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Principles underlying urinary catheterisation in the community
THE SCIENCE — CATHETERASSOCIATED URINARY TRACT INFECTION (CAUTI)
KEYWORDS:
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Continence Infection control Urinary catheterisation
highlighted that 23% of hospitalacquired infections (HAIs) are urinary (Plowman et al, 1999; Booth and Clarkson, 2012), which incurs significant financial costs and extra hospital stays for patients.
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rinary catheterisation in any of its forms — indwelling, suprapubic, or intermittent — is never simple. Over the past 40 years catheterisation techniques and the basic design of catheters themselves have changed little and research/evidence is frequently contradictory, even speculative. Consequently, it can be hard to maintain the correct knowledge and skill base. While recent clinical guidelines (National Institute for Health and Clinical Excellence [NICE], 2012) have produced audit tools, it is debatable how many nurses are actually aware of these and/or follow them rigorously.
BACKGROUND Booth and Clarkson (2012) outlined the indications for urinary catheterisations (see Table 1). However, there are few real clinical indications and any suggestion of catheterisation should always be questioned. The same authors Frank Booth is freelance continence advisor
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Catheterisation is a high-risk intervention and it is not unheard of for people to die as a direct result, — even when performed well, trauma as a result of catheterisation is still not uncommon (Holroyd-Leduc et al, 2007). It is important that clinicians, including community nurses do not catheterise for convenience, particularly given the ongoing revelations about poor care standards (Francis, 2013). It can be seen as more convenient for nurses to catheterise patients rather than move them several times a day to change bed sheets and clothing, to use a bed pan or walk to the bathroom, or to change pads. Nurses should never use those reasons to catheterise patients and catherisation should only be undertaken where there are sound
Urinary tract infections (UTIs) resulting from catheter use are a common healthcareacquired infection (HAI). Despite modern hygiene standards, approximately 1 in 10 people who have a catheter go on to develop a CAUTI. Because of this high risk of infection, a urinary catheter is only used when all other options have been excluded. The risk of infection is heightened with indwelling catheters. Patients who are required to insert catheters themselves intermittently, must receive proper training from the care team. Symptoms of a CAUTI include: Pain in the bladder or urethra Offensive-smelling discharge from the urethra Foul-smelling cloudy urine General symptoms of infection, e.g. high temperature (38°C/100.4°F or above), feeling generally unwell, tired or lethargic. Source: http://www.nhs.uk/ Conditions/Urinary-catheterization/ Pages/Risks.aspx
reasons that can be clinically justified (Getz, 2012).
INFECTION CONTROL IN THE COMMUNITY AND HOSPITAL Basic principles of care should not
Credit: Saltanat ebli@wikicommons
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This article examines the various elements that community nurses need to consider when attempting to provide best practice in urinary catheterisation. The author seeks to challenge what is considered best practice — particularly the requirement for all practice to be evidence based — while encouraging community nurses to think proactively about the care they are providing. The article stresses that the first principle of urinary catheterisation is to avoid the procedure where at all possible — catheterisation is potentially dangerous and can even be life-threatening if performed inappropriately. Overall, the author poses some key questions, including: should there be a difference in the care provided by community and hospital nurses; do community patients have the same needs as those in hospital; and can the manufacturers of drugs/products help to make avoiding urinary tract infections (UTIs) easier?
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Frank Booth
CONTINENCE
in excessive antibiotic usage — can have a significant impact (RCN, 2005). While this is no longer an active campaign, it has been maintained in many areas as a focus for the drive to reduce HAIs and improve patient care.
