URINARY CATHETERISATION IN ADULTS POLICY
Version / 1Name of responsible (ratifying) committee / Infection Prevention Management Committee
Date ratified / 16 November 2016
Document Manager (job title) / Consultant in Infection Prevention
Date issued / 06 January 2017
Review date / 05 January 2020
Electronic location / Infection Control Policies
Related Procedural Documents / Hand Hygiene Policy, Asepsis Policy
Key Words (to aid with searching) / Urinary catheter, urethral catheter, suprapubic catheter
Version Tracking
Version / Date Ratified / Brief Summary of Changes / Author1 / 16.11.16 / New policy / IPT
CONTENTS
QUICK REFERENCE GUIDE 3
1. INTRODUCTION 5
2. PURPOSE 5
3. SCOPE 5
4. DEFINITIONS 5
5. DUTIES AND RESPONSIBILITIES 5
6. PROCESS 6
7. TRAINING REQUIREMENTS 17
8. REFERENCES AND ASSOCIATED DOCUMENTATION 17
9. EQUALITY IMPACT STATEMENT 17
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS 19
QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural documents.
For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.
1. Good Practice Statements
· Only use indwelling urinary catheters in patients for whom it is clinically indicated following assessment of alternative methods and discussion with the patient
· Document the clinical indication(s) for catheterisation, date of insertion, expected duration, type of catheter and drainage system, and planned date of removal
· Remove the catheter as soon as no longer clinically indicated.
2. Indications for Urethral Catheterisation
Short term (1-2 days, less than 28 days)
· Intra or Peri-operative use (e.g. intra-operative urine output monitoring, spinal / epidural anaesthetic, genitourinary tract surgery)
· Hourly urinary output monitoring in critically ill patients
· Acute urinary retention (confirmed by bladder scan and residual volume measurement)
· Investigations – e.g. urodynamics; measurement of residual volumes
· To administer intravesical treatment
Long Term (up to 12 weeks)
· Chronic urinary retention in the symptomatic patient or bladder outlet obstruction not amenable to surgery or Clean Intermittent Self Catheterisation (CISC)
· Management of impaired skin integrity or to assist healing of open wounds (including surgical) or sores frequently contaminated with urine
· End of life care/dignity
· Neurological disorders causing paralysis or loss of sensation, hypotonic bladder if CISC not a viable option
· Patients requiring prolonged immobilisation (e.g. pelvic or spinal trauma)
Other
· Where a patient insists on a catheter after discussion and understands the risk
3. Catheterisation is an aseptic procedure using sterile equipment and should only be undertaken by healthcare workers trained and competent in this procedure (see appendix 2)
Catheter type / Duration / Material / Size and lengthShort term / Up to 7 days / · Plastic (PVC)
· Latex / · Female 12 – 14 Ch
· Male 12 – 14 Ch
· Female – 26cms*
· Male (standard) – 43cms*
Medium term / Up to 28 days / · Poly-tetra-fluoride-ethylene (PTFE)
· Sliver-alloy hydrogel coated
Long term / Up to 72 days / · 100% silicone
· Hydrogel bonded
4. Antimicrobials
· Prophylactic antimicrobials should not be offered routinely for catheter insertion or changes
· Antimicrobials must only be used to treat systemic infection and not bacterial colonisation of the urinary tract (bacteriuria) or colonisation of the urinary catheter
· For those with symptomatic catheter associated urinary tract infection, send a urine sample for microscopy and culture and commence the patient on antimicrobial therapy according to the Microguide. The catheter should be changed at the start of antimicrobial therapy.
5. The Trust requires a twice-daily review of catheters to minimise the length of time in place.
Catheters should be removed as soon as clinically possible, following individual assessment, which takes into account the patient’s condition and in collaboration with the healthcare team. Both the medical and nursing team are equally responsible for reviewing the indications for catheterisation and any competent HCP can make the decision to remove a catheter in the patient’s best interests.
1. INTRODUCTION
This policy sets out standards and guidance relating to urinary catheterisation in adults and catheter care for the organisation and practitioners employed within the Trust.
2. PURPOSE
The purpose of this policy is to ensure the Trust meets strategic and clinical best practice standards in delivering direct patient care to patients with or who require urinary catheters / catheterisation.
