Urinary incontinence affects people of any age and gender and can vary in severity from mild to very severe (National Institute for Health and Care Excellence [NICE], 2013). It is a common problem, with the Bladder & Bowel Community estimating that 12 million people in the UK are affected with a bladder or bowel problem, a figure that is probably underestimated (Bladder & Bowel Community, 2018).

Practice pointWhile catheterisation is a common procedure undertaken by healthcare professionals, it is neither simple nor risk-free (Booth and Clarkson, 2012).

According to the Health Economics Research Unit (HERU), about 15–25% of patients admitted to NHS hospitals each year will need urethral catheterisation, and approximately 5% are at risk of developing bacteriuria per day (HERU, 2015).

Bacteriuria is defined as the ‘presence of bacteria in the urine revealed by quantitative culture or microscopy’ (Fisher et al, 2017). Between 2 and 7% of catheterised patients will acquire bacteriuria every day despite best practice (Scottish Intercollegiate Guidelines Network [SIGN], 2012), with culture positive urine being effectively universal by 30 days across all clinical settings (Nicolle, 2014).

Causative pathogens may contaminate the urinary tract via a variety of sources. Endogenous bacteria are typically meatal, vaginal or rectal commensals. Exogenous sources include the contaminated hands of patients and healthcare personnel, as well as hospital equipment. Although Escherichia coli is classically the most common pathogen, many other strains have been isolated, including Pseudomonas aeruginosa, coagulase negative Staphylococcus and Candida species (Centers for Disease Control and Prevention, 2014). In long-term catheterised patients, two or more strains are commonly isolated (SIGN, 2012).

When entering the urinary tract, pathogens may migrate extraluminally via the outside of the catheter, or intraluminally through the catheter drainage system itself. There is little evidence to differentiate which route is more important in the pathogenesis of catheter-associated urinary tract infection (CAUTI), although the rapid decline in incidence following the introduction of closed catheter systems in the 1960s suggests that the intraluminal route may be of greater significance (Centers for Disease Control and Prevention, 2009).

Cost factsProgression from bacteriuria to CAUTI causes both increased risk to the patient and healthcare costs, i.e. longer hospital stays, treatment, etc (Loveday et al, 2014). Risk factors for progression to CAUTI include:
  • Female gender
  • Advanced age
  • Immunosuppression
  • Poor catheter care
  • Prolonged days with catheter inserted
  • Failure to maintain a closed catheter system (Loveday et al, 2014).
develop a CAUTI will have a severe complication, such as bloodstream infection (Loveday et al, 2014). CAUTI constitutes 8% of all hospital-acquired bacteraemia (presence of bacteria in the blood) (SIGN, 2012), with this figure rising to 50% in long-term healthcare facilities (Centers for Disease Control and Prevention, 2009).

The economic burden of catheterisation can be reduced by:
  • Ensuring that all catheterisation is completely necessary
  • Observing good catheter care
  • Monitoring the use of catheters
  • Ensuring timely cessation of catheter use to avoid prolonged, unnecessary use (see section below on CAUTI).

RATIONALE FOR URINAR CATHETER INSERTION

Urinary catheters are used when people have difficulty urinating naturally. Catheterisation can also help to empty the bladder before or after surgery and to help perform certain tests, such as haemodynamic monitoring during surgery, and continuous bladder irrigation for prevention of urethral obstruction from blood clots after genitourinary surgery.

Specific reasons for the insertion of a urinary catheter may also include:
  • Severe urinary retention and obstruction of urine outflow, for example, because of scarring or prostate enlargement
  • To improve comfort for those who are terminally ill
  • Non-healing sacral, buttock or perineal pressure ulcers or injuries in incontinent patients › Perioperative use during prolonged surgery, or during surgery of the genitourinary tract, or for patients with urinary incontinence
  • Measurement of urinary output in the critically ill
  • Urodynamic testing Imaging studies of the lower urinary tract (LUT)
  • To deliver medication directly into the bladder, such as chemotherapy for bladder cancer (Meddings et al, 2015).

Depending on the type of catheter in situ and why it is being used, the catheter may be removed after a few minutes, hours or days, or it may be needed for the long term (Fisher et al, 2017).

According to the guidelines of the author’s trust in line with the Nursing and Midwifery Council (NMC), nurses are required to maintain their own professional knowledge and competency regarding urinary catheterisation (NMC, 2015). Thus, it is the responsibility of the individual nurse to access training to ensure that they are competent to practice. Care assistants can undertake catheterisation with the support of a competent qualified nurse. The patient should be supported and encouraged to empty their bladder normally, and other alternative methods, such as trying to empty the bladder by drinking more, opening taps, or bladder stimulators or intermittent self-catheterisation should be considered before using indwelling catheterisation.

There should be a genuine clinical need for catheterisation, and the patient should be reviewed regularly. Catheters should be removed as soon as it is practical, or the patient’s condition allows (NICE, 2012; Loveday et al, 2014).

