Urinary Catheter Policy for Community Health Services, Inpatient Facilities and Primary Care

Policy for the management of Urinary Catheters Page 1 of 32

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The document describes the processes and procedures for insertion and management of urinary catheters for Staff in Community Health Services, Inpatient Facilities and Primary Care.

Key Words: Urinary Catheter, Infection Prevention & Control,

Version: Adopted document Approved by: QAC

Date Approved: 15 August 2013 Name of

originator/author:

Continence Team

Senior Nurse Advisor, Infection Prevention and Control

Name of responsible committee:

Infection Prevention and Control

Date issued for publication:

August 2013

Review date: January 2015 Expiry date: August 2015 Target audience:

All LPT Staff Type of Policy (tick

appropriate box)

Clinical



Non Clinical

NHSLA risk Management Standards if applicable: State Relevant CQC Standards

Outcome 8 –Infection Prevention and Control

Urinary Catheter Policy for Community Health

Services, Inpatient Facilities and Primary

Policy for the management of Urinary Catheters Page 2 of 32

Contribution List

Key individuals involved in developing the document

Name Designation

Chris Rippin Continence Lead Nurse Vera MacDonald Continence Lead Nurse Susan Baker Continence Lead Nurse Chris Hambridge Continence Lead Nurse

Amanda Howell Senior Nurse Advisor, Infection Prevention and Control Circulated to the following individuals for consultation

Name Designation

Una Willis Senior Infection Prevention and Control Nurse Antonia Garfoot Senior Infection Prevention and Control Nurse Deborah Moussous Senior Infection Prevention and Control Nurse Mel Hutchings Infection Prevention and Control Nurse

Fiona Drew Infection Prevention and Control Nurse Emma Spencer Lead Nurse, CHS division

Neil Hemstock Lead Nurse, FYPC division Claire Armitage Lead Nurse, AMH division Michelle Churchyard Lead Nurse, LD division

Diane Postle Lead Nurse and Professional Practice Bal Johal Head of Quality and Professional Practice Dr Margaret Leverment Occupational Health Physician

Bernadette Keavney Health, Safety and Security Manager Dr Andrew Swann Consultant Microbiologist

Tammy Bale Infection Prevention and Control Nurse CAUTI Safety

Thermometer work group

Leicestershire Partnership Trust

Version Control and Summary of Changes

Version

number Date

Comments

(description change and amendments)

1 Guideline reviewed

2 March-August

2013

Reviewed in line with NICE (2012) and Safety Thermometer requirements. Changed to policy and associated format

All LPT Policies and guidelines can be provided in large print or Braille formats, if requested, and an interpreting service is available to individuals of different nationalities who require them.

Did you print this document yourself? Please be advised that the Trust

discourages the retention of hard copies of policies and guidelines and can only guarantee that the policy/guideline on the Trust website is the most up-to-date version

Policy for the management of Urinary Catheters Page 3 of 32 Contents

Definitions that apply to this Policy Equality Statement 4 4 1.0 Summary 4-5 2.0 Introduction 5 3.0 Purpose 5

4.0 Roles and Responsibilities 5-6

5.0 Policy for the Management of Urinary Catheters in Community Health Services, Inpatient Facilities and Primary Care

6-17

6.0 Due Regard 17

7.0 Implementation Plan and Training Requirements 17-18

8.0 Monitoring and Audit Arrangements 18

9.0 Associated Documents 18-19

10.0 References 19-20

11.0 Appendices List 21

11.0 Appendices

Appendix 1 Community Management of Acute Urinary Retention 22 Appendix 2 STOP! Think! Is Catheterisation necessary 23

Appendix 3 When to Obtain a Specimen of urine 24

Appendix 4 Carers guide for Prosys drainage leg bag pack 25 Appendix 5 Essential steps to safe clean care: Urinary Catheter Care

Audit Tool

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Definitions and Abbreviations that apply to this policy ANTT Aseptic Non Touch Technique

Body Fluid splashes

Blood / blood stained body fluids or body fluids which have the potential for carrying blood borne viruses which could have the potential for transmitting infection by being splashed into the eyes, nose or mouth.

CAUTI Catheter Acquired Urinary Tract Infection CQUIN Commissioning for Quality and Innovation

CSU Catheter Specimen of Urine

HCAI Health Care Acquired Infection ISC Intermittent Self Catheterisation LPT Leicestershire Partnership Trust Mucocutaneous

exposure

Where the eye(s), the inside of the nose or mouth, or an area of non-intact skin of the healthcare worker are contaminated by blood or other body fluid.

NICE National Institute for Health Care Excellence

NMC Nursing and Midwifery Council

Personal Protective Equipment

Gloves, aprons, gowns, masks and eye protection.

PTFE Polytetrafluorethaline

UTI Urinary Tract Infection

Equality Statement

Leicestershire Partnership NHS Trust (LPT), Leicester. Leicestershire and Rutland PCT Cluster aims to design and implement policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and advances equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected

characteristics of their age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation.

In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which LPT is responsible, including policy development, review and implementation.

