Insertion and Management of short and Long term Urinary Catheters

Carol Robinson, RGN, Dip Inf Control, BSc Hons Nursing.

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Definition
Urinary catheterisation is the insertion of

a specifically designed tube into the bladder using asceptic technique for the purpose of draining urine, the removal of clots debris, and the instillation of medication.
Royal Marsden (2008)

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It is a common medical and nursing procedure with over 15-25% of patients in hospital being catheterized (Tenke et al, 2004).

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HIS study
The 2006 prevalence survey of 7518 patients to check for healthcare-associated infection (HCAI) in acute hospitals in the Republic of Ireland The overall rate of (HCAI) was 4.9%.
UTIs were one of the most common HCAI, accounting for 22.5% of HCAIs, of which 56.2% were catheter related.

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HALT prevalence study June 2010

4,170 residents were surveyed in 69 facilities (61 public,

8 private) The most common HCAI were urinary tract infections (40%), 234 (5.6%) had an indwelling urinary catheter on the day

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Classification of UTIs.
Asymptomatic bacteriuria

The absence of symptoms, such as dysuria, frequency, urgency, and fever, chills and suprapubic or flank pain. Is common in pregnant women, patients with diabetes and older adults especially women (Yoshikawa et al

1996).

It can lead to symptomatic invasive disease, bacteraemia or sepsis unless patients are monitored and treated appropriately (Travis and Lampley-Dallas 1997).

Symptomatic bacteriuria

It is caused by the inflammatory response that occurs when bacteria attach to the urinary mucosa. This response creates the symptoms of urgency, frequency and dysuria (Anderson 1999). Symptoms can be present in patients with uncomplicated and complicated UTI.

Uncomplicated UTI

Is an infection of the bladder or kidney occurring in a normal host without structural or functional abnormality of the urinary tract (Ronald and Pattullo 1991). The HPA (2005) suggests that this occurs in otherwise healthy individuals.

Complicated UTI

Complicated UTI is an infection in the presence of one or more of the following (Warren 1996): Urinary calculi, for example, renal or bladder stones. Cystic renal disease. Urinary obstruction in the kidney, ureter bladder or prostate. Anatomical abnormalities, for example, vesico-ureteral reflux. Neurogenic bladder dysfunction. A foreign body, for example, a urinary catheter.

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Naish W .et al (2007)

Natural defence mechanism

The urethra is the bodys natural defence mechanism in providing protection from infection to the bladder in a healthy person. It flushes out bacteria trapped by mucus that lines the urethra as they attempt to ascend the distal two thirds of the urethra.
The urinary tract is normally sterile with the exception of the distal urethra. Infection may develop if the voiding or urinary flow of the urinary system are altered, as in bladder outflow obstruction, reduced frequency of voiding or incomplete emptying.

Ensuring complete and regular emptying of the bladder helps to prevent UTI.
Urethral catheterisation interrupts these natural defence systems
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Female Risks

Structure of the Female Urinary Tract. In general, the higher risk in women is mostly due to the shortness of the female urethra, which is 1.5 inches compared to 8 inches in men. Bacteria from faeces at the anal opening can be easily transferred to the opening of the urethra. Sexual Behavior. Frequent or recent sexual activity is the most important risk factor for urinary tract infection in young women. Certain types of contraceptives can also increase the risk of UTIs. Pregnancy. Menopause. The risk for UTIs, both symptomatic and asymptomatic, is highest in women after menopause

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Male Risk

Men become more susceptible to UTIs after 50 years of age, when they begin to develop prostate problems. Boys who are uncircumcised are more likely than circumcised boys to develop UTIs.

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HALT Definition of UTI

Urinary tract infection Symptomatic urinary tract infection One of the following criteria must be met:

The resident does not have an indwelling urinary catheter and has at least three of the following;

(a) Fever (~38o C) or chills (b) New or increased burning pain on urination, frequency or urgency (c) New flank or suprapubic pain or tenderness (d) Change in character of urine*

(e) Worsening of mental or functional status (may be new or increased incontinence) (f) Diagnosis by physician

The resident has an indwelling catheter and has at least two of the following:

(a) Fever (~38 C) or chills (b) New flank or suprapubic pain or tenderness (c) Change in character of urine* (d) Worsening of mental or functional status.