Drainage
Prostatic hyperplasia Acute or chronic retention Hypotonic bladder Pre- and post-pelvic surgery Measurement of urine output To empty the bladder during labour
Investigations
To obtain an uncontaminated urine specimen Urodynamic investigations X-ray investigation
Instillation
Bladder irrigation Chemotherapy
Management of intractable incontinence
Only when all other methods have been tried
Source: Pomfret (1996)
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Overall, although there are fewer infection risks in the patient’s home, they are still high and nurses can contribute to this risk directly. This is why there are handwashing campaigns and the use of antiseptic gels at the end of every bed in hospitals — perhaps this is something that should be considered in the homes of bed-bound patients, and indeed many community nurses now carry alcohol hand gel.
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Similarly, in the case of highly dependent patients and/or those in the final stages of life being cared for at home, infection control facilities will not be as extensive or easily available as in a hospital setting, therefore, the individual nurse will be much more autonomous (Royal College of Nursing [RCN], 2005).
is much larger, including the socalled ‘superbugs’ such as meticillinresistant Staphylococcus aureas [MRSA] and Clostridium difficile. However,while the principle of infection control is the same in the community or in hospital, the implementation differs simply because of the volume of risk and the necessity for more aggressive action in hospital (NHS Professionals, 2010).
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change within healthcare settings, however, there are some differences between the management of infection in the hospital or in a community setting. For example, hybrid germs from multiple sources are more likely to develop in hospital, but there will be infection control nurses on hand to reduce these risks; whereas the facilities in primary care will be less sophisticated although infection risks from catheterisation remain equally high (Loveday et al, 2014).
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However, the principle difference between infection control in the patient’s home or community clinic and the inpatient setting is the higher concentration of people — and by definition the higher concentration of pathogenic organisms — in hospital. Thousands of people pass through a hospital’s various departments every day and a multitude of staff and visitors make contact with patients and hospital equipment, such as beds or medication trolleys. Conversely, only a few people, if any at all, come into contact with the patient at home. Similarly, any microorganisms present in the home are fairly constant and usually relatively low grade (NHS Professionals, 2010), whereas in hospital the range and scope of harmful microorganisms
Booth and Clarkson (2012) outline the types of catheters currently available, their composition and which ones are suited to different clinical purposes, for example, separate male, female and children’s indwelling urethral catheters; suprapubic catheters; and specialist catheters used in urology.
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Table 1: Indications for catheterisation
WHAT IS BEST PRACTICE? Infection prevention and control is the responsibility of all members of staff. It is not a new problem and infections — especially catheter-related infections — are a longstanding historical issue, representing a significant risk and incurring large costs. However, with the right measures, the risk can be significantly reduced, if not completely eradicated (NICE, 2012). Simple actions such as the principles of the RCN’s ‘Wipe it out’ campaign — including, for example, correct hand-washing techniques; use of alcohol-based hand gels; compliance with mandatory infection control programmes; and reduction
The Department of Health [DH] (2008) and NICE (2012) also offer guidance on preventing and controlling infections, including: Using systems to manage the prevention and control of infection, such as risk assessments and considering how susceptible patients are Providing and maintaining a clean and appropriate environment Ensuring that all staff are fully involved in the process of preventing and controlling infection Ensuring, so far as is reasonably practical, that care staff are free of and are protected from exposure to infections Using hand decontamination, wipes, gels and hand rubs as well as handwashing Using the correct medical products, for example, using intermittent rather than indwelling catheters where appropriate; ensuring that catheters are held in place properly using the correct fixation equipment Ensuring skin decontamination and the use of simple daily hygiene rather than antiseptic cleaning. Periodically, certain catheterisation products are found to be faulty in Red Flag
Admission...
Patients with catheters should be admitted to hospital if they develop fever, rigors, chills, vomiting or confusion.
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1 – What are the common symptoms of catheter-associated urinary tract infection (CAUTI)? 2 – Can you name some of the main differences between infection control in the hospital and the community? 3 – Do you understand what best practice is when considering catheterisation? 4 – What does some of the main guidance (DH; NICE) say about controlling and managing infections in catheterisation?
