Management of long-term urethral catheters: minimizing complications

Staff and patient perceptions of a community urinary catheter service

Introduction

Urinary catheters are used extensively throughout healthcare for various reasons including management of urinary tract dysfunction. The purpose of this study was to simultaneously explore both catheter user experience and staff perception of catheter services within community urinary catheter care.

Methods

A questionnaire was conducted to investigate the views of community nursing staff. During the same time period, patients were interviewed about i) catheter-care standards and adherence to guidelines ii) patients' feelings towards their catheter and iii) potential improvements to catheter practices and design.

Results

Sixty-nine staff were surveyed. Although 97% of staff indicated they used local guidelines, in up to 62% of cases findings suggested practices in sending urine samples for culture did not comply with guidelines. Seventy-five percent of staff were satisfied with catheter care, but weaknesses were identified in handover processes, communication between staff and patients, and excessive documentation. Staff results were compared with the findings from interviews of 29 long-term urinary catheter users, demonstrating a higher level of satisfaction with catheter care amongst patients (86%). Patients and staff agreed that generally the impacts of their catheter on personal hygiene, sense of independence, sense of dignity and of patient happiness, were neutral (neither positive nor negative). However, regarding improvements to catheter practices and catheter design; 73% of staff but only 45% of patients suggested improvements in service, while 76% of patients but only 49% of staff suggested improvement in design.

Conclusion

The study reveals general satisfaction with community catheter care, but indicates areas of potential improvements regarding communication, documentation and catheter design. When compared to patient responses, staff overall had a less positive view of patients perception of their relationship with their catheter.

Systematic Review of Interventions to Reduce Urinary Tract Infection in Nursing Home Residents

BACKGROUND

Urinary tract infections (UTIs) in nursing homes are common, costly, and morbid.

PURPOSE

Systematic literature review of strategies to reduce UTIs in nursing home residents.

DATA SOURCES

Ovid MEDLINE, Cochrane Library, CINAHL, Web of Science and Embase through June 22, 2015.

STUDY SELECTION

Interventional studies with a comparison group reporting at least 1 outcome for: catheter-associated UTI (CAUTI), UTIs not identified as catheter-associated, bacteriuria, or urinary catheter use.

DATA EXTRACTION

Two authors abstracted study design, participant and intervention details, outcomes, and quality measures.

DATA SYNTHESIS

Of 5794 records retrieved, 20 records describing 19 interventions were included: 8 randomized controlled trials, 10 pre-post nonrandomized interventions, and 1 nonrandomized intervention with concurrent controls. Quality (range, 8-25; median, 15) and outcome definitions varied greatly. Thirteen studies employed strategies to reduce catheter use or improve catheter care; 9 studies employed general infection prevention strategies (eg, improving hand hygiene, surveillance, contact precautions, reducing antibiotics). The 19 studies reported 12 UTI outcomes, 9 CAUTI outcomes, 4 bacteriuria outcomes, and 5 catheter use outcomes. Five studies showed CAUTI reduction (1 significantly); 9 studies showed UTI reduction (none significantly); 2 studies showed bacteriuria reduction (none significantly). Four studies showed reduced catheter use (1 significantly).

LIMITATIONS

Studies were often underpowered to assess statistical significance; none were pooled given variety of interventions and outcomes.

CONCLUSIONS

Several practices, often implemented in bundles, such as improving hand hygiene, reducing and improving catheter use, managing incontinence without catheters, and enhanced barrier precautions, appear to reduce UTI or CAUTI in nursing home residents. Journal of Hospital Medicine 2017;12:356-368.

Issues for people living with long-term urinary catheters in the community

People with a long-term urinary catheter living in the community often experience catheter-related issues, however, the frequency and extent of these issues has not been well described in the literature. A survey on issues clients (n = 62) experience with their long-term urinary catheter was conducted in one community health service. The majority (79%) had experienced at least one issue in the last two years, 62% had urinary tract infections, 33% had an emergency department visit and 29% had leakage. Discomfort at catheter change was at least moderate in 32% and predictive of more interference from the catheter in clients' daily lives and 55% reported at least moderate interference from the catheter in their daily lives. In conclusion, most clients with long-term urinary catheters experience issues and interventions need to be assessed for effectiveness in decreasing these problems.

