Infection control manual - NHS Lothian

INSERTION AND
MAINTENANCE OF
INDWELLING URINARY
CATHETERS IN
ADULTS
Author(s): Carol Rae, Audrey Pringle, Mary Brown
Version: 1
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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
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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
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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
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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
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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
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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
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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
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