Infection control manual - NHS Lothian

nhslothian.scot.nhs.uk

Infection control manual - NHS Lothian

INSERTION AND

MAINTENANCE OF

INDWELLING URINARY

CATHETERS IN

ADULTS

Author(s): Carol Rae, Audrey Pringle, Mary Brown

Version: 1

Page 1 of 11


Insertion and Maintenance of Indwelling Urinary Catheters in

Adults

Author(s): Carol Rae, Audrey Pringle, Mary Brown

Version: 1

Page 2 of 11

Summary of Recommendations

Date of Issue: March 2009 Date of Review: March 2012

1. Aim

Insertion and Maintenance of Indwelling Urinary Catheters in Adults

2. Statement

Catheter Associated Urinary Tract Infection (CAUTI) is the most common

nosocomial infection. Catheterisation places patients in significant danger of

acquiring a urinary tract infection (EPIC 2 2007). Urinary catheters are the

second leading cause of blood stream infections (Health Protection Scotland

2008).

3.Requirements

• A Health Care Professional who has been given formal training and is

competent in the procedure

• Where possible, informed patient consent should be obtained and

documented

• Prepare catheterisation equipment as per policy and ensure that

materials used are not contraindicated for each individual patient use.

• Consider containment options e.g. appropriate catheter bags for clinical

situations

4. Location

This procedure can be undertaken in a hospital, care home or domiciliary

setting.

5.Timing

When clinically indicated.

6.Procedure

1. Undertake procedure ensuring patient dignity and comfort is

maintained

2. Use of NHS Lothian Hand Hygiene Policy (2008) for

catheterisation Procedure

3. Thorough cleansing of glans penis/perineum to minimise risk of

urinary track infection

4. Procedure must be undertaken using NHS Lothian Insertion and

Maintenance of Indwelling Urinary Catheters

5. Maintain asepsis during procedure


6. Correct disposal of all equipment post procedure

7. After Care

• Regular review of necessity for indwelling urinary catheterisation using

urinary Catheter Maintenance Bundle (Health Protection Scotland

2008)

• Use of closed link system between catheter and urine bag to minimise

risk of Urinary Tract Infection (UTI). Only change urine bag weekly.

• Risk assessment is required to determine appropriate level of Personal

Protective Equipment (PPE)

• Hand Hygiene in accordance with NHS Lothian Hand Hygiene Policy

• Daily personal hygiene to minimise risk of urinary tract infection

• Any abnormalities/problems related to catheterisation or after care

must be clearly documented and shared with all staff providing the

patient care

• Symptomatic UTI’s should be treated as per NHS Lothian

“Management of Symptomatic Urinary Tract Infection in Catheterised

Patients”

• Patient leaflets are available on different aspects of catheterisation

• Further information can be obtained from the Continence Specialist

Nurses on 0131 537 4576 (Monday to Friday, 12.00-16.00) or the

Infection Control Nurses (via the hospital switchboard Monday to

Friday 8.00-16.00) or Microbiologist on call via hospital switchboard.

Within secondary care advice is available by telephoning Nurse

Urology, WGH 0131 537 1906/1874, Monday-Friday 8.00-17.30. For

advice out with normal working hours please contact NHS 24.

8.Obtaining a Urine Specimen – See page 10.

9.Patient Education – See page 10.

10.Further Help – See page 10.

References – See page 10.

Bibliography – See page 10.

Author(s): Carol Rae, Audrey Pringle, Mary Brown

Version: 1

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Author(s): Carol Rae, Audrey Pringle, Mary Brown

Version: 1

Page 4 of 11

NHS LOTHIAN

INFECTION CONTROL MANUAL

Insertion and Maintenance of Indwelling Urinary Catheters In Adults

1. Aim To minimise the risk of urinary tract infection as a result of urinary

catheterisation.

2. Statement Catheter Associated Urinary Tract Infection (CAUTI) is the most

common nosocomial infection. Catheterisation places patients in

significant danger of acquiring a urinary tract infection (EPIC 2 2007).

Urinary catheters are the second leading cause of blood stream

infections (Health Protection Scotland 2008).

Only use an indwelling urinary catheter after considering alternative

options.

Document the need for catheter insertion in the patient‘s notes.

Follow Urinary Catheter Insertion bundle developed by Health

Protection Scotland.

Follow the Urinary Catheter Maintenance Bundle developed by Health

Protection Scotland.

Regularly review the patient’s clinical need for continuing urinary

catheterisation and remove the catheter as soon as possible.


3.

Requirements

Healthcare Professional (HCP) who have been given formal training

and are competent in the procedure.