Older people, continence care and catheters: dilemmas and resolutions

Urinary incontinence (UI) is a common problem and has a profound impact on quality of life among older people. There are various nursing interventions and treatments which can improve UI for the majority of people. Catheterization should be considered for specific clinical indications only when other options have been ruled out. Many complications are associated with catheterization, including catheter-associated urinary tract infections (CAUTIs), which are the most common cause of hospital-acquired infections. It is important for nurses and other healthcare professionals to appreciate how catheters produce infection so that appropriate catheter care is used. The best way to avoid CAUTI is to avoid catheterization, whenever possible, and to remove indwelling catheters when they are no longer required. There is a need to raise public awareness about UI and the interventions and treatments available so that more older people seek help. The challenge for nurses is to avoid using catheters and develop alternative approaches to the care of older people with incontinence.

Relationship between catheter care and catheter-associated urinary tract infection at Japanese general hospitals: A prospective observational study

BACKGROUND

The risk factors for catheter-associated urinary tract infections (CAUTIs) that are associated with catheter care have not been examined in detail by prospective studies or randomised clinical trials.

OBJECTIVES

To examine the patterns of catheter care and to identify the CAUTI risk factors associated with catheter care.

DESIGN

Prospective observational study.

METHODS

Between January and December 2004, 555 adult patients who were catheterised for 3 days in five general hospitals in Japan were surveyed. One researcher collected the following data twice a week: catheter insertion method, catheter management, and signs and symptoms of urinary tract infections. The relative risk exceeding 1 by the Poisson regression were selected for Cox proportional hazard analysis in order to calculate adjusted risks. In addition, expected reductions in the incidence of CAUTIs by elimination of the risk factors were estimated using the population attributable risk percent.

RESULTS

The mean duration of catheterisation was 25 days. The overall incidence of CAUTIs was 3.9 cases per 1000-device days; the incidence of CAUTIs ranged from 0.6 to 7.2 cases per 1000-device days among the five hospitals. Only fecal incontinent patients were analysed since they accounted for 94% of the CAUTI cases. In the univariate analysis, the silver-alloy catheter, which contains antimicrobial property, emerged as a potential risk. Since silver-alloy catheters were used in only one hospital, silver-alloy catheter care was compared with that of the other types of catheter, and a significantly higher percentage of inappropriate care was observed. In the final Cox model, two variables remained: 'non-pre-connected closed system (standard system)' (RR 2.35, 95%CI 1.20-4.60, p = 0.013) and 'no daily cleansing of the perineal area' (RR 2.49, 95%CI 1.32-4.69, p = 0.005). The population attributable risk percent suggested that the use of a 'pre-connected closed system' and 'daily cleansing of the perineal area' could reduce the incidence of CAUTIs by nearly 50%.

CONCLUSIONS

Our investigation identified fecal incontinence as the major risk factor for CAUTIs in the study population. However, attributable risk percent indicates that the implementation of two basic elements of catheter care could reduce CAUTIs by nearly 50%. The hospital using silver-alloy catheters had the highest CAUTI rates, strongly suggesting the hazards of relying on the antimicrobial property of silver and the resultant laxity in care.

Aerobic Bacterial Culture of Used Intravenous Fluid Bags Intended for Use as Urine Collection Reservoirs

Numerous studies have shown a relationship between indwelling urinary catheters and bacterial urinary tract infection. Some veterinary hospitals utilize stored, used intravenous (IV) fluid bags as part of the urine collection system. The authors cultured 95 such bags to see if they were potential sources of bacterial contamination. Forty-two unused IV bags were emptied of their contents for use as controls. Results indicated no aerobic bacterial growth in either group. The authors conclude that properly stored, used IV bags are unlikely sources of aerobic bacterial contamination when used in a urine collection system.

Managing the self: living with an indwelling urinary catheter

AIMS

This paper reports the findings of a study that aimed to understand the perspectives of community dwelling adults' who lived with a permanently indwelling urinary catheter. The objectives of the research were to: reveal the participants' perspective of living in the community with a permanent indwelling urinary catheter, raise awareness of the experiences of catheterized men and women and to inform community nursing practice.

