CLINICAL GUIDELINES Urinary Catheterisation Guidelines

Reference Date approved Approving Body CLINICAL GUIDELINES Urinary Catheterisation Guidelines Matron s Forum Supporting Policy/ Working in Male Urethral Catheterisation New Ways (WINW) Package Implementation date Supersedes Version 2 Consultation undertaken Nursing Practice Guidelines Group, Ward Sisters/Charge Nurses, Practice Development Matrons (PDMs), Clinical Leads, Matrons. Target audience Nursing staff at NUH Document derivation / evidence base: Date of Equality Impact Assessment Review Date June 2014 Lead Executive Director of Nursing Author/Lead Manager Further Guidance/Information Distribution: Amy Cartwright Ward Sisters/Charge Nurses, PDMs, Clinical Leads, Matrons, Nursing Practice Guidelines Group (includes University of Nottingham representative), Clinical Quality, Risk and Safety Manager, Trust Intranet. This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using the guidelines after the review date. 1

Nursing Practice Guidelines for Urinary Catheterisation Introduction Urinary catheterisation is an intervention to enable emptying of the bladder by insertion of a catheter. When considering catheterisation for intractable incontinence, this intervention should only be considered after all other non invasive management options have been explored and found unsatisfactory. General principles of catheterisation and infection prevention and control apply to all patient groups; however, some patient groups will have particular need, e.g. children and patients with spinal injuries. Staff working with these groups of patients must familiarise themselves with their unique needs. (NHS Quality Improvement Scotland 2004). There is no policy or legal position regarding female practitioners catheterising male patients or male practitioners catheterising female patients. As with all procedures the practitioner should work within a competency framework and the wishes of the patient are paramount and should be sought and informed consent should be given prior to commencing the procedure. Patients should be offered a chaperone or be invited to request the presence of a chaperone, a full explanation of the examination, procedure or treatment to be carried out should be given to the patient, followed by a check to ensure the patient has understood the information (RCN 2006). Using any form of catheter has a number of associated risks. These risks are becoming more serious with the continued development of a wide range of multi resistant bacteria which cause catheter associated urinary tract infections and associated life threatening complications. 2

Best Practice When catheterisation is being discussed as a treatment option, intermittent catheterisation is always considered as the first option rather than indwelling catheterisation, providing this is safe and acceptable alternative for the individual and carer/s. NHS Quality Improvement Scotland June 2004 Indwelling Urethral Catheters Indications for use include Short term:- Treatment for acute or chronic retention of urine Instillation of drugs To monitor urine output in critically ill and unconscious patients Before and after certain operations To perform certain investigations, of a urological nature To maintain patency of the urethra Bladder irrigation for haematuria Long term:- Bladder outlet obstruction which is unsuitable for surgery Chronic retention as a result of neurological disease where intermittent clean catheterisation is not possible Conditions resulting in debilitation, paralysis or coma Spinal cord compression To relieve incontinence if all else fails and a full assessment has been undertaken 3

Common Hazards Associated with Indwelling Urethral Catheters. These include-: Chronic infection Trauma to the urethra, bladder mucosa and accidental trauma Leakage Encrustation (Getliffe 1992 & 2007) Biofilm formation (a biofilm is a collection of micro-organisms and their extra-cellular products bound to a solid surface Trautner & Darouche 2004) Pressure necrosis and urethral tissue erosion (long term) Contraindications for use include:- Immunosuppression Cytopoenia Poor cognitive awareness/confusion Intermittent Catheters Indications for use include:- Treatment of retention of residual urine Post operative retention To maintain patency of the urethra Benefits from Intermittent Catheters These include -: Reduced risk of chronic infection provided adequate training is given and suitable technique is used No encrustation Greater freedom for expression of sexuality (Getliffe 2007) Less reliance on body worn appliances Reduced bladder damage Potential for improved continence (Getliffe 2007) Common Hazards from using Intermitted Catheters Infection and trauma (at a reduced rate compared to indwelling urinary catheters) (Wyndaele 2002) Urethral bleeding May not be an option for patients with problems with dexterity (Getliffe 2007) 4

