Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures (SOPs)

Transcription

1 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures (SOPs) Authors Rachel Baker-Green and Alison Berry Clinical Nurse Specialists Continence, Urology and Colorectal Service (CUCS) Corporate Lead Paul Morrin Director of Nursing Interim Document Version 2 Date ratified by Quality Committee 20 th April 2015 Date issued 18 May 2015 Review date April 2016 Policy Number PL337

2 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures Executive summary This policy and SOPs have had a comprehensive review following the outcomes of a Serious Incident investigation for a Bacteraemia in June This policy provides information on how to manage the care and treatment of patients who require a urinary catheterisation procedure and maintaining standards and improving care of the patient, irrespective of whether the catheterisation is intermittent, short term or long term. The policy includes: best practice in urinary catheterisation specific documents to be completed competency framework prescribing prophylaxis recognising signs and symptoms of infection The implementation plan of disseminating the policy into practice will be led by the CUCS, highlighting the key changes in practice from the previous policy. 6 important messages to staff for the release of this policy: 1. Diagnosis of CAUTI using initial signs and symptoms and not dip testing 2. Appropriate CSU sampling process from old catheter, via port 3. CSU to be taken before commencement of antibiotics 4. When CAUTI identified change catheter at point of antibiotic commencement 5. Documentation requirements. Catheter Risk assessment, management Plan, change record and care plan 6. Competency requirements A clinical audit will be undertaken with staff in July 2015 measuring clinical practice compliance levels of care standards from within this policy. Equality Analysis Leeds Community Healthcare NHS Trust's vision is to provide the best possible care to every community. In support of the vision, with due regard to the Equality Act 2010 General Duty aims, Equality Analysis has been undertaken on this policy and any outcomes have been considered in the development of this policy. Page 2 of 51

3 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures Contents Section Page 1 Introduction 5 2 Aims and Objectives 5 3 Definitions 5 4 Responsibilities 6 5 Indications for urinary catheterisation 6 6 Resources and Equipment 7 7 Assessment and Risk Assessments Catheter Risk Assessments Catheter associated urinary tract infections (CA-UTI) Antibiotic prophylaxis 8 8 Discharge from Hospital 8 9 Documentation 9 10 Catheter Materials 9 11 Catheter Care refer to SOP 9 12 Education of patients/carers Monitoring Compliance and Effectiveness Approval and Ratification process Dissemination and implementation Review arrangements Associated documents References 12 Page 3 of 51

4 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures Section Appendices Page 1 Catheter Change Record 13 2 Urinary Catheter Management Plan 14 3 Catheterisation competency framework 15 4 Standard Operating Procedure for Obtaining a Catheter Specimen of Urine (CSU) 25 5 Patient undergoing trial without catheter who requires 27 antibiotic prophylaxis 6 Urinary Catheter Handbook 28 7 Standard Operating Procedure for Female Catheterisation 38 8 Standard Operating Procedure for Male Catheterisation 39 9 Standard Operating Procedure for Supra - pubic Catheterisation 10 Standard Operating Procedure for Intermittent Catheterisation Using Single Use Catheters: Female Patients 11 Standard Operating Procedure for Intermittent Catheterisation Using Single Use Catheters: Male Patients 12 Standard Operating Procedure for Changing a Catheter Bag (Adhere to manufacturer s guidance) 13 Standard Operating Procedure for Connecting a Night Catheter Bag 14 Standard Operating Procedure for Administering a Catheter Maintenance Solution (CMS) 15 Standard Operating Procedure for Disconnecting a Night Drainage Bag Standard Operating Procedure for Emptying a Catheter Bag Support Workers and catheterisation Poster: Has your patient got signs and symptoms of a CA- UTI? 50 Page 4 of 51

5 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures 1 Introduction This policy is for all health care professionals (HCP) caring for patients who require urinary catheterisation care within Leeds Community Healthcare NHS Trust (LCH). Catheterisation and catheter care is a key component of nursing care. Advice and support is available from the Continence, Urology and Colorectal Service (CUCS). Urinary catheterisation must be performed using the LCH Aseptic Non Touch Technique policy (ANTT). This policy is based on the most recent publications from National Institute for Health and Clinical Excellence (2012 Royal College of Nursing (2012) and Epic 3. The catheterisation procedure must only be performed after alternative methods of urinary management have been considered. The patient's clinical need for catheterisation must be reviewed regularly and the urinary catheter removed as soon as possible (NICE 2012). Patients/carers must be given the appropriate level of information, written and verbal, to allow them to continue to care for a urinary catheter safely, thus reducing risk of infection. 2 Aims and Objectives The aim of this policy is to provide evidence based instruction on the safe management of catheter systems. To identify the process of urinary catheterisation, maintain standards and improve care of the patient, irrespective of whether the catheterisation is intermittent, short term or long term. Objectives are: To provide a uniform process for all patients who experience urinary catheterisation; reducing adverse events To describe best practice in urinary catheterisation To provide an evidenced based framework To provide auditable practices. 3 Definitions Urinary catheterisation is the insertion of a catheter into the bladder via the urethra or abdomen (supra-pubic) using an aseptic non-touch technique (ANTT), for the purpose of evacuating urine or instilling fluids. Urethral catheterisation - a catheter is inserted into the bladder via the urethra. Intermittent catheterisation - patient (self-catheterisation) or carer inserts and removes catheter intermittently (clean procedure if done by patient) in order to drain bladder Supra pubic catheterisation - catheter inserted through stoma in lower abdomen into bladder. Catheter Change Record records each catheterisation see Appendix 1 Urinary Catheter Management Plan captures a record of the most recent catheterisations see Appendix 2 CA-UTI Catheter Acquired Urinary Tract Infection Page 5 of 51

