It is estimated that healthcareassociated infections (HCAIs) cost the NHS over one billion pounds per year (Mantle, 2015). However, financial implications are not the only consequence of HCAIs. Patient safety is compromised with an infection, which also increases the use of NHS resources. Urinary tract infection (UTI) is among the top six common HCAIs (alongside, meticillin-resistant Staphylococcus aureus [MRSA], Clostridium difficile [C. difficile], respiratory tract infections, wound/ surgical site infections, and poor hand hygiene), and these account for 80% of all HCAIs across healthcare settings (Mantle, 2015). 17.2% of these HCAIs are UTIs, and between 43% and 56% are associated with an indwelling urinary catheter (Mantle, 2015).

Reducing the incidence of inappropriate indwelling urinary catheterisation There is a risk of catheterassociated urinary tract infection (CAUTI) in both long- and shortterm indwelling urinary catheter use. This risk increases the longer the catheter remains in place (Loveday et al, 2014). This is well documented within National Institute for Health and Care Excellence (NICE, 2014) and epic 3 guidance (Loveday et al, 2014), so it is concerning that insertion of inappropriate urinary catheters, or prolonged use when no longer required continues (Shackley et al, 2017).

While CAUTI is a common healthcare associated infection (Pellowe, 2009), it is also potentially preventable with the implementation of best practice (NICE, 2017) and avoiding subjective catheterisation. Shackley et al (2017) suggested that 30–50% of urinary catheterisations are inserted without robust clinical indication. An indwelling catheter should not be inserted without comprehensive assessment to establish indication. In addition, alternative methods of management should always be considered before the use of indwelling catheterisation, i.e. it should be the last resort after other methods have been tried and failed (NICE, 2014; Simpson, 2017). Intermittent catheterisation (IC) or intermittent self-catheterisation (ISC) is seen as the gold standard for reducing the risk of infection (NICE, 2006) and should be used as an alternative to indwelling catheterisation wherever possible (Mantle, 2015).

Guidance to support healthcare providers understand the indications and contraindications of indwelling urinary catheterisation is widely available (Royal College of Nursing [RCN], 2012; Loveday et al, 2014; NICE, 2014). Such guidance supports:
  • Rationale for catheterisation
  • Consent
  • Catheter equipment
  • Procedure
  • Documentation
  • Patient education
  • Review and follow-up.

ASSESSMENT

Practice pointAs said, comprehensive assessment is required before an indwelling catheter is inserted and the healthcare professional must have a clear rationale for its use. The patient should also be involved in their care and provided with both written and verbal information to ensure that they can make an informed choice (RCN, 2012). The reason for catheterisation needs to be discussed with the patient and consent gained before insertion (NICE, 2014).

Assessment should consider the patient’s holistic needs, for example:Practice point
  • Has the patient had a bladder scan?
  • Are there any clinical signs of urine infection?
  • Does the patient have clinical indications for an indwelling urinary catheter?
  • Has an intermittent catheter been considered and discussed with the patient?
  • Has indwelling urinary catherisation been discussed with the patient and written information provided and consent gained?
  • Does the patient have any allergies?
  • Consider and document the patient’s current health status, including any long-term conditions, medical and surgical history, medications
  • Consider the health of the patient’s bladder.
It is also important to take into account the psychological implications of catheterisation and how the patient will cope with having a catheter, and if it will impact on their lifestyle — employment, home life, including sexual activity, sports and recreation, body image, confidence, socialising, travel and holidays (NHS England, 2015). Healthcare professionals need to provide support, reassurance and information to the patient, such as a urinary catheter passport and/or other written information (Jaeger et al, 2017; see below).

INDICATIONS

The clinical indications for urinary catheterisation include:
  • Monitoring renal function in critical care
  • Acute urinary retention
  • Chronic urinary retention with renal compromise
  • Instillation of medications, i.e. chemotherapy
  • Bypassing an obstruction
  • During and post specific surgeries
  • Supporting continence when the skin is compromised, and all other methods of management have failed (RCN, 2012).