Best Practice Intermittent self-catheterisation is the preferred alternative to indwelling catheters for individuals in whom bladder emptying is incomplete, providing they have the dexterity, ability and desire to manage the procedure. NHS Quality Improvement Scotland June 2004 Suprapubic Catheters Indications for Suprapubic catheters These include:- Where urethral catheterisation is not possible Where it is the patient s preferred choice Post operatively for bladder drainage or to monitor residual urine volumes Improved patient comfort for wheelchair-dependent patients and easier management of catheter changes Where limb contractures make urethral catheter insertion and management difficult Intractable bypassing of urethral catheter following long-term use (NHS Quality Improvement Scotland June 2004) Benefits of Suprapubic catheters These include:- No risk of urethral trauma necrosis or catheter induced urethritis The integrity of the urethra is retained (Fillingham 2005) Easer access to entry site for cleaning and catheter care (Getliffe 2007) Please note: Suprapubic catheters should be considered for all patients requiring long-term (i.e. permanent) catheterisation. It reduces changes of catheter hypospadias, dilation of bladder neck and catheter expulsion. Suprapubic catheters are much easier to change and better tolerated in long term use 5

Common Hazards Associated with Suprapubic Catheters Infection (this is less than indwelling catheters short term only) Bladder calculi Trauma Leakage Altered body image Drainage may be compromised (Getliffe 2007) Patients with a Latex Allergy As far as practicable the use of latex free devices is required in situations where staff or patients have a known latex allergy, and contact with the device is unavoidable (NUH 2009). 6

Male Catheterisation Nottingham University Hospitals expect any practitioner wishing to undertake male catheterisation to complete the appropriate Working in New Ways directed learning package (or equivalent) and have appropriate clinical skill training. It is advised that prior to any catheterisation the practitioner should have thoroughly read the medical notes noting the patients history and any previous problems when relating to urinary catheterisation. If unsure then the practitioner should not continue and should seek further advice from a urology specialist. The potential conditions which may make male catheterisation difficult include:- Abnormalities of the urethral meatus such as hypospadias or stricture Phimosis Abnormalities of the urethra, such as strictures, stenosis or false passages. Bladder neck stenosis An enlarged prostate gland Damage to delicate prostatic capsule tissue, especially within the first 48 hours of trans-urethral surgery Bariatric patients Female Catheterisation The potential conditions which may make female catheterisation difficult include:- Dryness of urethral post menopause Shrinkage of perineum causing meatal shift Bariatric patients Physical abnormality 7

Catheter Storage To minimise the risks of damage to catheters and their packaging, they should be stored in manufacturer s box away from sources of heat and off the floor. If this is not possible, they should be stored away from direct sunlight and should not be crushed in storage or tied together with elastic bands. Always follow the manufacturer s guidelines. Catheter Materials An effective catheter is designed to stay in the bladder, be removed easily, have a soft tip to prevent bladder trauma, provide effective drainage and conform to the shape of the urethra (Cottenden et al 2005). The hospital formulary (2009) should be consulted with regards to which catheters can be used. In specialist areas other products may be used to suit the patient s specific needs. If unsure always seek further advice from Urology specialists. 8

Catheter Selection When considering catheter selection the following points should be considered -: CONSIDERATIONS Long (Male) or short (female) length of catheter Size of catheter. RATIONALE Female catheters (approx 25cm in length) should be used for female patients to prevent pooling of urine in the excess tubing, trauma due to traction on the urethra and to enable women to wear a wider choice of clothes. Male length catheters (41-45cm) may be more practical for obese ladies to allow easier access to the drainage bag. Female catheters must never be used for males as the length is such that the balloon would inflate in the urethra Paediatric catheters are approx 30 cm in length Catheter width is measured in charrieres and is the external diameter of the catheter The catheter size for women should be chosen accordingly to the patients needs. As a guide female 12ch- 14ch and male 14ch 16ch. A larger size may be needed for a particular procedure, but please ask for advice first. 9

A larger size is needed if the urine contains large amounts of debris (Getliffe 2007). Size of the catheter balloon The balloon size should always be filled to the manufacturer s guidelines, which is usually 10 or 30 mls depending on the catheter. The balloon should always be inflated with sterile water according to the manufacturers instructions If it is partially inflated, it causes uneven pressure which may cause irritation and trauma to the bladder wall and inefficient drainage which causes residual urine to be left in the bladder (Getliffe 2007). 10

Drainage Systems Patient preference should influence the type of drainage system to be used and the following should be taken into consideration. A closed system must be maintained and gravity drainage should always be encouraged to prevent stagnant urine collecting. It is important to consider what is available to the patient on discharge, so as not to create confusion on using different products. CONSIDERATIONS Patient dignity Leg bags or free standing drainage system (overnight bag) Link system connector bags Urometer bags Large drainage bags (overnight bags) Length of tube on leg bag RATIONALE The drainage system needs to be discussed with the patient and chosen according to the patient s activities and type of clothing normally worn. Leg bags should always be used unless a larger or more easily accessible bag is required. Leg bags should have the facility to be connected to a compatible night bag to ensure adequate drainage facility overnight. If hourly measurements of urinary output is required the Urometer bag should be used prevent frequent emptying of the catheter bag. The overnight bag is for single use only and should always have an outlet tap. Emptying a bag with no tap is considered a cross infection risk. Leg bag tubing comes in a 11