BACKGROUND

Catheter care is a common nursing intervention. Clinical Nurse Consultants (CNCs) with a focus on continence drove this inquiry because it was believed that Community Nurses may underestimate the impact that a permanently indwelling catheter may have on peoples' lives.

DESIGN

Structured interviews were undertaken with twelve men and nine women (n = 21), aged between 24 and 82 years and who had a permanently indwelling catheter (either urethral or supra pubic) for longer than six months. Analysis of the interview transcripts was a collaboration between the researchers and clinicians.

RESULTS

The most significant finding was that participants wanted to learn urinary catheter self-care as this allowed them to take control and gave relevance to their daily life. Data revealed a learning pattern consisting of seven interrelated themes as people have learned to self-manage: (i) resisting the intrusion of a catheter, (ii) reckoning with the need for a catheter, (iii) being vigilant for signs of problems, (iv) reconciling between the needs of self and others, (v) reclaiming life, (vi) managing self-care, and (vii) taking control.

CONCLUSIONS

We do not suggest that people undergo a straightforward path toward catheter self-care, rather, that the seven interactive themes we have identified may be useful for observation in nursing practice whilst sensitizing nurses to clients' experiences of living with a catheter.

RELEVANCE TO CLINICAL PRACTICE

Promoting self-care of a catheter is not simply about educating clients about their condition or giving them relevant information. It is intrinsically a learning process, observing responses to every day events, such as the identification of the different sounds and sensations that may alert the individual to a full catheter bag, urine that has stopped flowing or signs of impending infection.

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.

Caring for catheterized patients: urinary catheter maintenance

This article brings together the evidence and opinions surrounding the ongoing problem of catheter blockage and how to help maintain catheter life. The reasons behind blockage are examined as well as the roles that pH testing and building a comprehensive catheter history, including all aspects of patients' general health, play in caring for the catheterized patient. The use of catheter-maintenance solutions is addressed with discussion on smaller volumes, the use of double instillations and gentle technique for a shorter time of instillation and improvement in catheter-intervention techniques.

Incidence of catheter-associated urinary tract infection among dogs in a small animal intensive care unit

OBJECTIVE

To determine incidence of and possible risk factors for catheter-associated urinary tract infection (UTI) among dogs hospitalized in an intensive care unit and compare results of bacterial culture of urine samples with results of bacterial culture of catheter tips.

DESIGN

Prospective study.

ANIMALS

39 dogs.

PROCEDURE

A standard protocol for aseptic catheter placement and maintenance was used. Urine samples were obtained daily and submitted for bacterial culture. When possible, the urinary catheter tip was collected aseptically at the time of catheter removal and submitted for bacterial culture. Bacteria that were obtained were identified and tested for antimicrobial susceptibility.

RESULTS

4 of the 39 (10.3%) dogs developed a UTI. The probability of remaining free from UTI after 1 day in the intensive care unit was 94.9%, and the probability of remaining free from UTI after 4 days was 63.3%. Bacteria isolates were generally common urinary tract pathogens and were susceptible to most antimicrobials. Specific risk factors for catheter-associated UTI, beyond a lack of antimicrobial administration, were not identified. Positive predictive value of bacterial culture of urinary catheter tips was only 25%.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that placement of an indwelling urinary catheter in dogs is associated with a low risk of catheter-associated UTI during the first 3 days after catheter placement, provided that adequate precautions are taken for aseptic catheter placement and maintenance. Results of bacterial culture of urinary catheter tips should not be used to predict whether dogs developed catheter-associated UTI.

Current practice of antibiotic prophylaxis for catheter procedures

The practice of giving prophylactic antibiotics to patients at the time of urinary catheter insertion, change or removal is variable since guidelines for their use have yet to be established. The use of prophylactic antibiotics to prevent urinary catheter-related infections and the possibility of bacteraemia and septicaemia, despite a lack of evidence for their efficacy, is a matter of concern in light of the reported overuse of, and increased resistance to, antibiotics. This article describes an audit of, and increased resistance to, antibiotics. This article describes an audit conducted in one trust to establish the current practice of antibiotic prophylaxis for urinary catheter procedures. The audit confirmed that in 60% of the recorded catheter procedures, patients were given antibiotics, usually gentamicin. Variations in gentamicin prophylaxis were revealed, including differences in the timing of administration relative to the catheter procedure. This audit revealed that intramuscular gentamicin was given simultaneously with the procedure or after the procedure in a number of cases, suggesting that on these occasions "prophylaxis" was suboptimal.