1.0 Summary

This document provides Trust-wide guidance for insertion of a urinary catheter and management of a patient with a urinary catheter thereby highlighting specific

implications for clinical practice; with particular reference to the publication: Infection Prevention and Control of Healthcare-Associated Infections in primary and

community care NICE (2012) and the national plan requiring action to reduce Healthcare associated infections, Department of Health (2003), it also has been developed in conjunction with the implementation of the Safety Thermometer (2011). Delivering harm free care is a national CQUIN with the first 4 harms being;

pressure ulcers, venous thromboembolism, catheter acquired infection and falls. It involves collecting data monthly on the 4 harms and submitting it to the NHS Information Centre; data is used by Trusts to benchmark, analyse improvements and target training. Financial penalties will be incurred by Trusts for avoidable harms

This document aims to:

 Standardise the care of urinary catheters, using evidence based guidelines to ensure best practice across the healthcare communities served by Leicestershire Partnership Trust

 Support the practice of ANTT for catheterisation and ensure that the patients privacy and dignity is maintained at all times

 Reduce the incidence of Urinary Tract Infections (UTI) related to indwelling urinary catheters

2.0 Introduction

Urinary Tract Infections are the largest single group of healthcare associated infections; and the presence of a urinary catheter and the duration of its insertion are contributory factors to the development of urinary tract infection (Emmerson 1996). Catheterising patients increases the risk of acquiring a urinary tract

infection. The longer a catheter is in place, the greater the danger of this risk. (NICE 2012).

3.0 Purpose

This policy is for the use of all staff employed within Leicestershire Partnership Trust to provide information for the management of urinary catheters.

4.0 Roles and responsibilities

4.1 Hospital Matron, Community Service Managers, On Call Managers and Heads of Services

It is their role and responsibility to:

 ensure that the policy for the management of urinary catheters is adhered to and that there is a clear process for dissemination

 ensure that staff are released to meet training needs

 Ensure that the Line Manager(s) are supported in monitoring compliance with this policy for the management of urinary catheters.

 assist in identifying physical and financial resources to assist in compliance with the policy

4.2 Line Managers

It is their role and responsibility to:

 Ensure that staff whose role includes urinary catheterisation attends mandatory catheter training on commencing employment with the trust (unless documentary evidence of previous competence can be produced) and keep records of attendance and non-attendance.

 Ensure that staff (as identified above) are L-Cat assessed by an assessor who has accessed the L-Cat assessor training prior to performing

catheterisations as part of their role.

 Work in line with the LPT Policy for Managing, Reporting and Investigating Incidents and Serious Untoward Incidents (NQ007)

 Contribute to Root Cause Analysis investigations as required 4.3 Healthcare Staff whose role includes urinary catheterisation It is their role and responsibility to:

 Attend mandatory urinary catheter training session on commencement of employment by the trust (or if included as an extended role, prior to the undertaking of this practice).

 Read and adhere to the Policy for the Management of Urinary Catheters.

 Report situation(s) where the equipment or facilities are not suitable to Ensure compliance to this policy to the line manager

 Contribute to Root Cause Analysis investigations as required

5.0 Infection Prevention and Control Policy for the Management of Urinary Catheters

5.1 Introduction to the Procedure

This policy has been developed to standardise practice according to current research and evidence base. It is designed to aid the health care professional in their decision making, training needs and provision of patient and carer information when inserting or caring for a urinary catheter.

As outlined in the department of Health Reference Guide to Consent to a procedure (2001), NMC (2008) and NICE (2012) the patient must give valid consent. They should understand the rationale, alternatives and consequences of being/not being catheterised and be provided with supportive written information in a format that they can understand. This process must be documented in the patient’s notes. Intermittent catheterisation (ISC) is the preferred alternative to indwelling

catheterisation providing this is safe and acceptable to the individual. The patient/carer must have received appropriate information. This should include a patient information leaflet on ISC and an ISC DVD which can be obtained from the Continence leads; also instruction from a competent practitioner must be provided and documented in the records when a patient or carer undertakes the procedure.

Patients managing their own catheters, and their carers, must be educated about the need for hand decontamination before and after manipulation of the catheter, a clean technique must be used for this procedure (NICE 2013)

This policy will focus on the following interventions:  Management of acute urinary retention (Appendix 1)

 Assessing and reviewing the need for catheterisation using the STOP! THINK Form (see Appendix 2)

 Procedure for inserting a urethral and suprapubic catheter  Documentation and record keeping

 Selection of catheter type

 Aseptic non touch technique (ANTT)

 On-going management and maintenance of catheter care

 Catheter acquired urinary tract infection (CAUTI) and antimicrobial guidelines 5.2 Assessing and reviewing the need for catheterisation

The insertion of a urinary catheter carries considerable risk. Urinary catheterisation is a major cause of urinary tract infection (UTI) in patients. There is consistent evidence that 80% of UTI’s can be traced to indwelling urinary catheters (National Audit Office 2004). The Trust has implemented the NHS Safety Thermometer which is a local improvement tool for measuring, monitoring and analysing patient harms which includes CAUTI. This policy and associated appendices support the

management of urinary catheters with the aim to prevent urinary tract infections associated with this indwelling device.

Initial catheterisation has to be authorised by a medical practitioner or in the case of acute retention; by a medical practitioner or Advanced Nurse Practitioner - ANP (the District Nurse may undertake this role for end of life care only) Appropriate

identification and risk assessment is crucial to inform the decision making process. (Appendix 1)

Infection, trauma, pain, blockage, bypassing and stricture formation are common complications following urinary catheterisation, affecting a patients quality of life (Royal College of Nursing 2012). The impact of this intervention should not be underestimated.

The STOP! THINK Form (Appendix 2) must be completed at every catheter insertion to ascertain the clinical need for catheterisation.