Clinicians are always told to provide evidence-based practice. However, is it always possible to rely on evidence? For example, a multitude of evidence has been produced suggesting that silver-coated/impregnated catheters significantly reduce UTIs (Franken et al, 2007). However, there is also a large body of evidence stating that the effect of silver is not proven (Lai and Fontecchio, 2002; Dixon, 2006; Beattie, 2011; Pickard et al, 2012). As well as relying on evidence, community nurses must take into account the clinical facts when considering catheterisation and the presence of infection, including: Cloudy urine Blood in the urine Pain in the back, abdomen or groin Acute urinary retention.
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themselves. The Medicines and Healthcare Products Regulatory Agency (MHRA) will issue a notice about any faulty product and
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5 – Can you explain the role of the infection control team in urinary catheterisation?
The ‘evidence’ problem
It is also vital to ensure that the patient/family understand the procedure and have provided informed consent for any procedures (DH, 2009).
Manufacturers
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Answer the following questions about this topic, either to test the new knowledge you have gained or to form part of your ongoing practice development portfolio.
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Five-minute test
own knowledge about patients when considering catheterisation — for example, are they flushed, experiencing rigor, sickness and/ or diarrhoea, or lethargic — as well as relying on their own skills and knowledge and what the inherent benefits and/or dangers are of procedures such as cathterisation.
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community pharmacists should be aware of these, as should the local hospital supplies manager who is responsible for notifying local staff. Individual clinicians can also notify manufacturers and the MHRA should they discover any product faults.
It is also vital that community nurses take into account their
Catheter manufacturers often provide training and information on their products and their use. However, it is important to remember: Not all urinary catheters are manufactured in the same way, have the same uses, or the same outcomes — community nurses must be product aware Only follow the manufacturer’s instructions for the particular catheter that you are using, and never mix literature/guidance from different companies’ products.
Best practice — general rules In the author’s experience, there are some clinical scenarios in which
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CliniFix® – the Universal Hydrocolloid Securement Device
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[email protected] [email protected] or or visit: visit: www.clinimed.co.uk. CliniMed® and CliniFix® are registered trademarks of CliniMed CliniMed Ltd. Ltd. 2013. 2013. CliniMed (Holdings) (Holdings) Ltd. Ltd. ©CliniMed CliniFix patent number: GB 2 448 517B EP 1982743 JCN PID 28 2014, Vol 28, No 5 1330/0111
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SKIN CARE
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CONTINENCE CARE LEARNING DISABILITIES STOMA CARE PRACTICE DEVELOPMENT
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Catheterising for convenience
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ROLE OF THE INFECTION PREVENTION AND CONTROL TEAM
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All NHS trusts will have an infection prevention and control team tasked with providing: Advice about the prevention and management of infection to all staff. This includes the management of outbreaks of infection such as diarrhoea and vomiting Advice and information to patients and carers
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Finally, it is vital for community nurses to consider if they actually have the skills necessary to carry out the procedure. They must be sure that they have undertaken some degree 76 JCN 2014, Vol 28, No 5
It is vital that community nurses use the infection prevention and control team as a resource to find out what is considered ‘best practice’. However, while it is important to keep up to date, it is also important to acknowledge that the risks of catheterrelated infections have been well documented over the past 30 years (for example, that indwelling catheters carry high risk of infection after just 48 hours) (Garibaldi et al, 1982; Plowman et al, 1999; Tambyah, 2002).
CONCLUSION Catheterisation is a procedure that can be undertaken safely, but is not without risk, particularly trauma, infection and, in rare cases, death.
Expert commentary
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In the author’s opinion, if a community nurse cannot critically justify the decision to catheterise, they must seriously consider whether it is appropriate to undertake the procedure at all. It is important to remember that as a registered professional any community nurse is responsible for their actions and any clinical decision-making (NMC, 2011; 2013). The NMC code is the foundation of good nursing and midwifery practice, and a key tool in safeguarding the health and wellbeing of the public.
