments Catheter balloon sizes o 10ml for adult routine drainage Correct catheter size; ensure patients have smallest size to meet their needs o 12ch, 14ch or 16ch for male long term usage o 12ch or 14ch for female long term usage o 16ch or 18ch for supra pubic usage in both male and female Correct length April 2014 Page 16 of 22 Our Ref: POL/001/042

17 7 TRAINING o Male/standard length for men in all situations o Male standard length is recommended for female patients in the following situations: bedbound, immobile, emergency situations, clinically obese and critically ill o Female standard length catheters have a limited role and are used for patients who are ambulant and normal weight ALERT NPSA 2009/RR0002 There is a significant risk of trauma if a female catheter is used on a male patient. Training required to fulfil this policy will be provided in accordance with the Trust s Training Needs Analysis. Management of training will be in accordance with the Trust s Learning and Development Policy. CPFT Trained nurses delegating any aspect of catheter care to another person must ensure the individual has been trained in accordance with this policy. 8 MONITORING COMPLIANCE WITH THIS POLICY The table below outlines the Trust s monitoring arrangements for this policy/document. The Trust reserves the right to commission additional work or change the monitoring arrangements to meet organisational needs. Aspect of compliance or effectiveness being monitored Urinary catheter insertion and daily care. Monitoring method Infection Prevention audit tools Individual department responsible for the monitoring Visiting District Nurse Frequency of the monitoring activity On each visit Group / committee which will receive the findings / monitoring report Infection Control Group / committee / individual responsible for ensuring that the actions are completed District Nurse Leads 9 REFERENCES/ BIBLIOGRAPHY National Institute for Health and Clinical Excellence. (2012). Infection Control: Prevention of Healthcare-associated Infection in Primary and Community Care. NICE 139, London. Royal College of Nursing (2011) Catheter Care. RCN guidance for nursing NHS Quality Improvement Scotland (2004). Urinary catheterisation and catheter April 2014 Page 17 of 22 Our Ref: POL/001/042

18 Healthcare Infection Control Practices Advisory Committee (HICPAC) (2009) Guideline for prevention of catheter associated urinary tract infection British association of Urological Surgeons (2010) Supra Pubic catheter practice guidelines EPIC 10 RELATED TRUST POLICY/PROCEDURES Standard Infection Control Precautions Policy (POL/001/042/001) Aseptic Technique Policy (POL/001/042/002) Prevention and Management of Occupational Exposure of Blood Bourne Viruses (BBV s) and Post Exposure Prophylaxis Policy (POL/001/042/006) Disinfection Policy (POL/001/042/008) Decontamination Policy (POL/001/042/009) Hand Hygiene and Glove Policy (POL/001/042/016) Packaging Handling and Delivery of Laboratory Specimens Policy (POL/001/042/?) Use and Care of Invasive Devices Policy (POL/001/042/?) April 2014 Page 18 of 22 Our Ref: POL/001/042

19 APPENDIX 1: URETHRAL CATHETERISATION Remove catheter as soon as possible to minimize risk of infection, especially with extended spectrum beta-lactamase producing Gram-negative bacilli (ESBL) INDICATIONS Temporary catheterization: o to relieve acute retention of urine o to improve pelvic access during surgery o to measure urine output after major surgery and during major illnesses Long-term catheterization: o male patients with urinary retention and prostatic hypertrophy who are unfit for prostatectomy o some patients with neurological problems (e.g. multiple sclerosis, myelodysplasia, or spinal trauma, where intermittent selfcatheterization is not feasible) o as a last resort in elderly or severely incapacitated incontinent patients CONTRA-INDICATIONS Suspected urethral injury after pelvic trauma (refer to urologist) Urinary tract infection (avoid catheter if possible) EQUIPMENT Clean gloves for cleaning Sterile gloves for insertion Dressing pack with gauze swabs, apron and dressing sheet Soap and water Tube of anaesthesic gel or syringe (lidocaine 2%, chlorhexidine 0.25%) Appropriate urethral catheter (see Choice of catheter) 10 ml syringe filled with sterile water or prefill catheter or complete kit Drainage bag Support mechanisms Choice of catheter Short term (up to 14 days) Longer term 12Fr or 14Fr is suitable for women 14Fr or 16Fr is suitable for men April 2014 Page 19 of 22 Our Ref: POL/001/042