(f) Diagnosis by physician

*Change in character may be clinical (e.g., new bloody urine, foul smell, or amount of sediment) or as reported by the laboratory (new pyuria or microscopic haematuria). For laboratory changes, thus means that a previous urinalysis must have been negative

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Incidence of CAUTI
3 - 6% risk / day of developing a UTI
50% of patients catheterised longer than 7-10 days

contract bacteriuria
20 -30% of patients with catheter associated

bacteriuria will develop symptoms (CAUTI), 1- 4% develop bacteraemia, 13 30 of these die

Cost & loss of bed days
(EPIC 2 Guidelines, 2004)

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Pathogenesis of CAUTI
Most organisms that cause CAUTI enter the

bladder by migrating along the internal (intraluminal) and external (extraluminal) catheter surface.
Intraluminal migration of microorganisms

occurs following contamination of the catheter lumen from failure of the closed drainage system or from contaminated urine in the drainage bag. (Reflux)

Extraluminal migration of microorganisms from the perineum can occur at insertion or later by capillary action via the outer surface of the catheter (staff hands)
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Types of Catheterisation
Suprapubic catheterisation.
Intermittent catheterisation. Urinary Catheterisation short term and

long term

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Indications
In male and female patients To empty the contents of the bladder, e.g. before or after abdominal, pelvic or rectal surgery and before certain investigations To determine residual urine To allow irrigation of the bladder To bypass an obstruction To relieve retention of urine To introduce cytotoxic drugs in the treatment of papillary bladder carcinomas To enable bladder function tests to be performed To measure urine output accurately, e.g. when a patient is in shock, undergoing bone marrow transplantation or receiving high-dose chemotherapy To relieve incontinence when no other means is practicable In female patients there are two further reasons To empty the bladder before childbirth, if thought necessary To avoid complications during intracavitary insertion of radioactive Dougherty and Lister 2008 caesium

For patient comfort in end of life care

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Risk factors and complications of urinary catheterisation

Infection May cause trauma by damage urethra Urethral stricture Encrustation. May cause bacteraemia. May cause bladder perforation Paraphimosis due to failure to return foreskin to normal position following catheter insertion. Problems with leakage, bypass and expulsion are common Higher risk of symptomatic urinary infection May be uncomfortable. Around 50% of patients with indwelling catheters are prone to blockage

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Factors to be considered before insertion of a urinary catheter

Is an indwelling catheter needed. Can a penile sheath (condom) be used. What length of time is the catheter expected to remain

insitu.

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Type of Catheter
Urinary catheters are available in various types, sizes and materials.

The most common type is the Foley catheter, which may have 2-3 lumens. Each lumen is used for different functions usually inflation, drainage and irrigation.
Catheters are sized by the diameter of the outer circumference

using the French (Fr) metric scale (range from 6Fr- 24Fr).
The National Patient Safety Agency (UK) issued an alert in 2009 on

the inadvertent use of short (female length) catheters in adult males which resulted in trauma to the urethra.

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 Use

a catheter with the smallest gauge suitable for the patients needs. Use an appropriate length of catheter to ensure patient safety and comfort. The selection of a specific catheter material should be based on an assessment of individual patients requirements and history of encrustation. Consider using antimicrobial/antiseptic-impregnated catheters if the CAUTI rate is not decreasing following implementation of a multi system approach including optimisation of aseptic technique, appropriate management of catheters and regular audit and feedback.
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Catheter Balloon
Use the smallest balloon size possible. This keeps residual urine

minimal, reduces the likelihood of bladder spasm, and minimizes damage to the bladder neck from the weight of the balloon. (Joanna Briggs Institute 2003)
Inflate with sterile water. Air is not suitable as it will cause the

balloon to float. Tap water is not sterile, and saline may block the inflation channel with crystals, making subsequent deflation difficult.

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A catheter valve
Is a device connected to the end of the

catheter. It allows urine to be stored in the bladder, eliminating the need for a urine collection bag. The valve is released at regular intervals to prevent over-distension of the bladder or dilation of the renal tract

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Catheter drainage bag selection

Indications for catheterisation The intended duration Wishes of the patient

Dexterity of patient Mobility of patient

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Disposable 2 litre plastic bags (night bag)

For general use.
Catheter bags should have 120cm length tubing

with an outlet port to allow emptying. It is recommended that catheter bags also have one-way valves to prevent urine backflow, and an access port for the collection of urine specimens. Bags should be changed when they become damaged, contaminated, malodorous and at catheter changes. (www.nhshealthquality.org 2004)
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Disposable 2 litre closed system bag (hourly measuring bag) with sample port.

Used when frequent measurement of urine

output is indicated. Tubing length should be 120cm. These are generally short term and only need to be changed if damaged, contaminated or malodorous.

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Disposable Leg bags

Designed for day wear and can be secured to the leg in a variety of

ways (Leg bags can also be used to reduce trauma for the confused or forgetful patient while in hospital) Tubing on leg bags is available in different lengths and can be tailored to individuals requirements. Some people may choose to wear the leg bag on their thigh, others prefer to wear the leg bag on their calf.

The general recommendation for changing disposable drainage bags is weekly or when they become damaged, odorous or have sediment in the bottom. (www.nhshealthquality.org 2004)

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Insertion of urinary catheters

Healthcare care workers (HCWs) must apply Standard

Precautions when inserting and managing urinary catheters with particular reference to hand hygiene and personal protective equipment. Antiseptic hand hygiene should be performed immediately before insertion of the catheter and before and after any manipulation of the catheter site or apparatus, even when sterile gloves are used. Aseptic techniques should be used during any invasive procedure that by-passes the bodys natural defences,. Asepsis must be maintained when handling equipment prior to carrying out invasive procedures e.g. sterile equipment for urinary catheters. Maintaining sterility can be difficult but it is important to prevent contamination of sterile equipment.