6 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures 4 Responsibilities All staff employed by LCH must work in concordance with the Leeds Safeguarding Multiagency Policies and Procedures and local policies in relation to any safeguarding concerns they have for service users and the public whom they are in contact with. The patient must be fully informed and give verbal consent, where able (if unable to give consent documentation must include rationale, for Best Interest decision made) prior to the procedure (for further guidance refer to the Consent to Examination or Treatment, Patient Information Leaflet Policy and Mental Capacity Act). Chief Executive and Director of Nursing the Chief Executive and Trust Board have a collective responsibility within LCH and a commitment to support and endorse measures to prevent, minimise and manage urinary catheter related risks. As well as ensuring all staff performing urinary catheterisation are appropriately trained. Service Managers and Professional / Clinical Leads must ensure all staff are aware of and adhere to this policy and related policies. Registered staff must complete training every three years and be assessed as competent to perform urinary catheterisation and catheter care using the catheter competency framework. Registered staff members have a duty to work within the NMC code of conduct in relation to catheter care. Non-registered staff involved in catheter care/catheterisation must complete training every three years and be assessed as competent to perform urinary catheterisation and catheter care. Training and Competency All HCP s performing catheterisations must provide evidence of their competencies see Appendix 3. The Urinary Catheterisation Competency Framework must be completed and includes observing practice and theory related to catheterisations, catheter care and management. HCPs are required to complete training 3 yearly via e-learning or face to face. CUCS deliver bespoke training to HCP s and in partnership with Clinical Professional Leads and a train the trainer approach is recommended for this work area. Refer to the Statutory and Mandatory Training Policy including Training Needs Analysis. Up to date information is available on the Intranet for course details. 5 Indications for urinary catheterisation To: re-establish a flow of urine in acute/chronic urinary retention monitor urine output and fluid balance in the seriously ill patient empty contents of bladder before and after abdominal, pelvic, rectal surgery and promote healing following surgery in the perineal region measure the volume of residual urine remaining in the bladder following micturition provide a channel for drainage of urine when micturition is impaired/obstructed remove residual urine when voiding does not completely empty the bladder facilitate bladder irrigation procedures Page 6 of 51

7 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures enable bladder function tests to be performed obtain an uncontaminated specimen of urine empty bladder during childbirth if necessary avoid complications during intra cavity insertion of radioactive sources maintain a dry environment and prevent skin maceration when a patient is suffering from urinary incontinence and all other forms of nursing intervention have failed instil pharmacological preparations for the therapeutic benefit in malignant and nonmalignant conditions empty the bladder when there is an inability to toilet self due to disability, chronic illness, terminal illness and alternative methods of urinary management have been considered. 6 Resources and Equipment Urinary catheters and accessories e.g. drainage bags, valves, straps; Catheter packs Cath-It ; Cleansing fluid normal saline; Lubricating/anaesthetic gel; Personal Protective Equipment (PPE) (aprons, sterile and non-sterile gloves); Hand cleansing kit; Catheter documentation. 7 Assessment and Risk Assessments Prior to any catheter change, the patient should be assessed for ongoing need for catheterisation and consideration for trial without catheter. If catheterisation is deemed necessary, assess need for prophylaxis. 7.1 Catheter Risk Assessment must be completed on SystmOne for every patient with an indwelling catheter (see example below). Page 7 of 51

8 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures Outcome of risk assessment score: 0-25 Low Risk Medium Risk Over 50 High Risk All high risk patients must be referred to CUCS. 7.2 Catheter associated Urinary Tract Infection (CA-UTI) Wherever possible, patients with long term indwelling catheters should have the catheter changed with appropriate antibiotic cover when treating for CA-UTI. For Guidance on Urinary Tract Infections with a Catheter (CAUTI) 7.3 Antibiotic prophylaxis Patients, who are found to be MRSA positive at hospital admission screening if not known to be MRSA positive as below, should have a CSU collected from the existing catheter and a meatal/suprapubic entrance site swab. See Appendix 4. Patients who are MRSA positive in their urine and/or on meatal / supra pubic site swab must be given antibiotic prophylaxis prior to changing catheter or removing for trial without catheter. See Appendix 5. Either Doxycycline 200mg 2 hours prior to catheter removal / insertion Or Gentamicin 1.5mg per Kg body weight 30 min pre manipulation. Further advice can be obtained from LTHT Microbiology Department or LCH CUCS Team. Patients identified as MRSA positive will require assessment for topical skin decolonisation. For prophylaxis in other circumstances refer to the Guideline for Antimicrobial Prophylaxis during Urinary Catheterisation in Adults. For Guidance on Urinary Tract Infections with a Catheter (CAUTI) 8 Discharge from hospital: The Hospitals are responsible for: Referring the patient to the Neighbourhood Team Community Nursing Providing a Home Catheter pack for patients on discharge Faxing via Gateway, or sending with the patient, a copy of the Urinary Catheter Management Plan detailing if the catheter can be changed in community and infection status. If a patient is discharged without a Urinary Catheter Management Plan the discharging ward/unit must be contacted by Gateway or the relevant Neighbourhood Team Community Nursing to establish rational for ongoing use of catheter, if there are any reasons why the catheter should not be changed in the community and the patients infection status. Any Discharge Incidents must be reported via the Datix system. Page 8 of 51