Bag capacity Sampling port variety of lengths; short tube (fits the thigh) and long tube (fits the calf). The type chosen will depend on the patient s needs and preferences Leg bag capacity of 500mls. Overnight bag capacity 2 litres All drainage bags need to have the facility for obtaining a sterile sample of urine incorporated. (Getliffe 2007). Some sampling ports do not need a needle to use them so reducing the potential of needle stick injury Catheter fixators Continued tension on catheters due to, for example, heavy unsupported drainage bags, can cause pressure necrosis (LeBlanc & Christensen 2005) Effective support using a catheter fixation around the thigh is essential (Getliffe 2007) e.g. G-Strap Incorrect use can cause damage to the bladder and prostate. 12

Leg straps, A minimum of 2 leg straps should be used to fix the bag securely to prevent problems Ensure that when fixing a man s catheter there is enough slack to allow for an erection If a catheter bag is in situ for a long period of time, it should be repositioned on alternate legs regularly. Outlet taps Catheter valves may be used as an alternative to drainage bags but only following assessment of bladder function by the appropriate medical or specialist personnel. These prevent catheters pulling or kinking, prevent trauma, pooling of urine and movement of exposed catheter material back up into the bladder. To prevent skin irritation and development of pressure ulcers. The patient should be able to manage these and their dexterity needs to be assessed in conjunction with the type of system used (Getliffe 2007) Catheter valves are unsuitable for patients with poor bladder capacity, an over active bladder, ureteric reflux or renal impairment (Getliffe 2007) These benefit many patients for comfort, reduced leakage and more discrete 13

Recording Details INFORMATION Obtain and record patient consent The reason for catheterisation Date of catheterisation The batch number lot and expiry date of the catheter Size of catheter How much water has been inserted to inflate the balloon? Type of catheter used Type of leg bag used When the drainage bag needs to be changed Type of catheter fixator, bag fixing Who catheterised client Ease/difficulty of procedure Record residual volume on insertion RATIONALE To maintain records. To ensure the need for catheterisation has been assessed appropriately. To enable an appropriate evaluation date to be set. To allow identification and detection of possible faulty catheter batches. To maintain records To ensure the balloon is not over inflated. To assist identification of date for changing the catheter. To allow identification and detection of faulty products. To minimise the risk of infection To maintain records To show accountability To assist assessment when recatheterising To assist assessment of bladder problems At NUH there is a Trust wide Catheter Insertion and Monitoring tool, where all of this information needs to be recorded for every patient with an indwelling urinary catheter. It also includes an assessment for the need of the catheter which is to be completed daily. 14

Managing the patient with an Indwelling Urinary Catheter Considerations Rationale Hygiene Normal daily bath or shower should be sufficient to remove dried secretions from around the meatal opening. (Fillingham & Douglas 2005) If meatal cleansing is necessary using soap and water, with a disposable cloth designated for this purpose (Pratt et al 2000) Fluid Intake Antiseptic solutions do not reduce bacterial infection Washing once a day is sufficient to prevent encrustation around the meatus. (Wilde 2002) Too frequent washing may upset patient normal meatal flora which acts as a defence mechanism (Pratt et al 2007) Aim for a fluid intake of 1500-2000mls over 24 hours, (Fillingham & Douglas 2005) providing there are no medical/surgical contraindications as this helps to prevent infection Diuresis may assist in voiding micro-organisms from the residual urine in the bladder, (Getliffe 2007) Dilute urine will reduce the concentration of encrustation components (Getliffe 2007) Managing Problems Considerations Catheter Associated Urinary Tract Infection It is important to ensure good personal hygiene including cleansing the area around the meatus daily Rationale Infection can be introduced: Via the peri-urethral space Via the catheter tip during catheterisation Via the catheter lumen 15