The infection prevention and control team is an important asset for community nurses as it can provide the latest up-to-date information, for example, on the prevention and control of healthcare-associated infections, in this case those associated with catheters (NICE, 2012).
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In the author’s opinion, catheterisation for staff convenience is never acceptable. Catheterisation can be justified only where every other avenue has been explored and excluded. This might be the case in the latter stages of terminal illness, for example,where skin integrity is significantly compromised and no other means of redirecting or collecting urine are practical (i.e. in males a condom sheath may not be appropriate as the penis will often retract with age and/or illness) (Booth, 2009).
Education for all clinical staff on infections and how to control and prevent them Policies, guidelines and protocols to ensure care is evidence based and high quality Input into monitoring of environmental cleanliness, working closely with clinical matrons and patient representatives.
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of performance training under the supervision of a senior and clinically competent colleague. If the nurse cannot be sure of his or her skill to perform the procedure, specialist help should be sought.
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catheterisation is the only option available, for example, in the final hours of life, where skin integrity is being severely affected and represents a health risk; or in acute or chronic urine retention. However, in most cases it is important to ask some key questions before considering the procedure: What is the clinical justification for catheterisation in a particular patient? Does catheterisation make sense given the presenting clinical facts? Has the case for catheterisation been discussed with colleagues and has their clinical opinion been sought? Have the clinical options been discussed with the patient and have their treatment choices been outlined? Of course, with an invasive procedure such as catheterisation, patients may be anxious about pain and trauma, and it is beholden upon the community nurse to answer any questions honestly and reasonably, as well as presenting the benefits Is there a better option than catheterisation (for example, more regular visits to the patient to change pads or more frequent ‘toileting’; educating relatives/ carers on taking the person to the toilet more regularly; the use of a condom-type sheath), even if it involves more clinical time or resources?
Carlene Igbedioh, integrated continence advanced nurse practitioner, pelvic floor unit; Guy’s and St Thomas’ NHS Foundation Trust, London
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his is an interesting article as being aware of the key indications for catheterisation is vital for community nurses. It is important that nurses are aware that, yes, urinary catheters have their use, but careful consideration should be taken before deciding to recommend them. The need for infection control as well as organisational support for
education and training is another important consideration. The author of this piece also helpfully describes how nurses should only follow manufacturer’s instructions for the particular catheter they are using. I also think it is pertinent to mention the importance of informed consent when considering catheterisation. .
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Similarly, manufacturers are constantly striving for innovations in product design to stave off infection, such as silver-coated catheters, but only time will tell if they will work or are simply a gimmick.
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Of course, increased nursing time and new product design is expensive, however, investment is needed if patients are to receive the care they expect and deserve. JCN
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REFERENCES
Beattie M (2011) Can silver alloy catheters reduce infection rates? Nurs Times Available at: http://www.nursingtimes. net/home/specialisms/leadership/cansilver-alloy-catheters-reduce-infectionrates/5032940.article (accessed 9 August, 2014) Booth F (2009) Why have we still not learned the lessons of catheterisation? Nurs Times. Available at: http://www. nursingtimes.net/why-have-westill-not-learned-the-lessons-ofcatheterisation/5001872.article (accessed 9 August, 2014)
Catheterisation is a procedure that can be undertaken safely, but is not without risk, particularly trauma, infection and, in rare cases, death.
Catheterisation should never be regarded as a first option. It may be a ‘necessary evil’ but is not one to be entered into lightly, or without offering the patient and family some insight into the risks and benefits.
Infection is always a high risk in people who have been catheterised.
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The rise of antibiotic-resistant strains of bacteria has meant that the use of antibiotics to combat infections is now becoming less certain — this means that nurses’ good practice is likely to come to the fore as a weapon in reducing risk.
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As increasing numbers of highdependent people are cared for at home, the community nurse’s role will change and the risks of procedures such as catheterisation will potentially become greater.