9 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures 9 Documentation The Urinary Catheter Management Plan should accompany the patient discharged from hospital with a new catheter. It must be placed in the patient held records, and clearly state if the catheter can be changed in community. The patient should also be supplied with a catheter passport on discharge. If this is not provided this should be supplied in the community. A Catheter Care Plan must be used to record the rationale for insertion; on-going management; relevant equipment required; including any need for antibiotic prophylaxis. All catheter changes must be recorded on the Catheter Change Record. 10 Catheter materials PTFE catheter Teflon coated latex (NOT latex free) for use up to 28 days only. Some patients are discharged home from hospital with PTFE catheters insitu and will need a catheter change within 28 days of insertion which may be soon after discharge check all patients Catheter Management Record or discharge information and the catheter itself. Hydrogel coated latex catheter (NOT latex free) for use up to 12 weeks only. These catheters should be used first line unless patient has a latex allergy 100% Silicone (Latex free) for use up to 12 weeks ONLY for patients with latex allergy/sensitivity. Hydrogel coated silicone (Latex free) - for use up to 12 weeks for patients with latex allergy. Catheter size Recommended catheter size Male Female Supra pubic Children under 12 Ch Ch 12 Ch Ch 6, 8, 10 URETHRAL catheterisation - Males must be catheterised with a STANDARD length catheter. Females and Supra pubics may be catheterised with a female or with a standard length catheter. In general, the balloon should be inflated with 10mls of sterile water in adults and 3-5mls in children, according to manufacturers instructions. Some adult catheters need only 5mls - always check manufacturers instructions. 11 Catheter Care - Refer to SOPs (Appendices) Indwelling catheters must be connected to a sterile closed urinary drainage system or catheter valve. A catheter valve may be used as an alternative to a bag by patients with the necessary cognitive ability. HCP s and formal carers must decontaminate hands with alcohol gel or soap and water and wear a new pair of clean, non-sterile gloves before handling a patient s catheter and decontaminate hands after removing gloves. Page 9 of 51

10 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures Urine drainage bags must be positioned below the level of the bladder and must not be in contact with the floor. A link system should be used to facilitate overnight drainage. A single use, drainable night bag is the first line of choice. The urinary drainage bag must be emptied regularly; no more than 2/3rds full. The closed urinary drainage system must not be disconnected for emptying. The bag or valve must be changed when clinically indicated and in line with manufacturers recommendations (usually 5-7 days). A strap/adhesive fixation device must be used to secure the catheter. If the patient declines, this must be recorded in their notes. Belly bags are available and must be used for 28 days. 12 Education of patients/carers Patients and carers must be taught how to decontaminate their hands correctly, insert catheters where applicable and manage their own catheter and equipment. The Neighbourhood Nursing team must offer ongoing support and monitor standards of catheter care being performed by patients. Patients must be given a Catheter Passport Appendix 8 which includes written advice on caring for their catheter. All discussions must be recorded in the patient s record including compliance and non compliance of advice given. Page 10 of 51

11 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures 13 Monitoring Compliance and Effectiveness Minimum requirement to be monitored / audited Process for monitoring / audit Lead for the monitoring/audit process Incident reporting Via Datix Specialist Reviewer for urinary catheter related incidents Training e-learning Workforce to gain report Face to face Training Catheter Risk Register Infection Monitoring including MRSA Meatal damage Datix Specialist Reviewer Staff implementing the policy into practice Competency framework Documentation Audit including compliance with Catheter Passport Frequency of monitoring / auditing Lead for reviewing results Lead for developing / reviewing action plan CUCS Lead for monitoring action plan HSEGG Ongoing Specialist Reviewer CUCS CUCS Monthly CUCS CUCS CUCS/Workforce Workforce Workforce Quarterly CUCS/Workforce CUCS/Workforce CUCS/Workforce SystmOne CUCS Quarterly CUCS CUCS CUCS ICNET IPC/CUCS Daily IPC/CUCS IPC/CUCS HSEGG Ongoing Specialist CUCS HSEGG CUCS Reviewer CUCS Audit CUCS Annual CUCS CUCS Clinical Effectiveness Governance Group Audit CUCS Initially annually and then 3 yearly CUCS CUCS CUCS Audit CUCS Annual CUCS CUCS CUCS Page 11 of 51