REDUCING THE RISK OF CAUTI

Avoiding unnecessary urinary catheterisation prevents the risk of CAUTI. Healthcare professionals should therefore challenge the need for a urinary catheter and ensure that patient assessment is completed before carrying out the procedure. In circumstances where there is a clinical requirement for an indwelling urinary catheter, the risk of CAUTI must be considered and reduced by reviewing the need for the catheter and removing as soon as clinically appropriate (Mantle, 2015).

Catheterisation is an aseptic procedure and should only be carried out by a competent healthcare professional trained in urinary catheterisation. Ensuring infection control measures are taken reduces the risk of CAUTI.

Practice pointAvoiding unnecessary urinary catheterisation prevents the risk of CAUTI. Healthcare professionals should therefore challenge the need for a urinary catheter and ensure that patient assessment is completed before carrying out the procedure. In circumstances where there is a clinical requirement for an indwelling urinary catheter, the risk of CAUTI must be considered and reduced by reviewing the need for the catheter and removing as soon as clinically appropriate (Mantle, 2015). Catheterisation is an aseptic procedure and should only be carried out by a competent healthcare professional trained in urinary catheterisation. Ensuring infection control measures are taken reduces the risk of CAUTI.

EDUCATION, CARE PLAN AND INDWELLING URINARY CATHETER PASSPORT

Following patient assessment, an individualised catheter care plan must be compiled with clear documentation, including reason for catheterisation, catheter size, type, balloon size fixation and drainage system — free drainage or flip flow — with their rationale. Documentation must be clear and completed in a timely manner (Nursing and Midwifery Council [NMC], 2015).

A plan for the removal of the catheter should be formulated and documented at the point of catheterisation, which should be reviewed regularly to avoid prolonged indwelling catheter use (RCN, 2012).

A patient should never be transferred or discharged without a documented catheter care plan and/or catheter passport to avoid inappropriate and prolonged catheter use. Onward referral to urology specialists should be organised if indicated.

Practice pointProviding patients with an indwelling urinary catheter passport can support appropriate catheter care across secondary and primary care settings.

The passport contains patient information regarding, for example:
  • The catheter
  • Troubleshooting for a bypassing catheter
  • How and when to change the catheter drainage system
  • How and when to empty the catheter using the drainage system
  • Hand and catheter hygiene
  • Advice on fluid intake to maintain patency
  • How to have sexual intercourse with the catheter in situ.
The document also contains demographics, i.e. patient details and contact of care provider, date of catheter insertion, catheter and equipment information, reason for catheterisation, date for trial without catheter (TWOC), or catheter change.

This document can support catheter care from one service to another, i.e. from hospital into the community, or vice versa, and avoid prolonged inappropriate catheter use. The catheter passport also involves the patient in their catheter care, which has been found to be empowering (Jaeger et al, 2017).

Research has reported successful implementation of catheter passports, with improved catheter care (Jaeger et al, 2017). The main challenge, however, has been in implementing change with staff who perceive the catheter passport as additional work. On the other hand, patient compliance has been reported as good, with patients bringing their catheter passports to all clinical appointments, both in primary and secondary care settings (Codd, 2013).
 

PATIENT STORY

Mrs H is a 78-year-old lady who lives alone with age-related macular degeneration (AMD) which affects her central vision in her left eye. She is also registered partially blind due to having no vision in her right eye. She has four care calls a day and regular family support.

Mrs H is prone to falls due to her vision and was under the care of the physiotherapy falls and occupational therapy teams. She has adaptations in her home, such as a commode, handrails and profiling bed to support her needs and ability to live at home with support.

Following a fall which resulted in a fractured neck of femur, Mrs H was admitted to hospital and required a hip replacement. She was discharged home with an indwelling catheter on free flow in situ following surgery. A referral was made to the community nursing team for catheter care, with no subsequent information. The patient did not have a catheter passport. The community nurses created a catheter care plan, which did not include a reason for the indwelling catheter or a forward plan for the catheter. The care plan only documented type of catheter in use and date to change the catheter. Catheter equipment was ordered by the community team and was available in the home.

The author was contacted and asked to visit Mrs H at home, as she had accidentally pulled her catheter out walking from her bed, which was situated in her lounge, to the lounge chair halfway across the room. She had forgotten her catheter was on her night stand and due to limited vision had not seen it and subsequently the catheter came out.