5.3 Complications of catheterisation (physical)

 Urethral trauma resulting in infection (and possible septicaemia)  Traumatic removal of catheter with the balloon inflated

 Urinary tract infection

 By-passing of urine around the catheter  Stricture formation

 Encrustation and bladder calculi  Urethral perforation

 Pain/bleeding  Catheter blockage

5.4 Documentation

Healthcare staff must record every catheter intervention clearly, accurately and correctly on the STOP! Think Assessment Form (Appendix 2). This should be filed in the patient’s community notes or the electronic version on SystmOne should be used. Healthcare staff must have an understanding of the importance of

documentation, and the legal and professional consequences of poor documentation (NMC 2008).

5.5 Selection of catheter type

The selection of the catheter to be used in the procedure is one of the most important aspects of catheterisation, if the outcome is to be effective and the risk minimised. Indwelling urethral catheters should only be used after alternative methods of management have been considered, (National Institute for Clinical Excellence 2012). When choosing a catheter there are certain factors to consider (refer to Catheter and Accessories Formulary, location on trust intranet site)  Length of catheter – Standard catheters can be used for male and female

urethral catheterisation. Female length catheters are available but must never be inserted into male patients. For supra-pubic use, standard length catheters must be used.

 Catheter Type – PTFE catheters should be used for all short term use (Maximum 28 days) For long term use hydrogel coated or all silicone catheters, which are licensed for maximum 12 weeks should be used. Ideally catheters should be changed before they block or before they encrust so much as to cause trauma on removal.

 Measured in Charriere (Ch) units, (catheters diameter in millimetres. 1Ch = ⅓ mm) always select the smallest size that will drain the bladder.

 12-14 for male  10-12 for female

Where a supra-pubic catheter has been inserted the size should be as specified by the urologist.

 Catheter balloon size – 10 ml only; the catheter is single use therefore the

balloon must not be deflated and re-inflated. Sterile water must be used (NICE 2012). The use of any other fluid will result in osmosis of the water with the balloon contents, resulting in crystal formation with the balloon.

5.6 Catheter drainage 5.6.1 Drainage systems

The choice of drainage systems to be used should follow individual assessment. However a closed system should be used to minimise risk of urinary tract infection (Pratt et al 2001). Single use night bags should be attached at the outlet of the leg bag and only used once then discarded. Leg bags should be changed every 7 days in line with manufacturer’s guidelines. Leg bags should be positioned below

bladder level to promote drainage and secured to prevent trauma to the urethra (NICE 2012). The exception to this is the use of a Belly bag.

5.6.2 Catheter valves

Catheter valves may be used (NICE 2013), but would be on the recommendation of the continence leads. If catheter valves are used they must be released regularly to prevent over-distension of the bladder. They are only suitable for people with mental awareness, have good manual dexterity, are mobile, physical awareness (can feel a full bladder) and who have adequate bladder capacity. They should be changed weekly (Fader et al 1997)

5.7 Aseptic non touch technique (ANTT)

Catheterisation is a skilled Aseptic procedure which must only be performed by a competent person who has undergone specific formal training and education. The practitioner must have attended the mandatory continence update bi-annually in line with the training for the management of catheterised patients. This includes staff for which catheterisation is a delegated duty/responsibility.

ANTT and sterile equipment are essential in the management of catheters as urinary tract infections are the second largest single group of HCAI’s in the UK (NHS Institute for Innovation and Improvement 2010). Designated dressing trolleys used for clean and sterile procedures should be used in inpatient areas. When not in use these trolleys should be cleaned and covered with an appropriate cover, which states ‘sterile/clean’ trolley only.

When carrying out catheterisation in a patient’s own home, the healthcare worker does not have access to specific equipment such as a procedure trolley. It is a requirement to ensure a suitable clean working area is achieved for example a bedside table, tray or chair.

5.8 Procedure 5.8.1 Equipment

 Sterile Vesica catheterisation pack (including sterile gloves)  Appropriate catheter

 Instillagel

 Universal specimen container if urine sample required.  Alcohol hand sanitiser

 Sterile water, syringe to inflate balloon if not included with catheter  Ridged catheter valve if required (Appendix 4)

5.9 All Urethral Urinary Catheterisation: 5.9.1 All Patients

Action Rationale

1. Explain and discuss the procedure with the patient and gain valid consent verbal, written or implied.

To ensure that the patient understands the procedure and gives valid consent.

2. Check the patient has no known allergies To prevent anaphylaxis or skin irritation

3. Ensure privacy and that there is appropriate protection on the bed, to prevent soiling or fluid ingress.

To ensure patient's privacy and protect bed

4. Assist the patient to get into the supine position with legs extended.

To ensure the appropriate area is easily accessible

5. Do not expose the patient at this stage of the procedure.

To maintain patient's dignity and comfort.

6. Wash hands using liquid soap and water. Dry thoroughly using single use disposable paper towels.

To reduce risk of cross infection from micro-organisms.

7. Prepare clean surface by wiping with a

detergent wipe, or suitable alternative placing all equipment required in easy reach.

To ensure a clean working surface

8. Open the outer cover of the Vesica

catheterisation pack and slide the pack onto a clean surface.