3. SCOPE
This policy applies to all Trust staff directly or indirectly involved with urinary catheterisation / catheters.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’
4. DEFINITIONS
A urethral catheter is a hollow tube inserted into the urinary bladder via the urethra, for the purpose of draining urine or instilling fluids as part of medical treatment.
A supra-pubic catheter is a hollow tube inserted into an artificial tract in the abdominal wall, just above the pubic bone and into the dome of the urinary bladder for the purpose of draining urine or instilling fluids as part of medical treatment.
Bacteriuria is the presence of bacteria in the urine with or without associated symptoms of infection. In the absence of symptoms this is referred to as asymptomatic bacteriuria (or in the case of a patient with an indwelling catheter as catheter colonisation).
Catheter-associated Urinary Tract Infection (CAUTI) occurs when microbes gain access to the bladder via the outer surface of the catheter and through the lumen, causing symptoms including fever and suprapubic tenderness. Once a catheter has been in situ for a few days bacteriuria is almost inevitable and recurrent symptomatic urinary tract infections and sepsis are very real risks.
Dysuria Pain during urination, or difficulty urinating. Dysuria is usually caused by inflammation of the urethra, frequently as a result of infection.
Urinary Tract Infection (UTI) involves the successful invasion, establishment and growth of microbes within the urinary system (kidney, ureter, bladder, or urethra) of the host. Any factor interfering with the normal flow of urine can increase susceptibility to infection.
5. DUTIES AND RESPONSIBILITIES
Infection Prevention Team:
· Review and update the Adult Urinary Catheter Policy in conjunction with the Urology Specialists
· Include good catheter insertion, management and removal practice in all induction and update training for clinical staff
· Promote good practice and challenge poor practice
· Conduct audit and inspection of catheter usage, dwell time and CAUTI.
Urology Specialists:
· Provide competency based training on catheter insertion, ongoing care and removal
· Provide expert intervention in patients with complex continence and catheter requirements
· Promote good practice and challenge poor practice and contribute to monitoring and maintaining standards.
Matrons / Ward Managers:
· Must ensure that all Healthcare Workers undertaking catheter insertion, ongoing care and removal have received suitable competency-based training
· Promote absolute compliance with good catheter practice, including asepsis and hygiene
· Ensure all urinary catheters are recorded on VitalPAC or Catheter Care Bundles, and that records of care and removal are kept up to date
· Promote good practice and challenge poor practice
All Healthcare Staff:
· Must adhere to the full terms and conditions of this policy
It is the responsibility of all registered health care practitioners undertaking urinary catheterisation to be confident and competent in doing so. The registered health care practitioner must take into consideration:
· Their professional body’s code of conduct
· Relevant Trust Policies
Individuals are responsible for identifying their learning and development needs.
If the registered health care practitioner delegates the task of insertion or ongoing care of an indwelling urinary catheter to a non-registered staff member, they are reminded that they are at all times accountable for the delegated task. If delegating task to others it is important to ensure:
· The non-registered staff member has received training and assessment of competence in the insertion and care of indwelling urinary catheters
6. PROCESS
6.1 Good Practice Statements
· Only use indwelling urinary catheters in patients for whom it is clinically indicated (see section 6.2), following assessment of alternative methods and discussion with the patient e.g. intermittent catheterisation, urinary sheaths, incontinence products
· The registered health care practitioner (HCP) should understand the high level of risk associated with short and long-term catheterisation
· Document the clinical indication(s) for catheterisation, date of insertion, expected duration, type of catheter and drainage system, and planned date of removal
· Assess and record the reasons for catheterisation every day. Remove the catheter as soon as no longer clinically indicated
· Indwelling urinary catheterisation is not a substitute for nursing care of the patient with urinary incontinence.
Supporting documentation for this guideline include the EPIC3 Guidelines for the maintenance of short-term indwelling catheters in acute care and the Infection Control Guidelines (NICE 2012) for care of patients with long-term urinary catheters. Additionally, ‘Essential steps to safe, clean care’ provides a review tool (High Impact Interventions No 6: Urinary Catheter Care Bundle) to enable self-assessment of care delivery against risk elements associated with urinary catheter care (DH 2006)
6.2 Decision to Catheterise
The competent HCP can make a clinical decision to undertake an initial urethral catheterisation. Initial suprapubic catheterisation will be performed by medical staff. Ideally, indwelling catheterisation should be performed following discussion with the patient and the patient’s clinical team in order that decisions regarding subsequent treatment/care can be made.