Aseptic non-touch technique in catheter insertion Effective hand decontamination and use of PPE during all catheter care The Catheter s sample port must be used to take a catheter sample of urine. Ensure the tap of the catheter bag is away from the floor Catheter bags should be emptied when 2/3rds full Catheter bags should be changed every seven days or longer if directed by the manufacturers (Getliffe 2007) Antibiotic treatment for asymptomatic bacteriuria is not recommended unless the patient is at risk Regular reassessment of the catheters need (Epic 2, 2007) Leakage of urine Urine bypassing the catheter with poor draining due to blockage of the catheter To prevent overuse of antibiotics in the treatment of bacteriurea To ensure the catheter is removed in a timely manner If the catheter is blocked there is always the potential risk of hydronephrosis, this should be resolved as soon as possible (Fillingham and Douglas 2004) Mechanical Problems Check for kinks and pressure on the tubing Relieve constipation and introduce measures to Poor positioning can impede urine flow Constipation can interfere with catheter drainage 16

prevent it Clots and debris Bladder washouts using a bladder syringe and 0.9% sterile saline can be used if the catheter is partially or totally blocked Saline instillation To remove partial blockage due to debris, clots or bladder mucosa where there is no evidence of encrustation To decrease debris and clots to keep the catheter lumen patent Instillations are recommended with caution for the treatment of encrustation Plan Catheter changes prior to expected lifespan of the catheter ( see NUH continence Formulary Guidelines 2009) Check urine PH. Encrustation associated with PH above 6.8 Urine by passing the catheter while still draining urine into the catheter bag is due to bladder spasm Recatheterise with different size catheter. Increase fluid intake To reduce irritation To prevent concentrated urine irritating the bladder Treat with anticholingerics e.g. oxybutinin To reduce bladder spasm Expulsion of catheters 17

Ensure the balloon is filled with the correct amount of water Ensure the catheter bag is adequately supported with straps etc Balloon deflation may allow the catheter to be expelled Inadequate support system, a too full drainage bag may cause catheter expulsion Detrusor spasm (the balloon will be intact. Treat with anticholingerics e.g. oxybutinin Self removal Trauma Careful insertion of the catheter Position the bag carefully and ensure it is attached with a catheter fixator and leg straps if appropriate If heavy haematuria persists medical/urological advice should be sought. To reduce bladder spasm Simple or topical analgesia to ease irritation or pain To prevent tissue damage To prevent catheter pressing against the bladder wall causing pressure necrosis and/or irritating the urethral wall causing erosions In case of a medical emergency Phimosis can make catheterisation difficult. If difficulty is encountered, seek medical advice. Phimosis (a tight foreskin that cannot be retracted) If paraphimosis occurs, seek medical advice immediately Paraphimosis (an oedematous fore skin that is fixed in the retracted position). (Fillingham and 18

Douglas 2004). Pain Use mild analgesia and/or locally applied anaesthetic gel Pain during or immediately after catheterisation may indicate that the catheter is incorrectly positioned Any pain should be temporary and should settle within 48 hours of catheterisation 19

Equipment needed for Catheterisation with an indwelling Catheter 1 suitable procedure pack 1 disposable kidney dish 1 pack of sterile gauze A Sterile field 2 pairs of sterile gloves Disposable plastic apron 1 under pad Sodium Chloride 0.9% for cleansing Syringe and sterile water to inflate the balloon (if there is not a water filled syringe in the catheter packaging) Sterile drainage bag or catheter valve Straps or stand to hold urine bag Catheter fixator Alcohol hand rub Disposal bag For female patients For male patients 6ml of local anaesthetic gel 11ml of local anaesthetic gel 2 short catheters of appropriate size 2 long catheters of appropriate size And materials and materials Instillagel Currently Instillagel is contraindicated in pregnancy during delivery, please see current BNF guidelines for up to date information. In this case a sterile, single use lubricant should be used instead. 20

FEMALE CATHETERISATION PRINCIPLE RATIONALE 1. Gain consent. Position patient in one of the following ways, - Supine with knees bent hips flexed and feet a comfortable distance apart. This being the optimal position To allow ease of access to the female urethra - Lateral, foetal position with pillows between the knees if possible. This may be difficult if inexperienced 2. Protect the bed using the under pad To avoid pooling of urine on the bed and subsequent discomfort to patient 3. If no clinical disposal bag in the dressing pack, attach a bag to trolley at this point. To maintain patient dignity Ensure there is provision for clinical waste. 4. Decontaminate hands and put on apron and sterile gloves 5. Empty sterile pack on to the trolley and open out the sterile field NUH Hand Hygiene Policy (2009) Saving Lives (DH 2007) To create a sterile field to work on 21