20 NB Female catheters exist which are shorter than standard catheters. They must not be used in men as the balloon will damage the urethra see also NPSA ALERT Use silver-coated catheters for: PROCEDURES o patients colonised with a multi-resistant organism o patients for whom infection control team has recommended this choice Consent Explain procedure and reassure patient Obtain and record consent Catheterisation in the male Lie patient supine Open sterile pack Don clean gloves Clean genital area Wash hands/alcohol gel and don sterile gloves Place sterile towel to protect area Open catheter set and/or syringe and anesthetic gel onto pack. Use left hand to hold penis (reverse if left handed) Retract prepuce as necessary Insert anesthetic gel into urethra Massage gel carefully down urethra to sphincter. Gently compress distal urethra to prevent gel escaping Allow at least 5 min to elapse before proceeding to catheterisation Hold penis vertically at commencement of catheterisation. Use free hand to insert catheter As catheter is advanced into bladder, gradually pull penis downwards to straighten the urethra and to align catheter with prostatic urethra. Urine will begin to drain if present If procedure difficult or painful, or bleeding occurs, abandon procedure inform GP Advance catheter until bifurcation Inflate catheter balloon with recommended amount of water. This should not cause any pain or bleeding Gently withdraw catheter until there is resistance Replace prepuce to avoid danger of paraphimosis Connect catheter bag Apply support mechanisms April 2014 Page 20 of 22 Our Ref: POL/001/042

21 Catheterisation in the female Lie patient supine Place patient s thighs apart, knees flexed and feet together Open sterile pack Don clean gloves Clean genital area Wash hands/alcohol gel and don sterile gloves Place sterile towel to protect area Open catheter set and/or syringe and anesthetic gel onto pack Part labia and insert anesthetic gel into urethra, allow at least 5 min to elapse before proceeding catheterisation Insert catheter, urine will start to drain if present and continue for a further 5cm. Inflate balloon with recommended amount of water Connect catheter bag Apply support mechanisms Complications Urethral Failure of catheter to reach bladder obtain specialist help. Do not make further attempts Bacteraemia or septicaemia may be caused by over-manipulation. Contact GP re treatment. Bleeding can occur, particularly if catheter inflated in the urethra. Remove catheter. Contact GP. Supra Pubic Catheter site infection use of antibiotics if evidence of cellulitis or appropriate dressings. Catheter site over granulation use of appropriate dressings Catheter site mucus/crustation Normal washing Loss of catheter track Ensure catheter replaced correctly if unable to pass refer to urology immediately as tract salvage may be possible. AFTERCARE Connect catheter to a closed drainage bag that is emptied as necessary. If system has to be opened (e.g. to change bag or provide washout) full sterile precautions are essential Patients who have had chronic retention of urine sometimes have obstructive renal failure. Catheterisation can be followed by a spectacular postobstructive diuresis with profound metabolic consequences. Observation should be made of amount of fluid drained with an awareness of systemic shock and actions to take. Contact GP. April 2014 Page 21 of 22 Our Ref: POL/001/042

22 An indwelling catheter almost always leads to bacteriuria within two weeks. When bacteriuria is established even the most intensive antibiotic treatment is unlikely to make urine sterile until catheter is removed or replaced. If changing the catheter when on antibiotics recommended to leave until half way through the course. Bacteriuria associated with an indwelling catheter without clinical evidence of infection does not require antibiotic treatment Bladder irritation can produce severe and painful bladder spasms, and can cause bypassing of urine alongside the catheter. Try using a smaller charriere or less rigid catheter. Medication can also be given to calm the bladder muscle. If there is leakage around catheter do not replace with a larger one. This simply commits patient to a spiral of increasing catheter size. The urethra becomes steadily more dilated until it can retain no catheter Removal of catheter Do not cut the catheter valve If catheter balloon fails to deflate when the time comes to remove it, do not try to burst it by over-distension, as bladder may burst first. Try attaching a syringe and removing the plunger. If this fails to work refer to urology team. April 2014 Page 22 of 22 Our Ref: POL/001/042

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24 Page 1 of 2 UDP-Gen Infection Prevention Quality Improvement Tools Clinical Practice Process Improvement Tool : Urinary Catheter Daily Care Functional Area: Start Date: Overall Auditors: Module: Urinary Catheter Daily Care Date: Auditors: Standard: Evidence based best practice is being consistently applied to prevent catheter associated urinary tract infections UDP-Gen Question Set: Urinary Catheter Daily Care - Urinary Catheter Daily Care Observation: 1 Question 1 Is there a daily documented assessment of the continued need for the urinary catheter? 2 Is the closed system continuously maintained? 3 Is meatal hygiene undertaken on a daily basis? 4 Is hand hygiene performed before manipulating a patient/resident s urinary catheter? (90) 5 Is a single use apron and gloves worn when emptying a patient/resident s urinary catheter? (20) 6 Is the urinary catheter bag emptied into an appropriate receptacle? 7 Is the urinary catheter bag positioned below the level of the bladder for effective drainage? 8 Is the urinary drainage bag positioned on a stand to prevent contact with the floor? 9 Are catheter specimens of urine taken aseptically using the needle-less port? 10 Is hand hygiene performed immediately following removal of personal protective equipment? (20, 90) 11 Is a link system used to facilitate overnight drainage and maintain the closed system? 12 Are single use items disposed of after use? (20, 79) Guidance Review documentation. Check: Catheter bag is only emptied as necessary to maintain urine flow and prevent reflux. Catheter bag is not disconnected except for good clinical reason e.g. changing bag in line with manufacturer s instructions. Check: Care plan for documentation/ask patient/resident. Check that the correct hand hygiene procedure is used. Moment 1 - before patient contact. Observe practice. Check a separate and clean container is used for each patient/resident and the urinary drainage tap is not touched by the container. Containers must be single-use or processed in a washer-disinfector between uses. Check that no part of the catheter system is touching the floor. Observe practice. Observe practice or ask a member of staff to describe procedure. Observe practice. Moment 3 - after body fluid exposure. Observe practice. Check night bags are disposed of after use. Yes No N/A Comment Page 1 of 2 Page 1 of 2