Developing alternative devices to the long-term urinary catheter for draining urine from the bladder

The self-retaining urinary catheter is used for long-term drainage of urine from the bladder only as a last resort because of serious associated complications, yet it remains a routine method for managing older and disabled patients with loss of bladder control. Blockage of the catheter from calcified deposits within its lumen is a common occurrence, obstructing the passage of urine and causing an urgent, unpredictable problem for patients, carers and the nursing staff. The need for further research on the subject has been recognized for many years. The SuPort Project aimed to develop an alternative suprapubic urine collection system. This report outlines the approach adopted towards the design and selection of the novel device, the production problems that ensued and the small clinical trial of a modified prototype.

The gastrostomy button as a catheterizable urinary stoma: a pilot study

PURPOSE

We assessed the impact of the gastrostomy button used as a catheterizable urinary stoma on the infection, encrustation and erosion rates, and quality of life in a series of 19 patients.

MATERIALS AND METHODS

Patients were selected as candidates for the button based on multichannel urodynamic studies that confirmed an areflexic neurogenic bladder. At study enrollment each patient completed a quality of life questionnaire based on a visual analog scale. If the patient had a preexisting indwelling suprapubic tube, it was replaced with a button. If no preexisting suprapubic tube was present, one was inserted. The button was then inserted approximately 1 month later after an adequate tract was established. For 1 year the patient underwent cystoscopy with urine culture every 2 months for a total of 6 times. Symptomatic infections were treated but asymptomatic colonization was not. A quality of life questionnaire was completed at each visit.

RESULTS

Of the 19 patients 10 had failure, necessitating button removal. These failures were due to an excessive suprapubic distance from skin to bladder, which prevented adequate button fit. All patients in whom the button remained showed significant improvements in quality of life. The colonization rate was 100% but the rate of symptomatic infections was low. The incidence of bladder stones was zero and the rate of encrustation was low.

CONCLUSIONS

When used as a catheterizable stoma to treat areflexic neurogenic bladder, a gastrostomy button is a safe, effective option for these patients. The rate of symptomatic infections is low, the risk of bladder stone formation is minimal and erosion was not observed in properly sized button insertions. The current limiting factor is the length of the button compared with the patient suprapubic measurement (length from skin to bladder). Each patient reported that quality of life with the button was significantly better than prior to button placement.

Troubleshooting common problems associated with long-term catheters

A catheter complications survey study, carried out over a 2-year period in three Bristol health districts, recorded 506 emergency referrals during a 6-month period (Kohler-Ockmore and Feneley, 1996). A further detailed study on 54 of the patients showed that 48% experienced catheter blockage and 37% reported urine bypassing. Urinary catheterization can cause many health problems; bacteriuria is inevitable in long-term catheterized patients (Cravens and Zweig, 2000). This article identifies some of the common problems that can occur with long-term catheters, makes recommendations and applies an evidence-based approach to catheter care. In order to identify and treat the associated problems, it is necessary to understand the anatomy and functions of the bladder. The article addresses this before examining the problems, which include: catheter blockage; bypassing of urine; catheter rejection and balloon non-deflation; and latex allergy. The psychological and social aspects, although not covered in this article, are also important and should always be considered along with all other aspects of care.

Catheterization and urinary tract infections: microbiology

Patients with urinary catheters are a substantial proportion of the total patient population and catheter care is an important area of nursing practice. Urinary tract infection associated with catheterization is known to be the most common nosocomial (hospital-acquired) infection. Urinary tract infections can be caused by exogenous microorganisms or endogenous faecal or urethral microorganisms. The different microorganisms which are responsible for causing urinary tract infections have particular characteristics. Many microorganisms form a biofilm, a living layer of cells which stick to the surfaces of the catheter and the catheter bag. Biofilms not only lead to urinary tract infections, but also they are associated with encrustation and catheter blockage. The article considers the microorganisms implicated in catheter-associated urinary tract infections and aims to develop an increased awareness of the characteristics of different pathogens which could lead to enhanced nursing practice and improved patient care.