12 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures 14 Approval and Ratification process The policy has been approved by the Clinical and Corporate Policies Group and ratified by the Quality Committee on behalf of the Board. 15 Dissemination and Implementation Dissemination of this policy will be via the Clinical and Corporate Policy Group to services and made available to staff via the intranet. Implementation will require: Operational Directors/ Heads of Service/General Managers to ensure staff have access to this policy and understand their responsibilities for adhering to it CUCS and Quality and Professional Development Department provide appropriate support and advice to staff on the implementation of this policy Launch, raised in training sessions, clinical forums, meetings and highlighted in CUCS and Adult Business Unit Newsletters which are shared with all clinical staff 16 Review arrangements This policy will be reviewed in one year, following ratification, by the author or sooner if there is a local or national requirement. 17 Associated documents Consent to Examination or Treatment and Patient Information Leaflet Policy LCH Aseptic Non Touch Technique (ANTT) Policy Mental Capacity Act Standard Operating Procedure The Deprivation of Liberty Safeguards Guideline for Antimicrobial Prophylaxis during Urinary Catheterisation in Adults Standard Precautions Policy (Includes Hand Hygiene, Personal Protective Equipment and Management of Spillages in the Community) Diagnostic and Screening Procedures including Safe Sampling, Handling and Transportation of Specimens Policy Management of patients with MRSA in Community Health and Social Care Settings 18 References Epic 3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. H.P. Lovedaya*, J.A. Wilsona, R.J. Pratta, M. Golsorkhia, A. Tinglea, A. Baka, J. Brownea, J. Prietob, M. Wilcox. National Institute for Health and Clinical Excellence (2012) CG139 Infection: prevention and control of healthcare-associated infections in primary and community, NICE Manchester Royal College of Nursing (2012) Catheter Care Guidance for Nurses, RCN, London. Page 12 of 51

13 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures Appendix 1 Catheter Change Record Catheter Change Record Patient Name: D.O.B: Date/time of catheter change Reason for change Weeks catheter in situ Encrustation/ mucus in lumen or outside of removed catheter? New catheter make, size, batch number, expiry date? Lubricant batch number/expiry date? Date of next planned change? Comments/ problems Signature Affix label here if available Affix label here if available Affix label here if available Affix label here if available Affix label here if available Affix label here if available Page 13 of 51

14 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures Appendix 2 Urinary Catheter Management Plan Page 14 of 51

15 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures Appendix 3: Catheterisation Competency Framework Competency Framework for Urinary Catheterisation Introduction This competency framework must be completed, as a minimum requirement, by all healthcare professionals who are involved with catheterising patients. All staff must be familiar with the Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and Standard Operating Procedures and carry with them the required procedures. The document records the required competencies for staff undertaking urinary catheterisation. The document is completed by the healthcare professional who is being assessed and signed off as competent by the supervisor. 1 Core Competencies 2 Removal and insertion of female indwelling urethral catheter 3 Removal and insertion of male indwelling urethral catheter 4 Removal and insertion of supra pubic catheter 5 Intermittent female catheterisation 6 Intermittent male catheterisation Performance Criteria You must demonstrate that: 1. Standard precautions for infection prevention and control are embedded into your clinical practice. 2. Patients consent is recorded and there is evidence of information provided. 3. Support and reassurance is given to the patient throughout the procedure 4. The Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and Standard Operating Procedures is used in your practice 5. Action is taken, where required, with any adverse effects. Page 15 of 51

16 COMPETENCY FRAMEWORK DOCUMENT FOR THE MANAGEMENT OF URINARY CATHETERISATION IN ADULTS 1: Core Competencies Application of knowledge to practice Observe procedure Observed by supervisor Date competence achieved Signature of supervisor Comments (1) Date (2) Date (1) Date (2) Date (1) Date (2) Date Reference to care plan and documentation prior to procedure. Deliver care and document appropriately post procedure Explain the procedure, address patient s concerns and obtain consent Standard precautions - Infection prevention and control and patient and staff safety Page 16 of 51

17 Selection of equipment Application of knowledge to practice Observe procedure Observed by supervisor Date competence achieved Signature of supervisor Comments (1) Date (2) Date (1) Date (2) Date (1) Date (2) Date Attach drainage system fixation devices Demonstrate knowledge of anatomy and physiology of female and male genito urinary system Process for CSU collection and swabs Fluid intake Urine output Skin integrity at insertion site and pressure areas Observe, assess and review for adverse effects taking appropriate action, i.e. meatal tear, safeguarding Page 17 of 51

18 Promotion of self care and health education Monitor stock control, equipment and take appropriate action Page 18 of 51

19 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures 2: Removal and insertion of female indwelling urethral catheter Application of knowledge to practice Observe procedure Observed by supervisor Date competence achieved Signature of supervisor Comments (1) Date (2) Date (1) Date (2) Date (1) Date (2) Date Removal of female catheter safely, implementing the Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and Standard Operating Procedures Insertion of the female indwelling urethral catheter safely, implementing the Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and Standard Operating Procedures Page 19 of 51

20 3: Removal and insertion of male indwelling urethral catheter Application of knowledge to practice Observe procedure Observed by supervisor Date competence achieved Signature of supervisor Comments (1) Date (2) Date (1) Date (2) Date (1) Date (2) Date Removal of male catheter safely including implementing the Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and Standard Operating Procedures Insertion of the male indwelling urethral catheter safely implementing the Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and Standard Operating Procedures Page 20 of 51

21 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures 4: Removal and insertion of suprapubic catheter Application of knowledge to practice Observe procedure Observed by supervisor Date competence achieved Signature of supervisor Comments (1) Date (2) Date (1) Date (2) Date (1) Date (2) Date Anatomy and physiology of supra pubic catheterisation Clean the suprapubic catheter site before and after removal of catheter Removal of catheter safely implementing the Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and Standard Operating Procedures Insertion of the suprapubic catheter implementing the Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and Standard Operating Procedures Page 21 of 51