To prepare equipment

9. Open removal pack; put on the disposable plastic apron and disposable gloves using ANTT. (as per training and policy)

To reduce risk of cross-infection from micro-organisms

10. Remove cover that is maintaining the patient's privacy

To expose genitalia. 11. To remove the catheter deflate catheter balloon

using 10ml syringe allowing the syringe to fill without applying any traction on the plunger (keep urine bag attached)

To prevent cuffing of the balloon To reduce the risk of potential infection

12. Gently withdraw the catheter (and urine bag) To avoid discomfort for the patient 13. Dispose of catheter and used equipment

including apron and gloves according to Trust Policy

To ensure safe disposal of waste

14. Wash hands using liquid soap and water. Dry thoroughly using single use disposable paper towels.

To reduce the risk of infection

15. Open catheter insertion pack; spreading out the wrapping to form a sterile working area, put on apron and using waste bag as sterile glove position equipment ready for use on sterile field. Position the waste bag for easy use during procedure. Open package and place Instillagel syringe on sterile field and empty saline in to gallipot. Wash/decontaminate hands and apply sterile gloves using ANTT.

To minimise the risk of infection

16. Place sterile field under patient To protect the bed

5.9.2 Male Patients

1. Retract the foreskin, and clean the glans penis with 0.9% sodium chloride.

To reduce the risk of introducing infection to the urinary tract during catheterisation

2. Place sterile towel from catheter pack

over the patients’ genital area. To reduce the risk of introducing infection into the bladder 3. Hold the penis firmly with a sterile swab To straighten the urethra

raising until almost totally extended. Squeeze the anaesthetic lubricating gel in to the urethra, remove and discard the syringe.

Cover end of penis with sterile swab and wait 5 minutes

Adequate lubrication helps to prevent urethral trauma. Using 11mls local anaesthetic gel minimises the

discomfort experienced by the patient. To prevent leakage of lubricating gel and to allow the anaesthetic gel to take effect

4. Place the receiver containing the sterile covered catheter between the patient's legs. Maintaining hold of the penis insert the catheter until urine flows maintaining hold of the penis until the procedure is finished

If resistance is felt at the external sphincter, increase the traction on the penis slightly and apply steady, gentle pressure on the catheter. Ask the patient to cough or strain gently as if passing urine.

When urine begins to flow, advance the catheter almost to its bifurcation.

Gently inflate the balloon according to manufacturer’s instructions having

ensured that the catheter is draining freely beforehand.

Withdraw the catheter slightly until

resistance is felt on the bladder neck and attach it to the drainage system.

Support the catheter using an appropriate fixation device and ensure that the

catheter will not become taut when patient is mobilising or when the penis becomes erect. Ensure that the catheter lumen is not occluded by the fixation device, and urine is able to run freely.

Ensure that the glans penis is clean and then reposition the foreskin.

This manoeuvre straightens the urethra and facilitates catheterisation. The male urethra is approximately 18-21 cm long

Some resistance may be due to spasm of the external sphincter. Straining gently helps to relax the external sphincter

Advancing the catheter ensures that it is correctly positioned in the bladder

Inadvertent inflation of the balloon in the urethra causes pain and urethral trauma

To ensure catheter is correctly positioned

To maintain patient comfort and to reduce the risk of urethral and bladder neck trauma.

Retraction and constriction of the foreskin behind the glans penis

(paraphimosis) may occur if this is not done.

5.9.3 Female Patients

1. Using sterile swabs, separate the labia minora so that the urethral meatus is seen. Clean around the urethral orifice with 0.9% sodium chloride using single downward strokes

This manoeuvre provides better access to the urethral orifice and helps to prevent labial contamination of the catheter

2. Place sterile towel from catheter pack

across the patients’ thighs. To reduce the risk of introducing infection into the bladder 3. Using sterile swabs, separate the labia

minora so that the urethral meatus is seen. One hand should be used to maintain labial separation until catheterisation is completed.

Squeeze the anaesthetic lubricating gel in to the urethra, remove and discard the syringe. Wait 5 minutes to allow the gel to take effect.

Place the receiver containing the sterile covered catheter between the patient's legs. Introduce the tip of the catheter into the urethral orifice in an upward and backward direction. If there is any

difficulty in visualising the urethral orifice due to vaginal atrophy and retraction of the urethral orifice GENTLY lift the parted labia upwards towards the pubic bone. Insert the catheter until urine flows. Gently inflate the balloon according to manufacturer’s instructions having

ensured that the catheter is draining freely beforehand.

Withdraw the catheter slightly until

resistance is felt on the bladder neck and attach it to the drainage system.

Support the catheter using an appropriate fixation device. Ensure that the catheter does not become taut when patient is mobilising. Ensure that the catheter lumen is not occluded by the fixation device.

This manoeuvre provides better access to the urethral orifice and helps to prevent labial contamination of the catheter.

Adequate lubrication helps to prevent urethral trauma. Using 6mls local anaesthetic gel minimises the

discomfort experienced by the patient. To maintain sterility. This manoeuvre facilitates ease of catheter insertion. The female urethra is approximately 5cm long.

Inadvertent inflation of the balloon in the urethra causes pain and urethral trauma

To ensure catheter is correctly positioned

To maintain patient comfort and to reduce the risk of urethral and bladder neck trauma.

5.9.4 All Patients

1. Make the patient comfortable. Ensure that the area is dry.

If the area is left wet or moist,

secondary infection and skin irritation may occur

2. Observe the amount and colour of urine drained and document.

To monitor renal function and fluid balance. It is not necessary to measure

the amount of urine if the patient is having the urinary catheter routinely changed.

3. Take a urine specimen for laboratory examination, if clinically indicated (Appendix 3).

To ensure appropriate treatment and prevent routine prescribing of antibiotics 4. Dispose of equipment according to local

policy.