6. Aseptically place extra equipment on to the sterile field (e.g. kidney dish, extra gauze, sterile dressing towel) the pack is a standardised wound care pack. A catheter anaesthetic gel and saline for cleansing should also be added So all equipment is ready to use, maintaining a sterile field. 7. Prepare the sterile field and equipment To minimise introduction of infection on catheter insertion 8 Position the sterile field over the under pad To provide a sterile working area 9. Cleanse the vulval area from the pubic bone towards the perineum using gauze soaked in saline To minimise the introduction of infection of the catheter, with rectal flora Best Practice Catheterisation is an aseptic procedure. Clean the urethral meatus with sterile normal saline prior to insertion of the catheter. Epic 2: National Evidence-Based Guidelines for reventing Healtcare-Associated Infections in NHS Hospitals in England 2007 22

PRINCIPLE 10 Remove disposable gloves wash hands, or use alcohol hand rub RATIONALE To minimise the risk of infection 11 Apply new sterile gloves To minimise the risk of infection 12 Insert anaesthetic gel (6mls) into urethra; wait for 5 minutes (Clinimed 2011). Alternatively a sterile lubricant can be used. To lubricate and dilate the urethra, reduce trauma from the procedure and maintain patient comfort 13 Ensure that there is no contamination of the glove by the skin. If this occurs then gloves should be changed as above. To prevent contamination of the catheter Best Practice Severe pain immediately after catheterisation indicates that the catheter is not situated in the bladder and the balloon may be inflated in the urethra. The catheter should be inserted up to the bifurcation in men and a further 5cm in women prior to balloon inflation. (Fillingham and Douglas 2004). 23

Insertion of the Catheter Principle 1 Place the catheter in the sterile receiver and position the receiver on the sterile field. Rationale To minimise the risk of contaminating the catheter 2 Separating the labia with one hand, identify the urethral orifice and insert the catheter until urine drains, continue to insert the catheter for a further 5cms. i) If no urine drains, leave catheter for 2 minutes To ensure the balloon is not inflated in the bladder closing mechanism In case the catheter eyelets are blocked with gel ii) iii) If still no urine drains leave catheter in situ and insert a new one. If still unsure of catheter position or if urethral bleeding occurs, stop the procedure and seek professional advice. Prevents the misplacement of a second catheter To prevent trauma or further trauma to procedure 3. Once the catheter is correctly positioned and urine is draining inflate the catheter balloon using the stated amount of sterile water. 4. Withdraw the catheter gently until resistance is felt and attach to the drainage device or catheter valve 5. Anchor the catheter to the thigh with a catheter fixator.(getliffe 2007) To ensure the catheter remains in the correct position, and ensure the catheter tip is upright and not rubbing the bladder wall To ensure the correct positioning of the catheter and to maintain a closed urinary system. To minimise trauma and the piston effect 24

6. Discard equipment and wash hands thoroughly To minimise risk of cross infection 7. Measure and record the amount of residual urine drained To enable accurate fluid balance and estimate bladder capacity 8. Record all details of the catheterisation in the patients records 25

3. PROCEDURE FOR MALE CATHETERISATION PRINCIPLE RATIONALE 1. Gain consent. Position patient in supine position with legs extended Ease of access to penis and urethra 2. If possible use dedicated treatment room. Protect bed by using an under pad To maintain patient dignity 3. Put on apron wash hands and put on sterile gloves 4. If no clinical disposal bag in the dressing pack, attach a bag to trolley at this point. 5. Empty sterile pack on to the trolley and open out the sterile 6. field Aseptically place extra equipment on to the sterile field (e.g. Kidney dish, extra gauze, sterile dressing towel) the pack is a standardised wound care pack. A catheter anaesthetic gel and saline for cleansing should also be added 7. Prepare sterile field and equipment. Place catheter in sterile receiver and put on sterile field. 8. Position sterile field over under pad and across thighs and supra pubic area NUH Hand Hygiene Policy (2009) Saving Lives (DH 2007) Ensure there is provision for clinical waste. To minimise introduction of infection on catheter insertion To minimise introduction of infection on catheter insertion 26

9. Use sterile gauze to hold the penis 10 Cleanse the glans penis with saline soaked gauze, in noncircumcised patients the prepuce (foreskin) will need to be retracted slightly 11 Introduce local anaesthetic gel slowly into the urethra holding the penis firmly at an angle of 60 90 to the body and gently extend away from the abdomen Ensure that this hand remains clean to take equipment from sterile field To remove smegma To lubricate, dilate the urethra, reduce discomfort and trauma during procedure Best Practice Use an appropriate lubricant from a sterile single use container to minimise urethral trauma and infection. Epic 2: National Evidence-Based Guidelines for preventing Healtcare-Associated Infections in NHS Hospitals in England 2007 27