KEY POINTS
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rise of antibiotic-resistant strains of bacteria has meant that the use of antibiotics to combat infections is now becoming less certain.
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means that nurses’ good practice is likely to come to the fore as a weapon in reducing reduce risk.
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Infection is always a high risk in people who have been catheterised. The community care setting may carry less risk of infection from socalled superbugs or other patients, for example, than in hospital, but simply being in primary care is not enough to eradicate risk entirely.
Booth F, Clarkson MJ (2012) Principles of urinary catheterisation. J Comm Nurs Available at: http://www.jcn.co.uk/ journal/05-2012/continence/1495principles-of-urinary-catheterisation (accessed 9 August, 2014) DH (2008) The Health and Social Care Act 2008: Code of practice on the prevention and control of infections and related guidance. DH, London DH (2009) Reference Guide to Consent for Examination or Treatment. Available at: https://www.gov.uk/government/uploads/ system/uploads/attachment_data/ file/138296/dh_103653__1_.pdf (accessed 9 August, 2014) Dixon A (2006) Silver-coated Foley Catheters: initial cost is not the only thing to consider. Am J Inf Control 34(5): e39–e40 Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Executive summary. The Stationery Office, London Franken A, van den Bosch EEM, CrespoBiel O, Loontjens JA. Dias AA (2007) Anti-microbial coatings for urological applications. J Euro Cells Materials 14(suppl 3): s130 Garibaldi R, Mooney B, Epstein BJ, et al (1982) An evaluation of daily bacteriologic monitoring to identify preventable episodes of catheter- associated urinary tract infection. Infect Contr 3(6): 466–70 Getz L (2012) Catheter conundrum: reducing unnecessary placement. Aging Well 5(2): 14 Holroyd-Leduc JM, Sen S, Bertenthal D, et al (2007) The relationship of indwelling urinary catheters to death, length of hospital stay, functional decline, and nursing home admission in hospitalized older medical patients. J Am Geriatr Soc 55(2): 227–33 Lai KK, Fontecchio SA (2002) Use of silver-hydrogel urinary catheters on the incidence of catheter-associated urinary tract infections in hospitalized patients. Am J Infect Control 30(4): 221–5 Loveday HP, Wilson JA, Pratt RJ, et al (2014) epic3: National evidence based guidelines for preventing healthcare associated infections in NHS hospitals in England. J Hosp Infec 86(1 suppl): s1–s70 Makuta G (2013) Measuring the efficacy of antimicrobial catheters. Nurs Times 109(44): 16–19 NHS Professionals (2010) Standard Infection Control Precautions. Available at: www. nhsprofessionals.nhs.uk/download/ comms/cg1_nhsp_standard_infection_ control_precautions_v3.pdf (accessed 9
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Therefore, catheterisation should never be regarded as a first option. It may be a ‘necessary evil’ but is not one to be entered into lightly, or without offering the patient and family some insight into the risks and benefits.
August, 2014) NICE (2012) Infection: Prevention and control of healthcare-associated infections in primary and community care. NICE, London NMC (2011) The Code: standards of conduct, performance and ethics for nurses and midwives. NMC, London NMC (2013) Raising Concerns: guidance for nurses and midwives. NMC, London Pickard R, Lam T, MacLennan G, et al (2012) Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised controlled trial. Lancet 380(9857): 1927–35 Plowman R, Graves N, Griffin M (1999) The Socioeconomic Burden of Hospital-acquired Infection. Public Health Laboratory Service, London Pomfret IJ (1996) Catheters: design selection and management. Br J Nurs 5(4): 245–51 RCN (2005) ‘Wipe it out’ campaign. Available at: www.rcn.org.uk/development/practice/ infection_control/wipe_it_out_campaign (accessed 9 August, 2014) Tambyah P, Knasinski V, Maki D (2002) The direct costs of nosocomial catheterassociated urinary tract infection in the era of managed care. Inf Contr Hosp Epidemiol 23(1): 27–31
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