To prevent environmental contamination.

5. Record information in relevant documents; this should include:

 reasons for catheterisation  date and time of catheterisation  catheter type, length and size  amount of water instilled into the balloon

 batch number  manufacturer

 batch number and expiry date of Instillagel;

 any problems occurring during the procedure

 review date to assess the need for continued catheterisation or date of change of catheter.

To maintain accurate information. Attach sticky labels from equipment to documentation.

5.10 Suprapubic Catheterisation 5.10.1 Equipment

 Sterile Vesica catheterisation pack (including sterile gloves)  Appropriate catheter

 Instillagel

 Universal specimen container if urine sample required.  Alcohol hand sanitiser

 Sterile water, syringe to inflate balloon if not included with catheter  Ridged catheter valve if required (Appendix 4)

5.10.2 All Patients

Action Rationale

1. Explain and discuss the procedure with the patient and gain valid consent

To ensure that the patient understands the procedure and gives valid consent. 2. Check the patient has no known allergies To prevent anaphylaxis or skin irritation 3. There is less chance of the bladder going

in to spasm if there is urine in the

bladder. Use of a catheter valve prior to re- catheterisation to allow bladder to fill should be considered.

To reduce bladder spasm and trauma

4. Ensure privacy and that there is appropriate protection on the bed.

To ensure patient's privacy and protect bed

5. Assist the patient to get into the supine position.

To ensure the appropriate area is easily accessible

6. Do not expose the patient at this stage of the procedure.

To maintain patient's dignity and comfort. 7. Wash hands using liquid soap and water.

Dry thoroughly using single use disposable paper towels.

To reduce risk of cross infection from micro organisms

8. Prepare clean surface, placing all equipment required in easy reach. (dressing trolley to be used in inpatient areas)

To ensure a clean working surface

9. Open the outer cover of the Vesica catheterisation pack and slide the pack onto a clean surface.

To prepare equipment

10. Open removal pack; put on the

disposable plastic apron and disposable gloves using an aseptic non touch technique, as per policy.

To reduce risk of cross-infection from micro-organisms

11. To remove catheter deflate catheter balloon as manufacturer’s instructions and gently remove the existing catheter.

To prevent cuffing of the balloon

12. Use sterile gauze from removal pack to contain any leakage from stoma site.

To contain any urinary leakage. 13. Discard removal pack and old catheter;

remove gloves and apron then wash/decontaminate hands. Dry

thoroughly using single use disposable paper towels.

To reduce risk of cross-infection from micro-organisms

14. Open catheter insertion pack;

spreading out the wrapping to form a sterile working area, put on apron and using waste bag as sterile glove position equipment ready for use on sterile field. Position the waste bag for easy use during procedure. Open package and place sterile lubricating gel if required on sterile field and empty saline in to gallipot. Wash/decontaminate hands and apply sterile gloves using ANTT. Dry thoroughly using single use disposable paper towels.

To minimise the risk of infection

15. Clean thoroughly around existing catheter site using 0.9% Sodium Chloride. If

required administer sterile lubricating gel.

To ensure stoma site is clean and reduce risk of infection.

16. Remove gloves; wash/decontaminate hands and put on sterile gloves. Place sterile towel from catheter pack across the patients thighs

To reduce the risk of introducing infection into the bladder

17. Gently insert the new catheter; some resistance may be felt, this will ease when the catheter enters the bladder.

18. Insert the catheter until urine drains. Occasionally urine does not drain

immediately: this is dependent upon the level of urine in the bladder. Asking the patient to move or cough often promotes urine drainage. Do not inflate the balloon until urine drains.

To ensure that the catheter is in the bladder and has not entered the urethra. To ensure that the catheter is correctly positioned.

19. Once urine drainage has occurred half inflate the balloon leaving the syringe attached; gently withdraw the catheter until it is felt to be firm against the bladder wall then completely inflate the balloon to 10mls.

To prevent the catheter entering the urethra via the supra pubic route.

20. Attach the catheter to a previously

selected urine drainage system or valve. Clear away equipment and dispose of any urine drained as per clinical waste policy. Take off and dispose of gloves and apron. Wash hands. Dry thoroughly using single use disposable paper towels.

To maintain closed drainage system and reduce the risk of infection.

21. Record in the patients records:

 the reason for the catheter change  type of catheter used

 (Charriere length, material, balloon size batch no, manufacturer)  cleansing solution used  Lubricant

 any problems negotiated  date for re-assessment

 colour, amount and consistency of urine drained

 patient’s condition following catheterisation

To ensure the correct care is provided. To avoid duplication of care. To ensure all equipment has been used as

instructed by the manufactures as to avoid liability on the part of the nurse. To pass on care to other nurses as required.

5.11 On-going management and maintenance of catheter care

Maintaining a sterile continuously closed urinary drainage system is fundamental to the prevention of CAUTI. Breaches in the closed system, such as unnecessary disconnection of the drainage bag increase the risk of CAUTI and should be avoided. Fluid and dietary advice should include how much fluid to drink and awareness of patient’s health needs that may restrict fluid intake such as heart failure and renal impairment. Advice should be given on prevention of constipation which can lead to catheter blockage due to pressure on the urethra from a full rectum.

5.11.1 Meatal Cleaning

 Twice daily routine washing, bathing or showering using un-perfumed soap and water is all that is needed to maintain meatal hygiene

5.11.2 Procedure for emptying urinary drainage bags:

 Wash hands with liquid soap and water and dry using disposable single use paper towel.