Insertion of Catheter PRINCIPLE RATIONALE 1. Remove sterile gloves, wash hands or use alcohol rub. Apply new sterile gloves 2 Position new sterile field over under pad if the original has become wet 3. Hold Shaft of the penis (with new sterile gauze) firmly at an angle of 60 90 to the body and gently extend away from the abdomen 4. Introduce catheter into the urethra until urine drains from the catheter (15-25cms) advance the catheter to the bifurcation of the catheter. To minimise risk of infection To minimise the risk of infection through a wet paper towel To straighten the penile urethra and facilitate introduction of the catheter To ensure that the catheter balloon is in the bladder and not in the urethra or bladder closing mechanism 5. Once catheter is correctly positioned and urine is flowing inflate the catheter balloon using sterile water. 6. Withdraw the catheter gently until resistance is felt, and attach it to a drainage device or catheter valve 7. Ensure the glans penis is clean and reposition the fore skin over the glans penis. To ensure the catheter remains in the correct position To maintain a closed drainage system and ensure catheter is in the correct position To minimise risk of paraphimosis 28

Best Practice Use of Catheter Fixator Continued tension on catheters, due to heavy unsupported drainage bags, can cause pressure necrosis (LeBlanc & Christensen 2005). Effective support is enhanced by securing the tubing to the thigh using a catheter fixator (Getliffe 2007). 8. Allow sufficient tubing for normal body movements and erection and anchor to the thigh with a catheter fixator. 9. Measure and record amount of residual volume drained To prevent trauma To ensure accurate fluid balance and estimate bladder capacity 10. Position bag securely on thigh or calf (see guidelines) 11. Discard equipment and wash hands thoroughly To prevent trauma To minimise risk of cross infection 12. Record all details of the catheterisation in the patients notes (see guidelines) 29

Connection of an overnight bag to a leg bag EQUIPMENT LIST Sterile 2 litre urine bag with tap 1pair of sterile disposable gloves and apron bed hanger PRINCIPLE RATIONALE 1. Decontaminate hands and put on gloves and apron To minimise cross infection 2. Ensure the outlet tap of the 2 litre bag is closed and remove the protective cap from the top of the drainage tube To ensure product is sterile before use 3. Connect the outlet part of the leg bag directly to the drainage tube of the 2 litre bag, taking care not to touch the ends To reduce the risk of cross infection 4. Place drainage bag on hanger and open the outlet tap of the leg bag 5. Ensure the outlet tap of the overnight bag does not touch the floor 6. The night bag, should be emptied and disposed daily 7. Decontaminate hands thoroughly To ensure free drainage To minimise risk of introduction of ascending infection To prevent introduction of infection To minimise risk of cross infection 30

Best Practice Maintaining a sterile, continuously closed urinary drainage system is central to the prevention of catheter associated urinary tract infections (CAUTI). The risk of infection reduces from 97% with an open system to 8-15% when a sterile closed system is employed. Epic 2 National Evidenced Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2007 Changing a catheter drainage bag / catheter valve EQUIPMENT LIST Sterile catheter bag or Sterile Catheter valve Clean bag holder 1 pair of disposable gloves Sterile dressing towel on a clean tray Paper towel PRINCIPLE RATIONALE 1. Help client into a position where the catheter bag junction is easily accessible, ensuring the patients dignity. 2. A catheter valve is to be changed after 7 days. To prevent infection. 3. Open the outer covering of the drainage bag, and close the outlet tap. 4. Decontaminate hands and position dressing towel on the surface beneath the junction of the catheter and drainage bag To maintain a sterile field 31

5. Decontaminate hands and put on disposable gloves. To prevent cross infection 6. Clean around the catheter, drainage bag (catheter valve) junction with alcohol wipe and allow to dry Place kidney dish underneath join 7. in catheter. To reduce infection To catch any spillage of urine during bag changing. 8. Remove the drainage bag tubing from the catheter, and discard onto paper towel 9. Remove the protective cap from the new drainage bag (catheter valve) and insert the ends as quickly as possible, ensuring the ends of the bag (catheter valve) and catheter are not touched. 10. If a urinary drainage bag is used quickly attach the tube to the patients thigh, the leg or side of the bed, as in catheterisation procedure 11 Attach label to the bag, specifying date of next change, in 7 days. To prevent contamination of bag and catheter. To facilitate gravity drainage In line with High Impact Interventions. 12. Empty old bag using outlet tap measure and record if required 13. Discard bag and equipment To minimise risk of cross infection from equipment 14 Decontaminate hands thoroughly To minimise risk of cross infection 32

