Addressing the problems of long- term urethral catheterization

Addressing the problems of long- term urethral catheterization: part 1

Abstract This is that first of a two-part article looking at the indications for long-term urethral catheterization and good practice, including the use of aseptic non-touch technique used in insertion, and the choice of catheter length and Charrière size. The various routes that bacteria can take to the bladder are discussed, and the reduction in catheter- associated urinary tract infection (CAUTI) through the use of the closed drainage system is considered. It is essential that adequate information is kept relating to catheter care and catheter insertion; documentation, and what should be recorded in the casenotes is discussed. The article then examines the series of Department of Health initiatives aimed at reducing CAUTIs. Recent safety driving programmes related to the Quality, Innovation, Productivity and Prevention programme, Safety Express, quality indicators, nurse- sensitive outcome measures, high impact actions and Energise for Excellence in Care are more fully discussed. Case studies of areas displaying how their High Impact Actions have made marked improvements in catheter care and the reduction in CAUTI are reported.

Key words: Urethral catheters n Catheter associated urinary tract infection (CAUTI) n Closed (catheter) drainage system n Department of Health Safety Driving Initiatives for reducing CAUTI n Documentation

Catheterization of the urinary bladder is a procedure carried out for a wide variety of reasons. Catheters may be passed on an intermittent ‘in-out’ basis, usually when the individual learns how to catheterize his or her own bladder, or alternately, self-retaining catheters are inserted either by the suprapubic or the urethral route. However, although the indwelling catheter can be a necessary device to enable specific care plans, urinary catheters are not problem free, and should only be inserted when their use can be justified.

The foremost reason for catheter-related concerns is that of catheter-associated urinary tract infection (CAUTI). Part one of this article discusses the problems caused by CAUTI, the reasons for these occurring and recommendations made to reduce CAUTI. It follows the Department of Health (DH) initiatives from the last 10 years, that have been aimed

Mary Wilson

Mary Wilson is Advanced Practitioner for Bladder and Bowel Health, Humber NHS Foundation Trust, Westwood Hospital, Beverley, East Yorkshire

Accepted for publication: September 2011

at addressing CAUTI. Part two will consider potential problems that cause disruption and discomfort to the patient and increasing workload for the nurse whose responsibility it is to find a solution.

Aseptic non-touch technique (ANTT) The insertion of indwelling catheters is an aseptic procedure (Pratt et al, 2001; Pratt et al, 2007). Although asepsis has long been regarded as good practice for catheter insertion, more recently its importance has been internationally recognized; in the UK, ANTT is now the standardized aseptic technique (, and likewise is accepted in Australia and the USA.

The ANTT guidelines, a theoretical framework and other educational material, are available from the ANTT (2011) organization website, to enable staff training. This includes ANTT (2011a) Clinical Guideline for Indwelling Urinary Catheterisation, which provides a pictorial step-by-step guide through aseptic catheterization, the rationale for each action, additional notes and references. This package underscores the importance of maintaining good practice for nurses who have already completed their training and facilitates learning in those not yet qualified.

Catheter sizes: the rights and the wrongs For adults, there are two available catheter lengths: the standard (male) length of 40-45 cms and the shorter, female length of 23-26 cms. The female length should never be used for adult males, as there is the danger of the balloon being inflated before it enters the bladder. When this has taken place, serious consequences can result (National Patient Safety Agency, 2009). However, for paediatric male patients, there is a catheter of 30–31 cm available. For obese or chair-

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Box 1. Indications for long-term urethral catheterization

n Chronic urinary retention when intermittent or suprapubic catheterization is not an option or not agreed to by the patient (Wilson, 2008)

n Accurately monitoring urinary output in critically ill patients n Increasing comfort for terminally ill patients (Hart, 2008) n To allow healing of grade 3 or 4 pressure ulcers on the

trunk, where other measures have been inadequate (Doughty and Kisanga, 2010)

n Intractable urinary incontinence – as the last resort Source: Association for Continence Advice (ACA), 2007



bound females, the use of the standard length catheter allows easier access (Hart, 2008; Nazarko, 2009).