 Use ProSys leg bag with sterile gloves as per catheter formulary (See Appendix 6 for full instructions).

5.11.3 Catheter Fixation

Principles Rationale

1.

Catheters must be fixed to the patient’s leg correctly to support the catheter. G strap or other fixation devices are recommended during the day alongside the leg straps provided with catheter bags. These must be changed if they become visibly soiled.

Catheter and catheter bag position must be alternated daily (from leg to leg)

Reduces unnecessary trauma to the bladder and urethra caused by tugging and dragging

To prevent erosion of the urethra and or pressure sores to the genital area 2. Never replace a used bag once it has

been disconnected from the catheter. A new bag must always be used

To reduce infection

3. Always use needle free sample port on bag to obtain catheter specimen of urine using a sterile syringe.

Please refer to CSU Flow chart regarding when to obtain a CSU (Appendix 5)

To maintain closed drainage system

To reduce CSU’s being sent unnecessarily.

4. The drainage bag must be kept below the

level of the patient’s bladder at all times To prevent back flow of urine into the bladder

5.11.4 Catheter Maintenance Solutions

1. Catheter maintenance solutions should only be used as part of a management plan for prevention of catheter blockage based on clinical need.

The solution should only be used following a patient assessment by a registered health care professional who will then arrange an authorisation and prescription.

To maintain urinary drainage, reduce blockage/encrustation and sustain urinary catheter life where appropriate in order to reduce the frequency of catheter replacement

To reduce unnecessary interventions and breaking of the closed system.

If a blockage occurs with no evidence of encrustation or treatment plan in place an Optiflo solution S may be attempted according to Patient Group Direction (PGD) for the ADMINISTRATION OF CATHETER PATENCY SOLUTION, OPTIFLO® S and blocked catheter flowchart (access via esource)

The effect of the treatment must be assessed, evaluated and reviewed and on-going care planned according to patient need.

For procedure follow manufacturer’s instructions

To reduce the incidence of hospital admission and re-catheterisation due to blocked catheter from debris or small blood clots which could be removed using mechanical catheter maintenance

5.12 Catheter Acquired Urinary Tract Infection (CAUTI) and Antimicrobial Guidance

When a urinary catheter is inserted into the bladder the chance of bacteria entering the bladder and colonising it is about 3-10% for each day of catheterisation Therefore, after one month almost all patients would be expected to have bacteria in the urine (bacteruria). They will commonly have white cells present too. As a consequence, a positive urine dipstick test for leucocyte esterase and nitrites is meaningless in a catheterised patient. A negative urine dipstick result can be helpful to rule out a UTI in patients with a short term catheter.

Cloudy bags and offensive urine are not indicative of a UTI. Advice should be given on fluid intake 1.5 – 2 litres per 24 hours providing patient is not on restricted fluid intake.

Catheterised patients should only be considered for antibiotic treatment if they develop symptoms of suspected UTI such as suprapubic pain, loin pain, fever, rigors or acute confusion without other obvious source (Appendix 3).

5.13 Patient/Carer Education

Wherever possible, patients and carers should be independent in the on-going management of the catheter. Information and advice should be given on hygiene, fluid intake, prevention of constipation, and correct use of drainage systems (NICE 2012).

All patients with a catheter in situ should be given relevant information. “Looking after your Urinary Catheter at home” Information for Patients and Carers leaflet; should be given when a patient is catheterised for the first time and is being discharged home from hospital or is being cared for in their own home or care home (available on the trust intranet site).

6.0 Due Regard

This policy provides LPT staff with clear information and procedures to ensure that patients, clients and carers receive timely, effective and appropriate care that reduces or eliminates the risk of healthcare acquired infections.

LPT want those accessing healthcare to feel confident that the care they receive will do them no harm.

There will be continuous monitoring of the operation of this policy and the associated procedures to ensure that they are not discriminating against any particular equality group and that there is equality of access to the protection that the procedures offer. This will be demonstrated by effective monitoring of relevant service user equality data.

All LPT policies are available in alternative formats on request both for staff and service users.

7.0 Implementation plan and training requirements LPT recognises the importance of education, training and audit.

Mandatory catheter training is identified through the organisations training needs analysis process for permanent employees including medical staff who work for LPT including those on bank, agency or honorary contracts within community facilities, in-patient facilities or primary care.

The Training Administration Team will annotate the record of all staff for whom training is indicated, according to the Training Needs Analysis, and if indicated to have competence in this practice on the Oracle Learning Management (OLM) database. Training may also be indicated for those who have been out of practice for some time or have identified gaps in skills or knowledge associated with the insertion and management of urinary catheters

Attendance on the relevant training and completion of the L-Cat assessment will assign competence to the individual’s record once confirmation of attendance and completion of the assessment has been received.

The OLM database can be utilised to provide efficient and accurate data for the monitoring of training and education activity, ensuring quality assurance

mechanisms are in place.

When a specific education or training need is identified, The Continence team will ensure that the relevant training and education is made available to the appropriate staff.

8.0 Monitoring and Audit Arrangements

Clinical audit seeks to improve patient outcome through a structured review of practices and results against standards and policies. Audit is particularly important

in infection prevention and control and contributes significantly to a multifaceted strategy to reduce rates of healthcare associated infections.