22 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures 5: Intermittent female catheterisation competency Application of knowledge to practice Observe procedure Observed by supervisor Date competence achieved Signature of supervisor Comments (1) Date (2) Date (1) Date (2) Date (1) Date (2) Date Insertion of female intermittent urethral catheter safely implementing the Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and Standard Operating Procedures Removal of female intermittent urethral catheter safely implementing the Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and Standard Operating Procedures Page 22 of 51

23 6: Intermittent male catheterisation competency Application of knowledge to practice Observe procedure Observed by supervisor Date competence achieved Signature of supervisor Comments (1) Date (2) Date (1) Date (2) Date (1) Date (2) Date Insertion of male intermittent urethral catheter safely implementing the Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and Standard Operating Procedures Removal of male intermittent urethral catheter safely implementing the Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and Standard Operating Procedures Page 23 of 51

24 EVIDENCE OF COMPLETION and TRAINING RECORD FOR THE MANAGEMENT OF URINARY CATHETERISATION IN ADULTS Healthcare Professional Name: Work address: Name of Supervisor: Commencement date: Competency Date of completion Signature of Healthcare Professional Signature of Supervisor 1: Core competencies 2: Removal and insertion of female indwelling urethral catheter 3: Removal and insertion of male indwelling urethral catheter 4: Removal and insertion of suprapubic catheter 5: Intermittent female catheterisation 6: Intermittent male catheterisation Signature of Supervisor: Date: Page 24 of 51

25 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures Appendix 4: Standard Operating Procedure for Obtaining a Catheter Specimen of Urine (CSU) for CA-UTI If CA-UTI is suspected (Symptoms: Generally unwell plus one or more of the following symptoms: Pyrexia/Rigors pain (tenderness in flank, back, supra-pubic, bladder), nausea, vomiting, confusion, lethargy, haematuria), collect CSU from sample port on catheter. DO NOT USE URINE DIPSTICK TO DIAGNOSE CA-UTI Collect urine sample via needle-free sample port from an existing catheter using an aseptic non-touch technique (ANTT). 1. Gain consent. Use interpreter if necessary. 2. Collect necessary equipment. 3. Label a red top universal urine container and laboratory form. 4. Write laboratory form with: MC & S, suspected CA-UTI, and also indicate method of collection i.e. from sample port. 5. Decontaminate hands and open pack. 6. Put on sterile gloves and apron. 7. Place absorbent pad under sampling port. Clean the access port with a swab, saturated with 70% isopropyl alcohol and allow to dry. 8. Needle- Free Sampling Port: Insert the syringe firmly into the sampling port (following manufacturer s instructions). Withdraw the required amount of urine, and ideally collection container to be filled to line indicated, and disconnect the syringe. 9. Re-clean sampling port with 70% isopropyl alcohol swab and allow to dry 10. Remove gloves and apron and decontaminate hands. 11. Ensure the specimen container and request form are correctly labelled and are transported as per Trust transportation of specimens policy. 12. Complete relevant documentation. 13 Wherever possible patients with long term indwelling catheters should have the catheter changed with appropriate antibiotic cover when treating for CA-UTI. Standard Operating Procedure for Obtaining Catheter Specimen of Urine CSU for MRSA Screen 1. Collect urine sample via needle-free sample port from an existing catheter. 2. Follow procedures outlined in section 1 12 above. NB. A site swab / meatal or suprapubic is also required and should be sent with the CSU. Page 25 of 51

26 Appendix 5: Patient undergoing trial without catheter who requires antibiotic prophylaxis 1. Administer prescribed antibiotic:- Doxycycline 200mg, 2 hours before removal of catheter Gentamicin 1.5mg /kg body weight, 30 min before removal of catheter. 2. Remove catheter after appropriate interval 3. If patient requires re-catheterisation this to be undertaken within 24hrs for Doxycycline and 8 hours for gentamicin. No further antibiotics are required. 4. If recatheterisation is needed outside of these parameters then a further dose of doxycycline or gentamicin is required. Page 26 of 51

27 Appendix 6: Urinary Catheter Handbook for LCH Staff URINARY CATHETER HANDBOOK Page 27 of 51

28 INDEX Introduction Page 3 Aims and Objectives Page 3 Catheter Bypassing Page 4 Catheter Blockage Page 5 Unable to deflate balloon Page 6 Difficulty removing catheter Page 7 Haematuria Page 8 Unable to insert catheter Page 9 Expelling Page 10 Autonomic Dysreflexia Page 11 Page 28 of 51

29 INTRODUCTION Indwelling urinary catheters often cause significant problems for community nurses. The indwelling catheter is prone to complications which can lead to significant mortality. It is important to choose catheter equipment and accessories which are appropriate for the individual patient to reduce the likelihood of complications with the drainage system. Urinary catheters are also prone to problems with blockage and bypassing which cause disruption to the patient s life and account for a significant amount of community nursing time. AIMS AND OBJECTIVES The catheter handbook has been developed to: Assist staff caring for catheterised patients to make safe clinical decisions when dealing with catheter problems. To promote good practice in urinary catheterisation Give guidance in line with relevant international, national and local clinical policies and procedures, namely EAUN Good Practice in Healthcare: Urethral Catheterisation (2005), RCN Catheter Care guidance (2008), Leeds Community Healthcare Guidelines for Urinary Catheterisation Adults and Children (2012) Page 29 of 51