16. Record the date the bag is due to be changed in the nursing notes. Indicating that the bag should only be changed every seven days. To reduce unnecessary breaking of the closed drainage system and preventing cross infection. Taking a Catheter sample of urine EQUIPMENT LIST Sterile syringe with Green needle 1 pair of non sterile disposable gloves Clean receiver Specimen pot 1 alcohol wipe Sterile dressing pad Sharps Box Best Practice A catheter specimen of urine should be collected using a needle and syringe from the aspiration port of the drainage bag situated along the inlet tubing. The specimen should be should be clearly labelled and sent immediately to the microbiology laboratory for analysis. If this is not possible, a specimen may be kept in a designated refrigerator designated for specimens overnight. Fillingham and Douglas 2005 Help the client into a position where the catheter bag junction is easily accessible ensuring the patients dignity To ensure that sufficient urine is in the catheter tubing, in order to collect an adequate specimen Collect equipment and label specimen pot Decontaminate hands and position dressing towel on the surface beneath the sampling port To ensure that patient details are recorded accurately prior to specimen collection To maintain a sterile field 33

Decontaminate hands and put on disposable gloves. Clean the sampling port with an alcohol wipe Insert syringe into the port and withdraw 5 10mls of urine To prevent cross infection To reduce infection To take sufficient urine for Microscopy and Sensitivity NB some sample points have self sealing port suitable for the end of a syringe making needles unnecessary Ensuring the sample port is on a steady surface insert syringe tip into the port, then expel the urine into the specimen pot and secure the lid Dispose of the syringe and needle into the sharp s box To prevent urine splashes To prevent needle stick injury Discard equipment and wash hands thoroughly To minimise risk of cross infection Complete the specimen form and send to lab. Document in the notes. 34

Removal of a Catheter EQUIPMENT LIST Sterile syringe (to accommodate the water from the catheter balloon) 1 pair of non sterile disposable gloves Clean receiver 2ml of sterile water PRINCIPLE RATIONALE 1. Check how much water was used to inflate catheter balloon, Ensure the correct amount of water is removed 2. Decontaminate hands and apply non sterile gloves. 3. Attach syringe to valve allowing pressure of water to push the plunger out. NB In silicone catheters up to 2mls of water may have been lost from the balloon due to osmosis. To prevent cross infection. If water is sucked out forcibly the balloon channel may be damaged and may cause discomfort to the patient (Fillingham and Douglas 2005). 35

4. If water does not drain Leave in place Try another syringe Insert 1-2mls of sterile water and draw back Gentle milking along the catheter ( Getliffe 1997 ) 5. If water does not drain seek medical advice Allow slow seeping In case of a faulty syringe This will demonstrate the patency of the inflation channel and indicate if water has been lost from the balloon. (Fillingham and Douglas, 2005) May move blockage and allow water to drain from inflation channel. Do not remove catheter and seek specialist urology advice 6. Withdraw catheter slowly, place into a receiver and observe to see if catheter condition and if it is intact. Document in the nursing notes. To ensure complete removal, minimising risk of retained foreign body, or to note evidence of encrustation. 7. Empty any urine in the bag into disposable container measure if appropriate and discard To minimise cross infection 8. Dispose of gloves and decontaminate hands To minimise cross infection 36

Suggested Audit Points 1. Identify all patients with indwelling urinary catheters, their clinical need for catheterisation is assessed and documented 2. To prevent catheter associated urinary tract infections (CAUTI s) Equality and Diversity Statement All patients, employees and members of the public should be treated fairly and with respect, regardless of age, disability, gender, marital status, membership or non-membership of a trade union, race, religion, domestic circumstances, sexual orientation, ethnic or national origin, social & employment status, HIV status, or gender re-assignment. All trust polices and trust wide procedures must comply with the relevant legislation (non exhaustive list) where applicable: Equal Pay Act (1970 and amended 1983) Sex Discrimination Act (1975 amended 1986) Race Relations (Amendment) Act 2000 Disability Discrimination Act (1995) Employment Relations Act (1999) Rehabilitation of Offenders Act (1974) Human Rights Act (1998) Trade Union and Labour Relations (Consolidation) Act 1999 Code of Practice on Age Diversity in Employment (1999) Part Time Workers - Prevention of Less Favourable Treatment Regulations (2000) Civil Partnership Act 2004 Fixed Term Employees - Prevention of Less Favourable Treatment Regulations (2001) Employment Equality (Sexual Orientation) Regulations 2003 Employment Equality (Religion or Belief) Regulations 2003 Employment Equality (Age) Regulations 2006 Equality Act (Sexual Orientation) Regulations 2007 37