On arrival, the author found the patient on the commode next to her bed. Mrs H had passed 350mls of urine. There were no clinical indications of urine infection, no pain or difficulty passing urine, no external signs of urethral trauma and Mrs H stated that she had the urge to void. Mrs H was asked why she had a urinary catheter, but she did not know. Her daughter arrived soon after and was also unclear as to why the catheter was in place. The author had read the patient’s catheter care plan within the home, however, this gave little holistic information and so she called the GP to gain further information about the reason for the urinary catheter. The GP confirmed no previous bladder or incontinence issues had been reported and that the catheter had been inserted before the surgery.

The author discussed the situation further with the GP and made a clinical decision to leave the catheter out, as following assessment it was not clinically indicated. The catheter was also potentially a greater falls and infection risk to the patient.

Fluid input and output charts were left in the patient’s home for a 24-hour period, which was discussed with the patient. The carers and family supported the completion of the chart due to the patient’s vision. A bladder scan was arranged for the following day and contact information was given for the community 24-hour service for the patient to access if required. Verbal information on reasons to contact the community nursing team and advice were given to the patient due to her eyesight. Written information was provided to the carers and family supporting Mrs H.

The author visited the patient the following day. She had continued to pass urine and the input balanced with the output on the fluid balance chart. A bladder scan showed 300mls pre-void and 0mls post void. The patient did not have any clinical need for an indwelling urinary catheter and had been at risk of CAUTI with each day the urinary catheter was left in situ.

The trust involved in this scenario subsequently implemented further training on individualised care planning to support holistic care. The importance of using the patient urinary catheter passport was also promoted within the services, with staff being encouraged to question the initial reason for an indwelling catheter and include this in their documentation with a concise plan and review for the catheter to ensure effective catheter care.

CONCLUSION

Ineffective communication between primary and secondary care services can result in prolonged indwelling urinary catheter use, which puts patients at risk of CAUTI each day the catheter remains in situ (Codd, 2013).

Ensuring that a patient has a full assessment before the insertion of a catheter and a clear clinical rationale for its use affords good indwelling urinary catheter practice. Providing patients with catheter education and written documentation in the form of a care plan or indwelling urinary catheter passport empowers patients. The care plan and/or catheter passport reduces the risk of inappropriate or prolonged catheter use when a patient moves between primary and secondary care services. Furthermore, patient education reduces the risk of CAUTI, which prevents the need for additional use of NHS resources.

Healthcare professionals should always challenge the use of an indwelling catheter if it is not clinically indicated. Clinical guidance provides information on catheter choice, insertion, catheter management and the removal of an indwelling urinary catheter in a timely manner to reduce the risk of CAUTI.

Improving communication between primary and secondary care services ensures that patients receive effective catheter care and/ or removal of an indwelling urinary catheter where appropriate. Accurate documentation, which is clear and individualised to meet the patient’s needs and completed in a timely manner, also supports continuity of care.

Currently, there is limited evidence on the effectiveness of urinary catheter passports for improving catheter care. There is also a lack of evidence regarding how many patients are discharged or transferred with an indwelling urinary catheter in situ with no care plan, catheter passport or forward plan. However, in the author’s clinical experience (see patient story), this is evident in practice and needs to be addressed both to ensure seamless care and to prevent patients being left with a catheter in place, which is no longer clinically indicated.

KEY POINTS

- There is a risk of catheterassociated urinary tract infection (CAUTI) in both long- and shortterm indwelling urinary catheter use.

- - An indwelling catheter should not be inserted without comprehensive assessment to establish indication.

- Patients should be involved in their care and provided with both written and verbal information to ensure that they can make an informed choice.

- A patient should never be transferred or discharged without a documented catheter care plan, and/or catheter passport to avoid inappropriate and prolonged catheter use.

- Ineffective communication between primary and secondary care services can result in prolonged indwelling urinary catheter use.

- Tools, such as the anagram HOUDINI, can help healthcare professionals to determine if a catheter is still clinically indicated.

References

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