Catheter patrols: a unique way to reduce the use of convenience urinary catheters

[Palliative long-term urinary bladder drainage: the uro-geriatric point of view]

A serious voiding disorder or urinary incontinence represent indications for long-term catheterization of the urinary bladder. Treatment by a transurethral or suprapubic bladder catheter for life-long bladder drainage is accompanied by technical short-term complications and long-term sequelae. The mortality risk associated with inserting a suprapubic catheter is approximately 2% due to an incorrect bladder puncture. Long-term consequences of life-long bladder drainage are hematuria, infection, spasms, stone formation, obstruction, catheter loss, risk of falls and automanipulation especially in cognitively impaired persons. These constitute frequent reasons for emergency treatment or hospitalization. Further problem areas are dependency on caregivers to perform the catheter change and dermal problems in the area of the fistula stoma. To what extent this limits the quality of life of those affected remains unclear up to now. The acute complications and the long-term consequences of life-long bladder drainage make careful decision-making necessary after other therapeutic options have failed, are not appropriate or not desired.

A systematic review of the management of short-term indwelling urethral catheters to prevent urinary tract infections

BACKGROUND

Indwelling urinary catheterisation is a relatively common procedure in hospital settings, associated with potential risk of infection. Around 80% of urinary tract infections (UTIs) are associated with urinary catheters and the risk of infection increases in patients who are acutely ill. The objective of this review was to present the best available critically appraised evidence related to preventing infections associated with the use of short-term indwelling urethral catheters. This review is an update of a previous review published in 2004.

REVIEW METHODS

The review considered randomised controlled trials that included adult patients with short-term indwelling urinary catheters. The main interventions related to catheterisation techniques, meatal care, catheter composition, bladder irrigation, drainage systems, care delivery practices and education programs. The primary outcome of interest was the difference in the rates of UTIs between the intervention group and control group. This review was limited to short-term urethral catheters, so studies that evaluated long-term or suprapubic catheters were excluded.

SEARCH STRATEGY

The search included both published and unpublished studies with an initial limited search of MEDLINE and CINAHL databases undertaken to identify key words contained in the title or abstract, and index terms used to describe relevant interventions. A second extensive search used all identified key words and index terms. The third step included a search of the reference lists and bibliographies of relevant articles.

METHODOLOGICAL QUALITY

The methodological quality of the included papers was assessed using a checklist developed by the Joanna Briggs Institute. Two independent reviewers conducted critical appraisal and data extraction and any disagreements that arose were addressed through mutual discussion.

RESULTS

The review found six new studies in relation to catheter composition and delivery care practices interventions. Studies from previous review have been reported on in the results, discussion and conclusion sections. No one type of catheter was found to be better than another in terms of reducing the risk of bacteriuria in hospitalised adults. The incidence of catheter associated bacteriuria and funguria (CABF) was lower in adult trauma patients when nitrofurazone-impregnated catheters were used. Nitrofurazone-coated and silver alloy-coated catheters reduced the development of asymptomatic bacteriuria during short-term (< 30 days) use when compared with latex or silicon control catheters. Studies that compared immediate versus delayed catheter removal following operations found that early removal of catheter after operation was safe and that there was a tendency for increased infection with longer duration of catheterisation. Stop (prewritten) orders for urinary catheters resulted in a significant reduction in duration of inappropriate catheterisation days.There was no significant difference in infection rate using either sterile surgical or non-sterile insertion technique. The use of water for cleansing prior to catheter insertion was recommended. There was no additional benefit from specific meatal care other than standard daily personal hygiene and removal of debris. Infection rates were similar for both latex and silicone catheters. Comparisons between silver and Teflon coating clearly favoured the silver alloy coating.The use of a complex closed drainage system in the intensive care environment did not confer any additional benefit. Studies comparing types of junction seals and use of junction seals either prior to or following catheterisation found no clear benefit from using either preconnected sealed systems or sealed systems with the addition of silver releasing devices. Neither the addition of chlorhexidine nor hydrogen peroxide to the drainage bag was found to be effective at reducing UTI rates. The findings indicated there was a higher incidence of bacteriuria associated with Foley catheters compared with intermittent catheterisation (P < 0.025). A single RCT examined the effect on UTI rates of routine bag changes against no routine bag change. Routine bag changes were not advantageous in reducing the risk of infection.

CONCLUSIONS

Current RCT evidence suggests the use of a surgical sterile catheterisation technique is not required, and that tap water is sufficient for cleaning genitalia. Following insertion, daily hygiene around the meatal area is as effective as catheter toilets; and catheters impregnated with silver may reduce the incidence of catheter associated bacteriuria. Sealed (e.g. taped, presealed) drainage systems should not be relied upon as the sole mechanism for prevention of bacteriuria. The addition of antibacterial solutions to drainage bags and the routine change of drainage bags had no effect on catheter associated infection.Identified evidence consistently supported early removal of catheter after operations. New evidence was also identified to support the use of "stop orders" for urinary catheters in reducing prolonged unnecessary catheterisation. However, most of the recommendations arising from this review were based on single studies, often with limited numbers of participants.

IMPLICATIONS FOR PRACTICE

The following are some of the recommendations based on the best available clinical evidence.Use of stop order approach to physicians by nurses can be recommended to reduce prolonged unnecessary catheterisations.

IMPLICATIONS FOR RESEARCH

Most of the recommendations arising from this review were based on single studies, often with limited numbers of participants. There is an urgent need to replicate these studies in other clinical settings.Further high quality RCTs with adequate allocation concealment and blinding are required with a focus on examining current techniques and methods in catheterisation and management. In addition, there are cost implications associated with new technologies for indwelling urethral catheter management that have not yet been adequately addressed.