Incidents, accidents and trends relating to infection prevention and control through the organisations trend review group are important for the monitoring and action of the following:

 Compliance of the policy.

 Agreed action plans and audits of practice.

 Analysis of incidents and claims data relating to infection prevention and control

 Review of appropriate entries from the Safety Alert Broadcast system log relating to infection prevention and control

 Review of risks either through risk assessments or risk registers relating to Infection prevention and control

 Review of the centrally held inventory for staff attending training Policy review occurs every year unless national guidance changes.

Incidents where non-compliance with this policy is noted and are considered to be an actual or potential risk to safe patient care should be documented on an incident report form, by the person witnessing the incident.

Audits must be undertaken as per the organisational audit calendar and audits using the audit tool for Safe Clean Care (Appendix 5) must be undertaken when there is an identified breach in practice or improvement requirement through the root cause analysis process. Results will be presented to the divisional and organisational Infection prevention and control meetings/committees. 9.0 Associated documents

LPT Infection Prevention and Control Policy for Community Facilities, Inpatient Facilities and Primary Care

LPT Infection Prevention and Control Policy for Hand Hygiene in Community Facilities, Inpatient Facilities and Primary Care

LPT Infection Prevention and Control Policy for Personal Protective Equipment in Community Facilities, Inpatient Facilities and Primary Care

LPT Infection Prevention and Control Policy for Cleaning and Decontamination in Community Facilities, Inpatient Facilities and Primary Care

LPT Infection Prevention and Control Policy for Aseptic Non Touch Technique in Community Facilities, Inpatient Facilities and Primary Care

10.0 References

Department of Health (2001) Reference guide to consent to the procedure. London. Department of Health

Department of Health (2003) Winning ways: Working together to reduce healthcare – associated infection in England. London. Department of Health

Department of Health (2006) The Health Act: A code of practice for the reduction of healthcare – associated infections. London. Department of Health

Department of Health (2006) Essential Steps to safe, clean care. London. Department of Health

Department of Health (2008) The Health and Social Care Act – Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance. London. Department of Health

Emmerson A.M., Enstone J.E., Griffin M., et al (1996) the second national prevalence survey of infections in hospitals – overview of the results. Journal of Hospital Infection: 32, p175-190

Fader et al (1997) A multi-centre comparative evaluation of catheter valves. British Journal of Nursing. 6 (7) p 359-67. PubMed

National Audit Office (2004) cited in NHS Institute for Innovation and Improvement (2010) High Impact Actions for Nursing and Midwifery. The Essential Collection. Coventry.

National Institute of Clinical Excellence (2003) Infection Control No 2. Care of patients with long term catheters.

National Institute of Clinical Excellence (2012) Infection Control: Preventing healthcare associated infection in primary and community care.

National Institute of Clinical Excellence (2006) Urinary incontinence: The management of urinary incontinence in women

NHS Institute for Innovation and Improvement (2010) High Impact Actions for Nursing and Midwifery. The Essential Collection. Coventry.

NMC ((2008) Nursing and Midwifery Council. Code of Professional Conduct. NMC London.

NPSA (National Patient Safety Agency) Female urinary catheters causing trauma to adult males. 30th April 2009. NPSA/2009/RRR02

Pratt R.J., Pellowe C., Loverday H.P., Robinson N.G.W. (2001) The epic project: developing national evidence – based guidelines for preventing healthcare associated infections phase 1: Guidelines for preventing hospital acquired infections. Journal of Hospital Infection, 47 (supplement) p s1- 82

Pratt R.J., Pellowe C., Wilson J.A. et al (2007) epic 2: National evidence based guidelines for preventing healthcare associated infections in NHS hospitals in England. Journal of Hospital infection, 65 (supplement) p s1- 31

Robinson*** (2005) Clinical skills. How to remove and change a supra-pubic catheter. British Journal of Nursing. Vol 14. No 1

RCN (2012) Catheter Care RCN Guidance for Nurses. RCN. London.

Rew M., Woodward S. (2001) Troubleshooting common problems associated with long term catheters. British Journal of Nursing. Vol 10, No 12 p764-774.

The Royal Marsden Hospital (2005) Manual of Clinical Nursing procedures 6th Edition. Ch 16 p 330-347. Blackwell Science. Cambridge

11.0 Appendices

Appendix 1 LPT Pathway for the Community Management of Acute Urinary Retention in Adults.

Appendix 2 Urinary Catheter Assessment and Monitoring Form. Stop! Think! Is Catheterisation Necessary?

Appendix 3 When To Obtain and Send a Catheter Specimen of Urine Flow Chart

Appendix 4 Carers Guide for Using ProSys Drainage Leg Bag Pack. Appendix 5 Essential Steps to Safe, Clean Care: Urinary Catheter Care

Audit Tool

Policy for the management Urinary Catheters Page 21 of 27

COMMUNITY MANAGEMENT OF ACUTE URINARY RETENTION (AUR) IN ADULTS

Catheterise with appropriate catheter as per policy using Aseptic-Non-Touch-Technique and record residual drained. Adhere to current PGD for Instillagel. If unable to catheterise refer back to GP for onward referral.

Appendix 1

GP/Advanced Nurse Practitioner to diagnose that patient is in AUR and refer to -

Community Nurse or Intermediate Care Team (ICT County) or Rapid Intervention Team

(RIT City) Nurse to visit within 2 hours of referral

Brief assessment of patient to ensure painful urinary retention and confirm by bladder scanning. If more than 1 litre in bladder then admit. Obtain consent for catheterisation. Full patient assessment to

include previous urinary symptoms, drug history, bowels.