Author(s): Carol Rae, Audrey Pringle, Mary Brown

Version: 1

Page 5 of 11

Sterile Dressing or Catheterisation pack.

A non-sterile procedure pad to protect bedding

Appropriately sized sterile catheter to facilitate urine drainage. Type

of catheter will depend on anticipated duration of catheterisation,

existing latex allergy, length required (standard or female) and patient

choice. Please note that a standard length catheter must always be

used to catheterize a male patient per urethra.

Catheter balloon size should not exceed 10ml. Urological patients

may require a 30ml balloon catheter following surgery.

Patient allergies e.g. latex, lignocaine or silver. (Please note patients

with Spina Bifida should be considered as a potential “high risk” for a

latex allergy).

Sterile single use antiseptic lubricant if not contra-indicated.

Sterile single use plain lubricating jelly if antiseptic lubricant is contraindicated

or if this is the lubricant of patient’s choice.

Two pairs of Sterile Nitrile gloves.

Normal saline sachet for skin cleansing. Cooled boiled water is

acceptable cleansing solution in the community setting.

Appropriate legbag and night bag according to the patients clinical

need, mesh sleeve may be used instead of straps depending on the

patients preference.

Catheter retaining device to prevent traction.

Catheter valve if this option to be used in cognitively intact patients.

Night bag stand for bed bound patients.

A light source may be required.

Alcohol gel.

Informed consent should be obtained prior to procedure. The HCP

must document how consent was obtained. In a clinical emergency

e.g. acute setting, a doctor will authorise and document in the patients

medical notes. They should inform nurses that the patient now has

an indwelling catheter and needs appropriate support and advice.

Consider need for chaperone (NHS Lothian 2007).

4. Location At the bedside, theatre or clinical environment. Due care must be

taken to ensure patient’s modesty and privacy.


5. Timing Only use an indwelling urinary catheter after full consideration of

alternative methods of management.

6. Procedure Explain the procedure and the rationale for the catheterisation to the

patient/formal carer and gain informed consent (Scottish Executive

2006).

Check patient has no contra-indications that would prevent use of an

anaesthetic lubricant.

Where appropriate encourage the patient to have shower or bath prior

to procedure.

Apply plastic apron and perform a social hand wash as per NHS

Lothian Hand Hygiene Guidelines (2008a).

Prepare a trolley or appropriate surface with the required equipment

and take to patient’s bedside.

Ensure privacy, then prepare patient: preserve modesty by limiting

exposure of patient’s body.

Author(s): Carol Rae, Audrey Pringle, Mary Brown

Version: 1

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Place non-sterile procedure pad under buttocks to protect bed.

Wash hands as per NHS Lothian Hand Hygiene Policy (2008a)

ensuring hand asepsis.

Open the sterile dressing/catheterisation pack and aseptically place

necessary equipment onto the prepared surface.

Apply 2 squirts of alcohol gel and rub in well to hands.

Apply first pair of sterile nitrile gloves.

CLEANSING PROCEDURE

Female patients

Thoroughly cleanse the vulval area with Normal Saline (community

patients could use cooled boiled water) swabbing from above

downwards. Cleanse the labia minora vestible in turn swabbing from

above downwards to prevent contamination from anal region. Use a

separate swab for each stroke. Identify the urethral meatus and

cleanse.

Male patients

Cleanse the glans penis with Normal Saline (community patients

could use cooled boiled water). In non-circumcised patients, retract

the prepuce (foreskin) slightly to enable the glans penis to be

thoroughly cleansed and urethral meatus visualised. N.B. Do not fully

retract a phimotic or tight foreskin. Remember to return the foreskin

to its normal position following the procedure.


CATHETERISATION PROCEDURE

Author(s): Carol Rae, Audrey Pringle, Mary Brown

Version: 1

Page 7 of 11

Place non-sterile procedure pad on bed to protect bedding.

Apply sterile drape beneath the patient.

Apply sterile drape on top of patient leaving genitalia exposed.

Insert anaesthetic lubricant e.g. Instillagel into the urethra and wait

five minutes for local anaesthetic to work (6ml for women and 11ml

for men).

Catheterisation can take place immediately if plain lubricating jelly

instilled.

Discard first pair of gloves and apply 2 squirts of alcohol gel and rub

in well to hands.

Apply second pair of sterile nitrile gloves.

Position sterile bowl/container to catch urine.

Remove inner cover from the catheter and place the catheter in the

sterile container. Some clinicians may prefer to attach the sterile leg

bag to end of the catheter at this point.

