The insertion of indwelling urinary catheters has been a common practice accredited to keeping the bladder empty during hospital stays, treatments and pre- or post-operative procedures. Through this practice, research has shown that many patients will acquire a catheter associated urinary tract infections. The purpose of this healthcare policy is to prove if catheterization is really necessary or is there an alternative, as a nurse what can one to do improve upon existing facility polices and where do we go from here to protect our patients.
The insertion presents a strong possibility of introducing an infection and if the patient had no pre-existing infectious process, the end result may be a urinary tract infection related to the catheter. The presence of a urethral catheter bypasses many of the bladder’s natural defenses and provides a direct connection from the colonized perineum to the usually sterile bladder. Entry of bacteria into the bladder can occur either at initial catheterization or later by ascent of the catheter tubing, for example, when a catheter bag is changed (Dailly, 2011).
This is the very step that we as healthcare professionals must work in unison to deem if this is really necessary and if so when should catheterization be discontinued and by whose judgment. Method In acute care settings, urinary tract infections account for at least 35% of all hospital-acquired infections, with 80% of those being attributed to the use of indwelling catheters (Bernard, 2012). With these statistics healthcare providers must ask the question if a catheter is really necessary, but not only that they must be given a protocol to follow.
Pellow, 2010 along with Critical Care Nurse 2012 have proposed the following protocol for guidelines for preventing infections associated with the use of short-term indwelling catheters. Assessing the need for catheterization: Only use indwelling urethral catheters after considering alternative methods of management. Document the need for catheterization, catheter insertion and care. Review regularly the patient’s clinical need for continuing urinary catheterization and remove the catheter as soon as possible.
Selection of catheter type: Choice of catheter material will depend on clinical experience, patient assessment and anticipated duration of catheterization. Select the smallest gauge catheter that will allow free urinary outflow. A catheter with a 10ml balloon should be used in adults. Urological patients may require larger gauge sizes and balloons. Catheter insertion: Catheterization is an aseptic procedure. Ensure that healthcare workers are trained and competent to carry out urethral catheterization. Clean the urethral meatus with sterile catheter.
Use an appropriate lubricant from a sterile single-use container to minimize urethral trauma and infection. Catheter maintenance: Connect indwelling urethral catheters to a sterile closed urinary drainage system. Ensure that the connection between the catheter and the urinary drainage system is not broken except for good clinical reasons, for example, changing the bag in line with manufacturer’s recommendation. Decontaminate hands and wear a new pair of clean, non-sterile gloves before manipulating a patient’s catheter and decontaminate hands after removing gloves.
Obtain urine samples from a sampling port using an aseptic technique. Position urinary drainage bags below the level of the bladder on a stand that prevents contact with the floor. Empty the urinary drainage bag often enough to maintain urine flow and prevent reflux. Use a separate and clean container for each patient and avoid contact between the urinary drainage tap and container. Do not add antiseptic or antimicrobial solutions into urinary drainage bags. Do not change catheters unnecessarily or as part of routine practice except where necessary to adhere to the manufacturer’s guidance.
Routine daily personal hygiene is all that is needed to maintain meatal hygiene. Bladder irrigation, instillation and washout should not be used to prevent catheter-associated infection. Education of patients, relatives and healthcare workers Healthcare workers must be trained in catheter insertion and maintenance. Patients and relatives should be educated about their role in preventing urinary tract infection. Changing the thought process is often difficult in the medical field and this is where nurses can make a significant impact (Bynum, 2008).
One study showed where the RN evaluates the patient upon admission and at each change of shift. If a patient with a urinary catheter does not meet the pre-specified criteria for catheter use, the RN has the autonomy to remove the device without a physician order (Bynum, 2008). The project entailed weekly “Foley Rounds”. These rounds involved the nurse practitioner, nurse manager, and primary nurse; each morning, every patient on the unit received a brief visit at the bedside to check for an indwelling urinary catheter.