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 HCWs have a duty to safeguard the wellbeing of their patients. Poor

asepsis can lead to the risk of cross transmission of microorganisms from the healthcare workers hands (HCW) and/or the equipment to susceptible patient sites which can result in serious life threatening infections, (Pratt et al 2007). HCWs who insert urethral, suprapubic and intermittent catheters should be trained and assessed as competent in aseptic and insertion technique or be undertaking the procedure under appropriate supervision. Sterile saline or water, or an antiseptic solution should be used to cleanse the urethral meatus. The indication for and insertion of a urinary catheter should be clearly documented and signed in the patients record.

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Documentation
Indication for catheterisation Time and date of catheterisation Type of catheter Amount of water in balloon Size of catheter Expiry date of product Any problems on insertion Description of urine, colour and volume drained Specimen collected Review date
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Management of urinary catheters

A closed drainage system should be used for all patients. Keep the catheter and collecting tube free from kinking. Indwelling catheters should be secured to prevent trauma to and irritation of the urethra. The drainage bag should be maintained below the level of the bladder and avoid contamination of the drainage tap by using a catheter stand . Empty catheters bags when 2/3 full to prevent reflux and excessive weight on the catheter use a clean container for each patient. Avoid touching the drainage tap with the container. Emptying the drainage bag regularly. Use PPE when emptying or changing the catheter bag to prevent splash injuries If required, a sterile, single use night drainage bag should be used with leg bags. The meatal area and suprapubic insertion site (once healed) should be cleaned daily using soap and water.
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Assess the catheter drainage system only when absolutely necessary (i.e., changing drainage bag as per manufacturers instructions). Catheter irrigation should not be undertaken to prevent infection. If required for other purposes (e.g., post surgery) a closed continuous irrigation system should be used. An individual care regime designed to minimise the problems of blockage and encrustations should be implemented for patients with long term indwelling catheters. Catheter maintenance solutions must be prescribed on an individual patient basis for each patient. An aseptic technique should be used during instillation and a new sterile drainage bag attached after the procedure. Catheter specimens of urine should only be taken from the drainage tubing sampling port using a non touch technique and preferably a needleless system.

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Removal of catheters

Remove indwelling catheters promptly when no longer required. This may be achieved through the following:

Daily review of the need for catheterisation by nursing and medical staff. Implementing a procedure specific guideline for post operative catheter removal Placing reminders into the patients chart or the electronic patient record if available. Implementation of care bundles.

Change catheters used for long term catheterisation as per the manufacturers instructions and individual patient requirements (e.g., before blockage occurs or is likely to occur). Check catheterto ensure it is intact. Document in patients notes why it was removed.

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Catheter specimens of urine (CSU)

Catheter specimens should only be taken when

clinically indicated.
Catheter specimens of urine should only be

taken from a disinfected ( with 70% alcohol and allowed to dry) sampling port using a non touch technique and preferably using a needleless system.
Document that specimen was taken and why in

patients notes.
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Soon to be realised are SARI Guidelines for the Prevention of Catheter-associated Urinary Tract Infection

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References

Smyth ET, McIlvenny G, Enstone JE, Emmerson AM, Humphreys H, Fitzpatrick F, et al. (2008)Four country healthcare associated infection prevalence survey 2006: overview of the results. J Hosp Infect 69(3):230-48. Tenke P, Jackel M, Nagy E (2004) Prevention and treatment of catheter-associated infections: myth or reality? EUA Update series 2: 106-15 Pomfret I.(2006) Nursing & Residential Care, October Vol 8, No 10 Joanna Briggs Institute (2003) Aged Care Practice Manual 2nd Edition Adelaide :JBI NHS Quality Improvement Scotland (2004) Best Practice Statement Urinary Catheterisation and Catheter Care www.nhshealthquality.org Marklew A( 2004), Nursing in Critical Care 2004 Vol 9 No 1 Urinary catheter care in the intensive care unit. Pratt et al. (2007) epic 2: National Evidence-Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England. Journal of Hospital Infection; 65: S1S64. Dougherty L. Lister S. (2008) Royal Marsden Manual of Clinical Procedures (7th edn). Naish W .et al (2007) Urinary tract infection: diagnosis and management for nurses. Nursing Standard. 21, 23, 50-57. Pellowe et al (2004) The epic project Updating the evidence based for National Evidence-Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England. British Journal of Infection Control Healthcare Infection Control Practices Advisory Committee (HICPAC) (2009) Guideline for prevention of catheter-associated urinary tract infections 2009

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Any questions?

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