30 TROUBLESHOOTING - CATHETER BYPASSING Bypassing Sudden Onset? UTI? Constipation Symptoms: Generally unwell plus one or more of the following symptoms Catheter bypassing and debris evident See Blockage History, PR/Abdo Exam Bowel Clearance Management Pyrexia/Rigors pain (tenderness in flank, back, supra-pubic, bladder), nausea, vomiting, confusion, lethargy, haematuria No Yes Collect CSU as per Appendix 4 Commence antibiotics Monitor patient condition Change catheter If frequent bypassing refer to CUCS CSU result to be followed up by appropriate practitioner Treatment course to be modified by appropriate practitioner if CSU demonstrates resistant organisms If frequent UTI s, refer to CUCS Page 30 of 51

31 TROUBLESHOOTING BLOCKAGE (No mechanical obstruction evident) Page 31 of 51

32 TROUBLESHOOTING UNABLE TO DEFLATE BALLOON If still unable to deflate balloon ring the LCH CUCs or if unavailable the Surgical Assessment Unit at SJUH Page 32 of 51

33 TROUBLESHOOTING DIFFICULTY REMOVING CATHETER Difficulty Removing Catheter (encrustation or cruffing) Apply firm traction Rotate catheter Apply firm traction Re-position patient Using a syringe, insert 1ml or normal saline or sterile water back into the balloon If urethral catheter, leave patient for one hour to see if catheter falls out If supra-pubic catheter, re-inflate balloon to 10ml If catheter remains If still insitu unable contact to the LCH CUCS team, if unavailable remove, contact ring the Surgical Assessment Unit at SJUH CUCS Page 33 of 51

34 TROUBLESHOOTING - HAEMATURIA Haematuria Sudden Onset/ Ongoing Slight/Moderate Haematuria Frank Haematuria Reassure patient Admit to A&E Attempt to establish cause, e.g. trauma, UTI If UTI, follow UTI flowchart If trauma, check if poorly supported, over-full or malpositioned Increase fluid intake Contact or visit after 4 hours and then as necessary If persists speak to GP If persists, and GP refer may to need refer Urologist to urology Page 34 of 51

35 TROUBLESHOOTING UNABLE TO INSERT CATHETER If LCH CUCS are unavailable and patient has retention of urine ring the Surgical Assessment Unit at SJUH Page 35 of 51

36 TROUBLESHOOTING EXPELLING If problem persists refer to the LCH CUCS team Page 36 of 51

37 TROUBLESHOOTING AUTONOMIC DYSREFLEXIA A sudden rise in blood pressure triggered by acute pain or stimulus. Unique to spinal cord injured people at T6 T10. Autonomic nervous system attempts to lower blood pressure above T6 but not below this level which continues to rise. THIS IS A MEDICAL EMERGENCY SEE MANAGEMENT BELOW SYMPTOMS Pounding headache Flushed appearance Sweating Pallor below T6 Nasal congestion No urine output Tight chest Bradycardia CAUSES Catheter blockage Constipation/full rectum UTI/ bladder spasm Renal/ bladder stone DVT Pain or trauma Wound site, burn, in growing toenail Pregnancy Over stimulation during sexual activity MANAGEMENT Identify and remove cause If catheter blocked change no bladder washout If bowels encourage emptying proceed with caution Check blood pressure Administer prescribed vasodilator if required Page 37 of 51

38 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures Appendix 7: Standard Operating Procedure for Female Catheterisation 1. Decontaminate hands 2. Check care plan and/or prescription sheet. Collect and ensure correct equipment is available and in date 3. Gain consent - Use interpreter if necessary. 4. Instruct/assist (put on PPE) the patient to empty bag, adjust their clothing as appropriate and to lie on their back with legs extended or in foetal position. Bed clothes or towel etc. should be used at this stage to cover the patient s genital area. 5. Decontaminate hands and open catheter packs Cath-It and add additional items i.e. catheter, gel, drainage bag. Put on a disposable plastic apron 6. Put on non/sterile gloves and having released any straps securing catheter or leg bag use a syringe to deflate the balloon. Do not pull back on syringe, allow water pressure to push plunger out. 7. Ask patient to relax and gently remove catheter. 8. Dispose of used catheter, bag and gloves having examined catheter tip for signs of blockage/ crystals. 9. Decontaminate hands and put on sterile gloves 10. Place sterile towel across the patients thighs 11. Use low-linting swabs, separate the labia minora so that the urethral meatus is seen. One hand should be used to maintain labial separation until catheterisation is completed. 12. Clean around the urethral meatus with 0.9% sodium chloride soaked swabs, using single downward strokes. 13. Apply the lubricating/anaesthetic gel around and into the urethra. 14. If gloves have become contaminated put on new pair sterile gloves. 15. Place the receiver containing the catheter between the patient s legs or attach drainage bag or valve. 16. Introduce the tip of the catheter into the urethral meatus in an upward and backward direction. 17. Advance the catheter until urine begins to flow and then advance a further 3-5cm. 18. Having ensured the catheter is draining gently inflate the balloon according to the manufacturer s instructions. 19. Withdraw the catheter gently until resistance is felt and attach it to the drainage system. 20. Support the catheter using a strap/adhesive fixation device. Ensure that the catheter does not become taut, that it will not kink or become trapped when patient is mobilising. Ensure that the catheter lumen is not occluded by the fixation device. Support drainage system by attaching straps or sleeve The drainage system must not be in contact with the floor. 21 Ensure the perineum is dry and advise the patient to redress. 22. Dispose of equipment. 23. Remove gloves and apron and decontaminate hands 24. Record information in relevant documents. Use of a Change Record is required. Information should include date and time of catheterisation, reason, catheter type, amount of water instilled in balloon, manufacturer, batch number and expiry date of catheter, any problems, date next change due. Description of urine draining Ensure patient has a copy of Catheter Passport and document change for patient record. Page 38 of 51