25 Page 2 of 2 UDP-Gen Infection Prevention Quality Improvement Tools Clinical Practice Process Improvement Tool : Urinary Catheter Daily Care UDP-Gen Page 2 of 2 Question Set Comments/Recommendations for Urinary Catheter Daily Care - Urinary Catheter Daily Care Pratt RJ, Pellowe C, Wilson JA, Loveday HP, Harper PJ, Jones SRLJ, McDougall CM, Wilcox MH. (2007) Epic2: National Evidence Based Guidelines for preventing Healthcare-Associated Infection in NHS Hospitals in England. Journal of Hospital Infection. 65 (1) Supplement 1. Pellowe CM, Pratt RJ, Harper P, Loveday HP, Robinson N, Jones SR, MacRae ED, Mulhall A, Smith GW, Bray J, Carroll A, Chieveley, Williams S, Colpman D, Cooper L, McInnes E, McQuarrie I, Newey JA, Peters J, Pratelli N, Richardson G, Shah PJ, Silk D, Wheatley C, Guideline Development Group. ( 2003 ) Infection control: prevention of healthcare-associated infections in primary and community care. Guidelines for preventing healthcare-associated infections during long-term urinary catheterisation in primary and community care. Simultaneously published in: Journal of Hospital Infection December 2003; 55 (Supplement 2): and British Journal of Infection Control December 2003 (Supplement): 4(6): Personal Protective Equipment Policy and Procedure (an element of Standard Infection Control Precautions). In: Health protection Scotland, editor, 2009 World Health Organisation (2009) Guidelines on hand hygiene in health care. Geneva, Switzerland: World Health Organisation Page 2 of 2

26 Page 1 of 2 UCP-Gen Infection Prevention Quality Improvement Tools Clinical Practice Process Improvement Tool : Urinary Catheter Insertion Functional Area: Start Date: Overall Auditors: Module: Urinary Catheter Insertion Date: Auditors: Standard: Evidence based best practice is being consistently applied to prevent catheter associated urinary tract infections UCP-Gen Question Set: Urinary Catheter Insertion - Urinary Catheter Insertion Observation: 1 Question 1 Have alternatives to urinary catheterisation been considered and documented? 2 Is the clinical reason for insertion specified and documented? 3 Is the healthcare worker trained in catheterisation or supervised by a trained person? 4 Is the smallest gauge catheter used for effective drainage? 5 Is hand hygiene performed before urinary catheterisation? (90) 6 Is a single use apron worn for urinary catheterisation? 7 Are single use sterile gloves worn for the aseptic procedure? 8 Is the urethral meatus area cleaned with sterile normal saline prior to urinary catheterisation? 9 Is asepsis maintained throughout the procedure? 10 Is sterile, single use lubricant used prior to insertion? 11 Is the catheter connected aseptically to a sterile closed drainage system? 12 Is the urinary catheter bag positioned below the level of the bladder for effective drainage? 13 Is waste discarded into the appropriate waste stream according to local policy? 14 Is all personal protective equipment removed? Guidance Review documentation. Review documentation. Check training records. Check gauge. Observe practice. Moment 2 - before an aseptic task. Observe practice. Observe practice. Observe practice. Check: Sterile Items are intact. Sterile Packs integrity. Equipment is in date. No unsterile items are touched. Contaminated items are replaced. Observe practice. Observe practice. Check that no part of the catheter system is touching the floor. Observe practice. Observe practice. Yes No N/A Comment Page 1 of 2 Page 1 of 2

27 Page 2 of 2 UCP-Gen Infection Prevention Quality Improvement Tools Clinical Practice Process Improvement Tool : Urinary Catheter Insertion UCP-Gen Question Set: Urinary Catheter Insertion - Urinary Catheter Insertion Observation: 1 Question 15 Is hand hygiene performed immediately following removal of personal protective equipment? (20, 90) Guidance Observe practice. Moment 3 - after body fluid exposure. Question Set Comments/Recommendations for Urinary Catheter Insertion - Urinary Catheter Insertion Yes No N/A Comment Page 2 of Pratt RJ, Pellowe C, Wilson JA, Loveday HP, Harper PJ, Jones SRLJ, McDougall CM, Wilcox MH. (2007) Epic2: National Evidence Based Guidelines for preventing Healthcare-Associated Infection in NHS Hospitals in England. Journal of Hospital Infection. 65 (1) Supplement 1. World Health Organisation (2009) Guidelines on hand hygiene in health care. Geneva, Switzerland: World Health Organisation Page 2 of 2