References Cottenden A. Bliss D. Fader M. (2005) Management with continence products, in Abrams, Cardoza L. Khoury S. Wein A. (Eds) Incontinence. Health Publications, Paris. Clinimed www.clinimed.co.uk/urology-continence-care/products/instilligel Accessed 21/02/11 Department of Health (2007) Saving Lives: reducing infection, delivering clean safe care (revised edition), London, Crown Copyright DH Saving Lives High Impact Interventions: Insertion Actions of Urinary Catheter Urinary. Catheter Care bundle: Ongoing Care (2007) Fillingham S, Douglas J (2005) Urological nursing (third edition). BaillièreTindall, London Getliffe, K & Dolman, M. (2007) Promoting Continence (Third edition). Bailliere Tindall, London Le Blanc K. Christensen D. (2005) Addressing the challenge of providing nursing care for elderly men suffering from urethral erosion Journal of Wound, Ostomy and Continence Nursing. 32 (2) pp 131 134 Madeo, M. and Roodhouse, A.J. (2009) Reducing the risk associated with urinary catheters. Nursing Standard. 23 (29) pp 47-55 N.I.C.E. (2007) Care of Acutely Ill Patients in Hospital, N.I.C.E. July 2007 National Institute for Health and Clinical Excellence NHS Quality Improvement Scotland (2004) Best Practice Statement: Urinary Catheterisation & Catheter Care Nottingham University Hospitals NHS Trust (2009) Hand Hygiene Policy Nottingham University Hospitals NHS Trust (2008) Glove Selection Guidelines Nottingham University Hospitals NHS Trust (2009) Continence Formulary Guidelines 38

Nottingham University Hospitals NHS Trust (2009) Management of Latex Policy and Procedure Pillona S. Krhut J. Mair D. Maderbacher H. Kessler T. (2004) Intermittent catheterisation in older people, a valuable alternative to indwelling catheters. Age and ageing 34. 57 60 Pratt, R.J, Pellowe, C.M., Wilson, J.A., Loveday, H.P., Harper, P.J., Jones S.R.L.J., McDougall, C. & Wilcox, M.H. (2007) Epic 2: National Evidence Based Guidelines for Prevention Healthcare-Associated Infections in NHS Hospital in England. Journal of Hospital Infection. 65S S1-S64 Royal College of Nursing (2008) Catheter Care. RCN, London Royal College of Nursing (2006) Chaperoning: The role of the nurse and the rights of the patients. RCN, London Trautner B. Darouiche R. (2004) Role of bio film in catheter-associated urinary tract infection. American Journal of Infection Control 32 (3) pp 173-183 Wilde M. (2002) Urine flowing: a phenomenological study of living with a urinary catheter Research Nurse Health 552 pp 14-24 Wyndaele J. (2002) Complications of Intermittent catheterisation: their prevention and treatment Spinal Cord 40 (10) pp 536 541 Recommended Reading Department of Health (2007) Saving Lives: reducing infection, delivering clean safe care (revised edition), London, Crown Copyright DH Saving Lives High Impact Interventions: Insertion Actions of Urinary Catheter Urinary. Catheter Care bundle: Ongoing Care (2007) Fillingham S, Douglas J (2005) Urological nursing (third edition). BaillièreTindall, London Getliffe, K & Dolman, M. (2007) Promoting Continence (Third edition). Bailliere Tindall, London 39

Johnson J. Kuskowskil. Wilt T. (2006) Systematic review; Antimicrobial urinary catheters to prevent catheter-associated infection in hospitalized patients. Annals of Internal Medicine 144 (2) pp 116-126 Nottingham University Hospitals NHS Trust (2009) Hand Hygiene Policy Nottingham University Hospitals NHS Trust (2008) Glove Selection Guidelines Nottingham University Hospitals NHS Trust (2009) Continence Formulary Guidelines Pratt, R.J, Pellowe, C.M., Wilson, J.A., Loveday, H.P., Harper, P.J., Jones S.R.L.J., McDougall, C. & Wilcox, M.H. (2007) Epic 2: National Evidence Based Guidelines for Prevention Healthcare-Associated Infections in NHS Hospital in England. Journal of Hospital Infection. 65S S1-S64 Royal College of Nursing (2005) Indwelling Devices. RCN, London Authors: Amy Cartwright, Jenny Adcock and Stephen Smith NPGG Link: Ellie Dring For Review: June 2014 40