Gently insert the catheter into the urethra and observe the flow of

urine.

Extra precautions/tips:

Female patients - Do not touch any part of the vulva with the

catheter. If the catheter is accidentally inserted into the vagina, leave

in situ and use a new catheter to be inserted into urethra. Remove

catheter from vagina.

Male patients - Hold the penis at a 90° angle to abdomen to help

facilitate smooth insertion of the catheter through the prostatic bed

and into the bladder. This should not cause the patient any

discomfort.

Hold catheter in place and instill sterile water into catheter balloon as

per manufacturer’s instructions. Apply catheter retaining device to

thigh and attach leg bag or mesh sleeve to calf or thigh as per

patient’s preference.

Ensure stand is available to hold night urine drainage bag whilst

patient in bed.

Check patient is cleaned of any lubricant and left dry. The patient

should not experience any pain/discomfort from the catheter.

Clear away any equipment, remove gloves and dispose of clinical

waste as per NHS Lothian Waste Disposal Policy (2008b).


Perform social hand wash.

Document procedure in patient’s notes as per Nursing and Midwifery

Council (NMC) Guidelines (2005): include reason for catheterisation;

insertion date and time; lubricant and catheter used with expiry dates,

batch numbers, number of milliliters, fluid in balloon and size of

catheter.

7. After Care Regularly review the continuing use of a urinary catheter (daily in

acute settings using the Urinary Catheter Maintenance Bundle) and

remove if safe to do so. In the community the need for continuing

catheterisation should be considered at each re-catheterisation.

Author(s): Carol Rae, Audrey Pringle, Mary Brown

Version: 1

Page 8 of 11

Document continuing care and review date in patient’s Care Plan.

Catheters should be changed in accordance with Manufacturer’s

instructions and reflect the clinical need of the patient.

Maintain closed link system between the catheter and leg bag or

drainable night bag to minimise the potential risk of introducing

infection into the bladder.

Risk assessment should be undertaken to establish level of personal

protective equipment (PPE). PPE must be used when emptying the

leg or night bag.

Change leg bag every 5-7 days as per manufacturer’s instruction (4

weeks if belly bag used). To maintain the closed link system, the leg

bag should be changed every 5-7 days and the non-drainable night

bag that is attached to the end of the leg bag is disposed of each

morning. A drainable night bag may be left insitu for 7 days.

Social hand wash should be done before and after any catheter care.

In a hospital or care home setting it is important to wipe the outlet tap

with an alcohol wipe, leave for 30 seconds to allow for air drying

before emptying the leg bag. Patients living at home should use a

tissue o wipe outlet after emptying.

The leg bag should be emptied when it is approximately ¾ full. Leave

5-10ml in the leg bag to prevent a “vacuuming” effect and apparent

catheter blockage that may result in unnecessary re-catheterisation.

In a hospital or care home setting this problem can be easily

remedied by aseptically opening the catheter and leg bag to allow air

into the system. The urine should then flow freely. Patients living at

home should wash hands thoroughly before and after disconnecting

the catheter and leg bag.

All catheterised patients should have daily cleansing of

perineum/glans to minimise potential risk of infection.

All HCP’s should report any abnormalities/problems to others involved

in patient care.


8. Obtaining

a Urine

Specimen

Patients with a long-term catheter in situ should have a Catheter

Record card describing their individualised care. This may include

specialist charts indicating appropriate use of Catheter Maintenance

Solutions (CMS) to prolong the life of a catheter when encrustation is

present, especially if living at home or in a care home setting.

Author(s): Carol Rae, Audrey Pringle, Mary Brown

Version: 1

Page 9 of 11

Record fluid intake and output where appropriate.

Monitor and record the patient’s temperature where appropriate.

Monitor and record urine abnormalities e.g. colour, odour and debris

and action to resolve e.g. increase fluid intake. Please note that all

patients with a long-term catheter will eventually have blood and

protein in their urine. This sign alone is NOT an indication for

antibiotic treatment (Scottish Intercollegiate Guidance Network 88

2006).

When symptomatic urine infection is present, change the urinary

catheter, obtain specimen of urine and send to Microbiology for

Culture and Sensitivities. Commence on appropriate antibiotics as

per NHS Lothian Antibiotic prescribing guidelines in adults (2008c)

and the Management of Symptomatic Urinary Tract Infection in

Catheterised patients (NHS Lothian 2008e). Change the catheter 48-

72 hours after commencement of antibiotics. Check results of urine

specimen. If organism sensitive to prescribed antibiotic, complete

course of treatment. If a different antibiotic is indicated, the catheter

should be changed 48-72 hours following commencement of second

antibiotic and patient instructed to take full course of treatment. In a

critical care situation, medical staff will prescribe appropriate

antibiotics and length of treatment. Please see full guideline in the

NHS Lothian Continence Protocol Manual (2008d), where

comprehensive information regarding Urethral and Supra-pubic

catheter issuescan be found.