39 Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures Appendix 8: Standard Operating Procedure for Male Catheterisation 1. Decontaminate hands Check care plan and/or prescription sheet. Collect and ensure correct equipment is available and in date. 2. Gain consent. Use interpreter if necessary. 3. Instruct/assist (put on PPE) the patient to empty bag, adjust their clothing as appropriate and to lie on their back with legs extended. Bed clothes or towel etc. should be used at this stage to cover the patient s genital area. 4. Decontaminate hands and open catheter packs Cath-It and add additional items ie catheter, gel, drainage bag. Put on a disposable plastic apron 5. Put on non/sterile gloves and having released any straps securing catheter or leg bag use a syringe to deflate the balloon. Do not pull back on syringe, allow water pressure to push plunger out. 6. Hold the penis upright. Ask patient to breathe in and out; as patient exhales gently remove catheter. Male patients should be warned of discomfort as the deflated balloon passes through the prostate gland. Instruct to cough to ease passage at this point. 7. Dispose of used catheter, bag and gloves having examined catheter tip for signs of blockage/ crystals. 8. Decontaminate hands and put on sterile gloves 9. Place sterile towel across the patients thighs 10. Wrap a sterile topical swab around the penis. Retract the foreskin if necessary and clean the glans penis with 0.9% sodium chloride soaked gauze, using single strokes. 11. Holding the penis upright insert the nozzle of the lubricating/ anaesthetic gel into the urethra. Squeeze the gel slowly into the urethra, remove the nozzle and discard the tube. Hold penis upright if possible while anaesthetic gel takes effect- approximately 6 minutes 12. If gloves have become contaminated put on new pair sterile gloves 13. Grasp the penis, wrapped in sterile swab, firmly and hold in an upright position degrees to body, gently extended away from body. Maintain hold of penis until procedure is completed. 14. Place the receiver containing the catheter between the patient s legs or connect catheter to drainage system or valve. Insert the catheter and advance the catheter along the urethra to the bifurcation of the catheter. If resistance is felt at the external sphincter, increase the traction on the penis slightly and apply steady, gentle pressure on the catheter. Ask the patient to strain gently as if passing urine. 15. Having ensured the catheter is draining gently inflate the balloon with sterile water according to the manufacturer s instructions. 16. Withdraw the catheter gently until resistance is felt and attach it to the drainage system. If slight haematuria occurs this will usually settle down over a few hours. Refer to handbook for advice. SEEK MEDICAL ADVICE if unexpected frank haematuria is observed 17. Support the catheter using a strap/adhesive fixation device. Ensure that the catheter does not become taut that it will not kink or become trapped when patient is mobilising. Ensure that the catheter lumen is not occluded by the fixation device. Support drainage bag with straps or sleeve. The drainage system should not be in contact with the floor 18. Ensure that the glans penis is clean and dry and then reposition the foreskin. Instruct/assist the patient to redress. Page 39 of 51

40 19. Dispose of equipment according to Trust policy. 20. Remove gloves and apron and decontaminate hands. Record information in relevant documents. Use of a Change Record is required. Information should include date and time of catheterisation, reason, catheter type, amount of water instilled in balloon, manufacturer, batch number and expiry date of catheter, any problems, date next change due. Description of urine draining Ensure patient has a copy of Catheter Passport and document change for patient record. Page 40 of 51