If one was in place, the team met to review the clinical indications for placement of the device in that particular patient. As per the protocol, if the criteria were not met, the nurse practitioner and manager provided the initial support for the RN to remove the catheter without a physician order. Currently, the team performs monthly “spot” checks on all patients on the unit as an ongoing quality assurance measure (Bynum, 2008). Overall, anecdotal evidence suggests that the medical staff at UNC overwhelmingly supports the independence given to the nursing staff to discontinue a urinary catheter when needed (Bynum, 2008).
It should also be noted that confusion over whose responsibility it is to make the decision to remove urethral catheters may be one of the reasons for delayed removal and increased catheter associated urinary tract infections. A staff questionnaire at the Royal Hampshire County Hospital found that nurses thought doctors should make the decision, while doctors thought nurses could make the decision, delaying catheter removal. Nurses or doctors could make the decision based on the reason for insertion and the patient’s clinical need and condition (Dailly, 2011).
Results Evidence-based states that urethral catheters should only be used when there is no suitable alternative, and should be kept in place for as short a time as is practical. In evaluation of the program, follow-up data were collected from October 2006 through February 2007. Over this period of time, the daily prevalence (number of patients with an indwelling urinary catheter on the unit divided by total number of patients on the unit) fell from 24% to 17%. Of the 17% who had an indwelling urinary catheter left in place, the ast majority met the strict clinical guidelines to justify their continued use. A recent prevalence follow up in April 2008 was conducted; indwelling urinary catheter use rate dropped to 16. 33%, indicating ongoing effectiveness of the intervention. Additionally, during the 5 months of follow up (October 2006 through February 2007), a total of only 5 urinary catheter associated infections occurred. Similarly, baseline data collected from the previous January 2006 through May 2006 revealed 5 catheter-associated urinary tract infections (Bynum 2008).
Although not all UTIs associated with the use of short-term indwelling urethral catheters are avoidable, many can be prevented. Nurses and other healthcare workers should adhere to national infection prevention and control guidelines and ensure that all of the elements of the Saving Lives high impact intervention for catheter care are incorporated into their practice each and every time they use this intervention (Pellowe, 2010).
Indwelling urinary catheterization is an invasive intervention with potentially serious outcomes that can lead to morbidity and mortality issues in hospitalized patients. Although there is a clinical agreement on the indications for catheterization in acute care, more evidence is required to determine the optimum method of ensuring timely removal of indwelling urethral catheters in all settings. The current studies identify both nurse led and informatics-led interventions as successful in reducing the length of catheterizations, and subsequently, the incidence of CAUTI.
Research into the barriers of translating knowledge about CAUTI into practice may be important in application of these interventions (Bernard, 2012). These studies show that once nurses got involved with the implementation of guidelines that the health of the patient was preserved. By implementing rounds and using guidelines for the criteria that one must meet to receive and keep a urinary catheter one can see how this alone has decreased the catheter associated urinary tract infection.
One can also conclude from the studies that along with these interventions and policies all healthcare providers must be on the same page without any confusion on that of facility policy and if there is confusion this must be cleared up before patient care is given to avoid any harm to the patient These policy and procedure are in the best interest of the patient and in the long run is the best policy for the facility.
Catheter-Associated urinary tract infections. Critical Care Nurse, 32 (2), 75. Bernard, Michael S. , Hunter, Kathleen F. , Moore, Katherine N. (2012). A review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheter associated urinary tract infections. Urologic Nursing, 32 (1), 29-37. Bynum, Debra. , Carr, Carlye. , Epperson, Carla. , Gotelli, John M. , Merryman, Priscilla. McElveen (2008). A quality improvement project to reduce the complications associated with indwelling urinary catheters. Urologic Nursing, 28 (6), 465-467. Dailly, Sue (2011). Prevention of indwelling catheter-associated urinary tract infections. Nursing Older People, 23(2), 14-19. Pellowe, Carol. , Pratt, Robert. (2010). Good practice in management of patients with urethral catheters. Nursing Older People, 22 (8), 25-29.