Do not add antiseptics or antimicrobial solutions into the urine

drainage bag.

Deleted: Page Break

Obtaining a urine specimen e.g. for pH monitoring to determine if a

Catheter Maintenance Solution is required. This should be done via

the needle free port on the leg bag. The port should be cleansed with

an alcohol wipe and left for 30 seconds before specimen of urine is

obtained. It should be wiped with an alcohol wipe following the

procedure.


9. Patient

Education

10. Further

Help

Catheterised patients and their carers should be provided with verbal

and written information regarding the catheter and its maintenance.

An information booklet can be downloaded from NHS Lothian intranet

site sqiweb (Continence Care site).

These leaflets (male and female) include discussion on fluid intake,

personal hygiene, prevention of constipation and how to recognise

the signs and symptoms of urinary tract infection. They also identify

how supplies can be obtained in the community. The leaflets contain

a “troubleshooting” section so that the patient or carer can identify

and resolve simple problems independently.

Encourage daily shower, bath or bed bath. Use of simple soap and

water and dedicated flannel/cloth to cleanse the catheter area. Wash

catheter with downward strokes away from the body. Antiseptics are

not recommended.

Supra-pubic catheterisation - Full information regarding the

reinsertion of Supra Pubic catheters can be found on sqiweb as part

of The NHS Lothian Continence Protocol Manual (2008d)

The NHS Lothian Continence Protocol Manual (2008d) contains

extensive information from choosing the right catheter to dealing with

complications. This information is available on the NHS Lothian

intranet site sqiweb.

The Continence Care Service has a dedicated Advice Line for

professional use that operates 12.00-16.00 Monday to Friday 0131

537 4576.

Specialist Nurses are accessible all clinical areas to help advise and

support staff and patients on any aspect of continence or catheter

care.

Infection Control Nurses (ICN) are also available to give advice on the

prevention of UTI’s in catheterised patients. Contact ICN’s via the

hospital switchboard between 08.00-17.00hrs Monday-Friday. After

17.00hrs and at weekends contact Microbiologist On Call via

switchboard.

Sqiweb is the internet site for the Continence Care Service. This site

provides useful advice and information regarding all aspects of

continence and catheterisation care.

Within secondary care advice is available b telephoning Nurse

Urology, WGH 0131 537 1906/1874, Monday-Friday 8.00 – 17.30.

Author(s): Carol Rae, Audrey Pringle, Mary Brown

Version: 1

Page 10 of 11


REFERENCES

EPIC 2 (2007) National evidence based guidelines for preventing Health Care

Associated Infections in NHS Hospitals in England. Journal of Hospital

Infection 65S S1-S64. Also available on line http://www.epic.tvu.ac.uk.

Health Protection Scotland (2008) Urinary catheterisation bundle. Available

on line http://www.hps.scot.nhs.uk.

NHS Lothian (2007) Chaperone, intimate examination procedures and care

policy NHS Lothian Edinburgh.

NHS Lothian (2008a) Hand Hygiene Policy NHS Lothian Edinburgh.

NHS Lothian (2008b) Waste Disposal Policy NHS Lothian Edinburgh.

NHS Lothian (2008c) Antibiotic Prescribing Guidelines in Adults Policy NHS

Lothian Edinburgh.

NHS Lothian Continence (2008d) Continence Protocol Manual NHS Lothian.

NHS Lothian (2008e) The Management of Symptomatic Urinary Tract

Infection in Catheterised Patients.

National Midwifery Council (2005) Guidelines for records and record keeping

NMC London.

Pillow C (2007) Preventing healthcare associated infections when using

urinary catheters 3 (4)

Scottish Executive (2006) A good practice guide on consent for health

professionals in NHS Scotland Scottish Executive Health Department

Edinburgh.

Scottish Intercollegiate Guidance Network 88 (2006) Management of

suspected bacterial urinary tract infection in adults SIGN Edinburgh.

Bibliography

Royal College of Nursing (2008) National Occupational Standards for

Continence Care. Available on line www.skillsforhealh.org

NHS Lothian intranet sqiweb provides information and advice leaflets

on a variety of continence and catheterization issues.

Author(s): Carol Rae, Audrey Pringle, Mary Brown

Version: 1

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