Wherever possible, intermittent (self) catheterisation should be the preferred alternative. However, if it is determined that this is unacceptable or unsafe, then indwelling catheterisation might be considered as the next best option.
6.2.1 Alternatives to Indwelling Urinary Catheterisation
The most common alternatives to indwelling urinary catheters are:
· External catheters for men (sheath/condom catheters)
Intermittent (“in-and-out” or “straight”) catheterisation
· Programmed toileting
External sheath/condom catheters lower the risk of infectious and other complications of urinary catheterisation and are more acceptable to patients. When using condom catheters, it is important to choose an appropriate size to improve fit and adherence despite patients’ movement.
Intermittent catheterisation, often used in patients with neurogenic bladder or spinal cord injury, lessens the risk of urinary tract infection. Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction. When the patient returns to the community, intermittent catheterization enhances patient privacy and dignity, and facilitates return to activities of daily living. When in hospital, use bladder scanners to detect if a patient has insufficient quantities of urine to justify catheterisation.
Toileting programs typically consist of a patient-specific assessment of incontinence followed by a program of prompted voiding, habit retraining, and/or timed voiding as part of an individualized care plan. Evidence from one investigation demonstrates toileting programs can significantly lessen risk of falls and skin breakdown.
The indications for indwelling urinary catheterisation include:
Short term (1-2 days, less than 28 days)
· Intra or Peri-operative use (e.g. intra-operative urine output monitoring, spinal / epidural anaesthetic, genitourinary tract surgery)
· Hourly urinary output monitoring in critically ill patients
· Acute urinary retention (confirmed by bladder scan and residual volume measurement)
· Investigations – e.g. urodynamics; measurement of residual volumes (less invasively achieved by a portable bladder scanner)
Long Term (up to 12 weeks)
· Chronic urinary retention in the symptomatic patient or bladder outlet obstruction not amenable to surgery when CISC not a viable option
· Management of impaired skin integrity or to assist healing of open wounds (including surgical) or sores frequently contaminated with urine
· End of life care/dignity
· Neurological disorders causing paralysis or loss of sensation, hypotonic bladder when CISC not a viable option
· Patients requiring prolonged immobilisation (e.g. pelvic or spinal trauma)
Other
· Where a patient insists on a catheter after discussion and understands the risk
The use of indwelling catheterisation should not be considered routine in any of these situations. Other options should be explored first.
6.3 Consent
Valid consent to undertake an initial insertion or renewal of a catheter must be obtained verbally from the patient where possible and with approval from the person with continuing medical responsibility for the patient. This consent should be recorded in the patient’s clinical records or Urinary Catheter Insertion Record (see appendix 1). If the patient does not have capacity to consent to urinary catheterisation – the Mental Capacity Act Policy must be followed.
Complications
· There is a strong association between the duration of catheterisation and the risk of infection. The daily risk of acquisition of bacteriuria when an indwelling catheter in situ is 3–7%. The rate of acquisition is higher for women and older persons. Bacteriuria is universal once a catheter remains in place for several weeks. Approximately 24% of bacteriuric patients will develop CAUTI, and of these, up to 3-4% develop a severe secondary infection such as bloodstream infection
· Additional infectious complications, usually identified in patients with a chronic indwelling catheter, include bladder urolithiasis, purulent urethritis, gland abscesses and, for males, prostatitis
· Non-infectious complications urinary catheter obstruction, nonbacterial urethral inflammation, urethral strictures, mechanical trauma, including traumatic hypospadias in men and mobility impairment.
6.4 Documentation
The assessment and decision to use indwelling urinary catheterisation should be clearly documented, along with the rationale, in the patient notes and on VitalPAC (Indwelling Devices – Urinary Catheter) or the paper Urinary Catheter Insertion Record and Care Plan. On-going, documented review is a fundamental element to ensure that the catheter is considered for removal at every opportunity.
6.5 Selection of Catheter
Selection is based on a number of factors;