41 Appendix 9: Standard Operating Procedure for Supra - pubic Catheterisation 1. Decontaminate hands 2. Check care plan and/or prescription sheet, collect and ensure correct equipment is available and in date 3. Gain consent. Use interpreter if necessary. 4 Instruct/assist (put on PPE) the patient to empty bag, lie on their back and expose catheter site. Position a disposable waterproof sheet or towel under the patient s buttocks and thighs if possible. 5. Decontaminate hands and open catheter packs Cath-It and add additional items i.e. catheter, gel. Put on a disposable plastic apron 6. Put on non-sterile gloves. Remove dressing (if applicable) from catheter site 7. Release any straps securing catheter or bag to leg and use a syringe to deflate the balloon (having first confirmed the volume of water that was inserted into the balloon).do not pull back on syringe, allow water pressure to push plunger out. 8. Remove catheter ensuring some gauze is ready as there may be a gush of urine, by pulling firmly. 9. Dispose of used catheter, bag and gloves having examined catheter tip for signs of blockage/ crystals, completeness. 10. Decontaminate hands and put on sterile gloves. 11. Place a sterile towel across the patients abdomen. 12. Clean the insertion site with 0.9% sodium chloride soaked gauze and dry with gauze. 13. Place the receiver containing the catheter between the patient s legs or attach drainage bag or valve. 14. Apply a little lubricating/anaesthetic gel to outside of supra pubic site before insertion 15. As quickly as possible insert new catheter into the tract a little further than the one removed 16. Having ensured the catheter is draining gently inflate the balloon with sterile water according to the manufacturer s instructions. 17. Withdraw the catheter gently until resistance is felt and attach it to the drainage system if required. 18. Support the catheter using a strap/adhesive fixation device. Ensure that the catheter does not become taut and that it will not kink or become trapped when patient is mobilising. Ensure that the catheter lumen is not occluded by the fixation device. Support drainage system with straps or sleeve plus top strap. The drainage system must not be in contact with the floor. 19. Ensure the area is dry and advise the patient to redress. 20. Dispose of equipment according to Trust policy. 21. Remove gloves and apron and decontaminate hands 22. Record information in relevant documents. Use of a Catheter Change Record is required. Information should include date and time of catheterisation, reason, catheter type, amount of water instilled in balloon, manufacturer, batch number and expiry date, any problems, date next change due. Description of urine draining Ensure patient has a copy of Catheter Passport and document change for patient record. Page 41 of 51

42 Appendix 10: Standard Operating Procedure for Intermittent Catheterisation Using Single Use Catheters: Female Patients 1. Decontaminate hands 2. Gain consent. Use interpreter if necessary. 3. Check care plan. Collect necessary equipment ensuring in date 4. Ask the patient to pass urine normally if possible 5. Ask the patient to decontaminate their genital area 6. Instruct/assist the patient to get into a supine position with knees bent, hips flexed and feet resting 60cm apart. Bed clothes or a towel etc should be used at this stage to cover the patient s genital area. 7. Decontaminate hands and put on a disposable plastic apron. 8. Prepare the catheter equipment as per manufacturers instructions. If unsuitable to be placed onto a sterile field, position so that can be used following no touch technique. Open packs, placing on suitable surface within easy reach 9. Remove cover exposing the patient s genital area. 10. Decontaminate hands and put on sterile gloves 11. Using low-linting swabs, separate the labia minora so that the urethral meatus is visible. One hand should be used to maintain labial separation until catheterisation is completed 12. Clean around the urethral orifice with 0.9% sodium chloride soaked gauze using single downward strokes. 13. Introduce the tip of the catheter into the urethra in an upward and backward direction 14. Advance the catheter until urine starts to flow (usually 6-8cm in total) and then a further 2-3 cm 15. When urine stops flowing gently remove the catheter, twisting it slightly to free any trapped mucosa & pausing if stream resumes to ensure bladder is completely emptied. 16. If slight haematuria is observed this will usually resolve within a few hours. Refer to catheter handbook for advice SEEK MEDICAL ADVICE if unexpected frank haematuria is observed 17. Dispose of urine down the toilet 18. Dispose of equipment according to Trust policy. 19. Instruct/assist patient to redress 20. Remove gloves and apron and decontaminate hands. 21. Record in patient notes date, time, catheter type, batch no., ch, expiry date, volume drained, nature of urine drained and any problems. Page 42 of 51

43 Appendix 11: Standard Operating Procedure for Intermittent Catheterisation Using Single Use Catheters: Male Patients 1. Decontaminate hands. 2. Gain consent. Use interpreter if necessary. 3. Check care plan. Collect necessary equipment ensuring in date 4. Ask the patient to pass urine normally if possible. 5. Ask the patient to decontaminate his genital area. 6. Instruct/assist (put on PPE) the patient to adjust their clothing as appropriate and to lie on their back with legs extended. Bed clothes or towel etc. should be used at this stage to cover the patient s genital area. 7. Decontaminate hands and put on a disposable plastic apron 8. Prepare the catheter equipment as per manufacturers instructions. If unsuitable to be placed onto a sterile field, position so that can be used following no touch technique. Open packs placing on suitable surface within easy reach 9. Remove cover exposing the patient s genital area. 10. Decontaminate hands and put on sterile gloves 11. Wrap a sterile swab around penis. Retract the foreskin if necessary and clean glans with 0.9% sodium chloride soaked swabs 12. Grasp the penis, wrapped in sterile swab and hold in an upright position degree to body, gently extended away from body. Maintain hold of penis until procedure is completed. Holding the penis upright insert the catheter until urine flows, then a further 2-3cm. 13. If resistance is felt at the external sphincter increase traction of the penis and apply steady but gentle pressure on the catheter. Ask the patient to strain as if passing urine. 14. When urine stops flowing, gently remove the catheter, twisting it slightly to free any trapped mucosa & pausing if stream resumes to ensure bladder is completely emptied 15. Reposition foreskin if necessary. Dry. 16. If slight haematuria is observed this will usually resolve within a few hours. Refer to catheter handbook for advice SEEK MEDICAL ADVICE if unexpected frank haematuria is observed 17. Dispose of urine into the toilet. 18. Dispose of equipment according to Trust policy 19. Instruct/assist patient to redress. 20. Remove gloves and apron and decontaminate hands. 21. Record in patient notes date, time, catheter type, ch, batch no. expiry date, volume drained, nature of urine drained and any problems. Page 43 of 51