If additional drainage less than 300ml in the 4th hour,

patient stays at home. If drainage exceeds 300ml _{in the fourth hour GP to} arrange admission to Urology Unit. Send all relevant documentation with patient.

Ask patient to record intake and output for 24 hours.

Arrange visit the next day to do U&E blood test and Urinalysis dipstick. If nitrites positive send C.S.U. Clinical Observations B/P, Temp, Pulse.

If intake / output balance, continue catheter care as appropriate. Inform GP of any abnormalities. GP to prescribe Alpha Blockers for males.

If more than 1000mls negative fluid balance, GP to arrange admission to Urology Unit. Send all relevant documentation with patient.

Arrange treatment of any reversible causes of retention e.g. UTI,

constipation, medication induced. Arrange Trial without Catheter (TWOC) after 7 days. Male patient to commence on an alpha blocker the day before TWOC.

Successful TWOC and normal U&E arrange bladder scan in the community within one month. GP to review if any concerns.

Unsuccessful TWOC and/or abnormal U&E’s, infection, suspicion of prostate cancer, Benign Prostatic Hyperplasia not responsive to medication or 2nd episode of acute retention- GP to arrange Urology Outpatients appointment (at local Community Hospital if available). Provide patient information leaflet on catheter care and give Single Point of Access (SPA) number. Advise patient to Inform Nurse if leg bag filling rapidly (500ml bag full in less than half an hour).

Advise patient to empty leg bag after 3 hours. Contact patient 4 hours after catheterisation to check drainage in 4th hour and any problems.

Urinary Catheter Assessment & Monitoring Form

Stop! Think ! Is Catheterisation Necessary?

Ward/Unit/District Nursing Team ……….

Is the catheter in for Urinary Retention Yes No

If No have you considered another option Pads Intermittent Self Catheterisation Penile Sheath

Informed consent obtained Yes No

If No was Mental Capacity assessed Yes No

If no capacity was mental capacity assessment completed Yes No

If no why ……….

Procedure fully explained and understood by patient Yes No

Patient Catheter Information Booklet given Yes No

Catheter Type Short Term (up to 28 days) Long Term (5-12 weeks)

Urethral Supra-Pubic Date Change Due ……….

Routine change Blocked Catheter

Is patient pyrexial Yes No Urinalysis done Yes No

CSU Sent Yes No

Date Sent ……….

Aseptic Technique Yes No

Sterile Saline for Meatal Cleansing Yes No

If No specify cleansing agent used………..

Sterile Lubricant used Yes No

Lot Number ……….. Expiry Date ……….

Sterile closed drainage system used Leg Bag 2L Drainage Bag Catheter Valve

Method of securing to leg Leg Straps Yes No G Strap used Yes No

Catheter secured safely to leg Yes No

Post Insertion

Difficulty with catheter insertion? Yes No

Did any bleeding occur? Yes No

Volume of urine drained ……….

Colour of Urine ……….

If no urine drained state action taken ……… ……….. Print Nurse’s Name ……… Signature ...………. Job Title ……….. Date and Time …...………

Version 1 Number 2 Date: 13/05/2013

Patient Name:

NHS No:

D.O.B:

Allergies None Latex Lidocaine Medication Others …………..…... Please Specify

Catheter Label Information Attach Label From Catheter Package

When To Obtain and Send a Catheter Specimen of Urine

If an infection is suspected in a patient with a long term catheter DO NOT perform a urine dipstick test except for those on the AUR Pathway.

Is the patient systemically

unwell i.e. suprapubic pain,

loin pain, fever, or acute

confusion without other

obvious source

Yes

No

Do not send a Catheter

Specimen of Urine. Cloudy

bags and offensive urine are

not indicative of a UTI (refer

to antimicrobial guidelines)

Send Catheter Specimen of

Urine using needle free

port to obtain sample

GP or Nurse Prescriber to

prescribe treatment as stated in

Antimicrobial Guidelines for the

Management of Catheterised

Patients in the Community (NP104)

Catheter to be changed 24 hrs after

commencement of antibiotics.

Nurse taking sample has

responsibility to ensure CSU

result is followed up and

appropriate medication has

been prescribed. Document

result in notes and systm1.

Based on the Antimicrobial Guidelines for the Management of Catheterised Patients in the Community (NP104)

Appendix 4

Carers Guide for Using ProSys Drainage Leg Bag Pack

1. Wash and dry hands; apply non-sterile gloves and apron.

2.

Check client’s documentation; prepare client and area for leg

bag change.

3. Empty existing leg bag and discard urine.

4. Remove non-sterile gloves.

5. Wash/decontaminate and dry hands.

6. Peel open ProSys Drainage Leg Bag pack and place on firm

surface.

7. Open sterile glove packing and apply one sterile glove without

touching the outer surface of glove.

8. Using gloved hand; pick up second sterile glove by the edge

and insert hand.

9. Position new ProSys leg bag ready for use- Do Not Remove

protective cap.

10. Disconnect used leg bag from catheter.

11. Squeeze the end of the catheter with one hand to reduce urine

leakage.

12. Remove protective cap from the new catheter with other hand

and immediately connect the new ProSys Leg bag to the

catheter.

13. Ensure urine is flowing and make the client comfortable.

14. Discard equipment in the usual manner.

15. Remove and discard ProSys gloves and apron, wash and dry

hands