Patients should be informed of the risks associated with urinary catheterisation and it is essential to gain consent before carrying out a catheterisation procedure. Catheterisation care bundles form the care plan for patients and their catheters, and should be used to document catheter care and management. Risk assessment should be carried out before all catheterisations, especially in the community, to ensure the patient’s safety.

URINARY CATHETER COMPLICATIONS

Practice pointAccording to NHS England (2015), regular audits by the Healthcare Quality Improvement Partnership (HQIP), the latest being in 2010, show that despite the amount of guidance available, the quality of continence care remains variable across the country and poorer overall for the elderly. In the author’s clinical experience, many continence problems can be cured and certainly managed better.


Bladder spasms

Bladder spasms feel like abdominal cramps and are usually caused by the bladder trying to squeeze out the balloon that holds the urinary catheter in place. If spasms are causing distress, patients can be prescribed medication to help relax the bladder muscles (Davey, 2015).


Leakage/bypassing

Leakage around the urinary catheter is called ‘by-passing’. It is sometimes caused by bladder spasms, or it can happen when opening the bowel. It can also occur if the urinary catheter is blocked and stops draining. In the author’s experience, any incidence of urinary catheter bypassing has cost implications, as the catheter has to be changed to a different one, involving the cost of staff to perform this procedure. The following measures may help to prevent bypassing of urine around the catheter:
  • Use a small Charrière (Ch) size (diameter size) (10–12 Ch in women, 12–14 Ch in men)
  • Anticholinergic medication may help reduce bladder spasm
  • Consider using an all-silicone catheter which has a wider lumen and larger eyes to allow optimum drainage, rather than a hydrogelcoated latex catheter
  • Check for UTI
  • Avoid restrictive clothing
  • Check for constipation
  • Consider the position of the catheter and troubleshoot to find out cause of leakage
  • Secure the fixing device. Temporarily raise the urine bag above the level of the bladder to reduce suction and avoid occlusion of the drainage eyes by bladder mucosa.


Blockage

Blockage can cause a great deal of pain and needs urgent attention. Patients are advised to check that their drainage bag is below the level of their bladder, that the urinary catheter and tubing is not kinked or twisted, and that there are no clots or debris in the urinary catheter. However, if the urinary catheter fails to unblock and no urine is draining, patients are advised to contact their district nurse or GP immediately, as this could indicate acute urinary retention.

Expulsion

Practice pointUrinary catheters can sometimes fall out. If this occurs, patients should contact their district or specialist urology nurse immediately so that it can be replaced. If this continues to happen, patients may be referred to the urologist for further advice and reassessment of the type of catheter in use.


Infection

Infection will present as blood or debris in the urine (cloudy urine). The longer a urinary catheter has been in the bladder, the more likely this is to occur. Blood and debris can sometimes block the urinary catheter and when this occurs, patients are advised to contact their district nurse, GP or continence specialist nurse.

Urinary tract infection can also be detected when patients develop symptoms such as pyrexia (high temperature), discomfort, pain in the urethra, or increased confusion in those with dementia, etc. If this happens, patients can contact their district nurse or GP who will decide whether they need antibiotics and may send a urine sample for laboratory testing to find out the cause of the blood in the urine, such as renal problems, bladder cancer, etc.

However, it is important to remember that there will always be some bacteria in the urine if a patient has had a urinary catheter for more than a few days, so this does not necessarily mean that the patient has an infection and needs to take antibiotics (British Association of Urological Surgeons [BAUS], 2017).


Catheter-associated urinary tract infection

(CAUTI) Urinary tract infections (UTIs) are the most common healthcare-acquired infection (HCAI), accounting for 17.2% of all HCAIs, and between 43 and 56% of UTIs are associated with an indwelling urethral catheter (Loveday et al, 2014).

CAUTIs are likely to prolong hospital stays (an estimated 0.5–5 extra days), and increase readmissions and mortality (HERU, 2015). They are estimated to cost the NHS up to £99 million each year or £2,000 per episode (Loveday et al, 2014). They can also adversely affect quality of life, particularly older people, who are also more likely to be using catheters that are not appropriate for their needs. In the author’s clinical opinion, the aim should always be to:
  • Reduce avoidable harm to patients from inappropriate catheter days and CAUTI
  • Improve care
  • Reduce costs resulting from treating these infections.

CONCLUSION

Practice pointIn the UK, there are over 14 million adults who have bladder control problems and six and a half million with bowel control problems (Buckley and Lapitan, 2009). In addition, 900,000 children and young people suffer from bladder and bowel dysfunction (NICE, 2010).

In addition to the added cost that treating CAUTI incurs, there is also the additional use of NHS resources, greater patient discomfort and a decrease in patient safety.

Improving continence care provision through integrated services brings many benefits, including a better quality of life and more independence through finding solutions appropriate to individual needs, less reliance on pads and products by using alternative treatments, a reduction in admissions to hospitals and care homes, fewer complications, such as UTIs, faecal impaction and skin breakdown, and thus a reduction in costs.

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