A case study looking at appropriate catheterization

The use of indwelling urinary catheters in older adults is not without its consequences. Catheters used appropriately are cost effective and very useful in clinical practice. However, what happens when catheters are used as a means of aiding the nurse rather than the patient? What sort of problems can practitioners inadvertently create? In this case study Mrs Seymour is tracked through the process of admission for osteoporosis. The relative advantages and disadvantages of catheterization are discussed.

Preventing and managing catheter-associated urinary tract infections

Since the Foley catheter was introduced in the 1930s it has become one of the primary sources of hospital acquired infections and long term urinary catheters used in community based patients account for some 4% of community nurses' time. This burden is likely to increase given the projected rise in life expectancy and size of the ageing population. This article considers the current literature around indwelling urinary catheterization and its management with a focus on long term catheterization in the community. The authors discuss contemporary strategies to manage or prevent CAUTI that are based on best practice guidelines. However, it is clear from the dearth of empirical evidence that there is an urgent need to establish well constructed research studies to investigate the prevalence of long term urinary catheterization in the community and the prevention and management of CAUTI.

Management of short-term indwelling urethral catheters to prevent urinary tract infections

BACKGROUND

This systematic review updates a previous review published in 2000. The objective of this review was to present the best available evidence relating to the prevention of catheter-associated urinary tract infections (UTI).

SELECTION CRITERIA

This review considered randomised controlled trials (RCTs) of adult patients with short-term urethral catheters. In the absence of RCTs, other research designs such as non-randomised controlled trials and before and after studies were considered for inclusion. Interventions of interest were those related to the prevention of catheter-related UTI and included: sterile versus non-sterile insertion technique, special coatings to catheters versus standard non-coated catheters, the use of flush solutions, the use of solutions added to urinary drainage bag, maintenance of a closed urinary drainage circuit, the use of antireflux valves, antibiotic creams applied to the external meatus-catheter interface, meatal care regimens, education programs, and changed care delivery practices. This review was limited to short-term urethral catheters, and so studies evaluating long-term or suprapubic catheters were excluded. The primary outcome of interest was the difference in the rates of UTI between experimental intervention and the control.

SEARCH STRATEGY

The search included both published and unpublished studies with an initial limited search of MEDLINE and CINAHL databases undertaken to identify key words contained in the title or abstract, and index terms used to describe relevant interventions. A second extensive search used all identified key words and index terms. The third step included a search of the reference lists and bibliographies of relevant articles. The databases searched included: CINAHL, MEDLINE, Current Contents, Cochrane Library, Expanded Academic Index, and Embase. The Dissertation Abstracts International database was searched for unpublished studies.

ASSESSMENT OF METHODOLOGICAL QUALITY

Methodological quality was assessed using a standardised checklist. Critical appraisal and data extraction were conducted by two independent reviewers; discrepancies were addressed through discussion with a third reviewer as required.

RESULTS

There was no significant difference in infection rate using either sterile surgical or non-sterile insertion technique. The use of water for cleansing prior to catheter insertion was recommended. There was no additional benefit from specific meatal care other than standard daily personal hygiene and removal of debris. Infection rates were similar for both latex and silicone catheters. Comparisons between silver and Teflon coating clearly favoured the silver alloy coating. The use of a complex closed drainage system in the intensive care environment did not confer any additional benefit. Studies comparing types of junction seals and use of junction seals either prior to or following catheterisation found no clear benefit from using either preconnected sealed systems or sealed systems with the addition of silver releasing devices. Neither the addition of chlorhexidine nor hydrogen peroxide to the drainage bag was found to be effective at reducing UTI rates. The findings indicated there was a higher incidence of bacteriuria associated with Foley catheters compared with intermittent catheterisation (P < 0.025). A single RCT examined the effect on UTI rates of routine bag changes against no routine bag change. Routine bag changes were not advantageous in reducing the risk of infection.

CONCLUSIONS

Current RCT evidence suggests the use of a surgical sterile catheterisation technique is not required, and that tap water is sufficient for cleaning genitalia. Following insertion, daily hygiene around the meatal area is as effective as catheter toilets; and catheters impregnated with silver may reduce the incidence of catheter associated bacteriuria. Sealed (e.g. taped, presealed) drainage systems should not be relied upon as the sole mechanism for prevention of bacteriuria. The addition of antibacterial solutions to drainage bags and the routine change of drainage bags had no effect on catheter associated infection. However, most of the recommendations arising from this review were based on single studies, often with limited numbers of participants. There is an urgent need to replicate these studies in other clinical settings.

Why catheterize?: audit findings on the use of urinary catheters

Urinary catheters can be associated with complications such as urinary tract infection, pain and discomfort. This article reports on an audit of 51 patients who had a urinary catheter inserted during their hospital stay. Urinary incontinence meant catheterization in 37.5% (n = 27) of cases, with 64.7% (n = 33) being catheterized by nurses. The study highlighted the need for accurate documentation and care planning; 15 patients did not have a plan of care for their catheter and only eight patients had a plan for the removal of the catheter. Catheterization is the most common cause of hospital-acquired infection, and therefore the use of catheters needs careful examination to reduce this type of infection. The question is raised whether catheterization is used as a convenience for nursing staff or as an essential aspect of care.

Indwelling catheter care: dispelling the misconceptions

Long-term indwelling catheters often are incorrectly used and managed. Nurses insert and manage catheters, yet studies have shown that most nurses have limited scientific knowledge in the area of catheters and their care. This article will review the Agency for Health Care Policy and Research guidelines for recommended catheter use and suggest troubleshooting tips for catheter-related problems. The problems of infection, catheter selection and size, urinary leakage, encrustation, catheter blockage, and inadvertent catheter removal will be addressed. Patient and caregiver education tips also will be listed.