Another variable is the Charrière (Ch.), otherwise known as French Gauge indicating the diameter. As 1Ch. is equivalent to 0.33 mm, a 12Ch. catheter has a diameter of 4.0 mm. For routine drainage, 12-14Ch. is sufficient, although 14-16Ch. may be necessary if debris or particulates are present, and 18Ch. may be necessary for haematuria or clots (Hart, 2008).

The epithelial walls of the urethra lie in longitudinal folds (Figure 1) unless urine is being passed and can be easily

damaged. When a small Ch. catheter (12-14Ch.) is in situ, these folds close round the shaft (Devine, 2003). However, a larger Charrière does not allow this closure, and urine may then bypass the catheter (Rew and Woodward, 2001).

The use of a high Ch. catheter in men can result in the mucus-secreting paraurethral glands found within the male urethra becoming blocked, risking urethritis and infection (Robinson, 2006; Wilson, 2008). These glands are not found in the female urethra (Devine, 2003), which emphasizes the need for inserting a lubricant when catheterizing women. The requirement for the use of lubricant in a single-use container to minimize urethral trauma and infection is included by the National Institute for Health and Clinical Excellence (NICE) (2003) in their Infection Control Guidelines, and is now the advice given by many online NHS policies and guidelines written by PCT and Foundation NHS Trust personnel, suggesting that this practice is becoming routine.

The route of ascending infection in urethral catheterization Because of the short urethra, in female patients, bacteria enter the urinary tract along the external surface of the catheter, in the mucous sheath between the catheter and urethral mucosa; however, in both gender, micro-organisms can also ascend to the bladder via the intraluminal route, and this is the predominant route in male patients (Tenke et al, 2004).

In order to avoid this, a closed drainage system must be maintained and only broken for good clinical reasons; for example, the changing of the leg drainage bag or catheter valve (as recommended by the manufacturer but usually every 5–7 days). This should also be carried out if the leg drainage bag is damaged or if it becomes disconnected from the catheter.

The maintenance of a closed drainage system: the avoidance of CAUTI When the valve or the leg bag is changed, contamination of the lumen is avoided by hand decontamination, the use of non-sterile gloves and a non-touch technique. A night drainage bag can be added as a link system without breaking the closed drainage (NICE, 2003; Pratt et al, 2007). The literature review commissioned by the arm’s length body of the DH – the NHS Institute for Innovation and Improvement (NHS Institute) – suggested that the risk of infection fell from 97% with an open system to 8-15% when a sterile closed system was adopted as standard practice (although two of the three studies identified were from the 1970s) (NHS Institute, 2010).

Documentation of catheter care and catheter insertion As in the recommendations in both Epic guidelines (Pratt et al, 2001; Pratt et al, 2007) and other sources (DH, 2003; NHS Institute, 2010b), it is essential that adequate records are maintained relating to catheter insertion and subsequent care. The reason for insertion must be recorded, not only because this represents good practice, but it also enables those caring for the patient to assess the continuing need for the catheter, preventing the scenario of the patient being admitted with a catheter in situ but no documentation of why this should be.

Figure 1. Cross sections of the urethra to display longitudinal folds within the urethra. Kind permission for use given by CliniMed

Figure 2. Closed (link) catheter drainage system (Wilson, 2009)

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Documentation relating to the actual insertion must include consent, the manufacturer of the catheter, catheter name, material, length, Ch. size, balloon size, batch number and expiry date (usually supplied by the manufacturer in the form of a sticker that can be attached to the casenotes). It is also necessary to record the cleaning fluid and lubricant used, and whether a leg drainage bag or a catheter valve has been attached.

Information relating to genital and meatal abnormalities or discharge, likewise difficulties encountered or discomfort felt during insertion or balloon inflation and the amount and nature of the urine drained, must also be entered in the patient’s notes (Royal College of Nursing (RCN), 2008).

Regarding aftercare, verbal information and written backup when the patient or the carer is unfamiliar with catheter care is necessary and should also be recorded.

DH safety driving initiatives for reducing CAUTI CAUTIs not only cause problems for the patients with indwelling catheters and for the health professionals looking after them, but they also represent additional cost to the NHS. The National Audit Office (2009), reporting on an audit carried out in hospitals in England during 2006, stated that 20% of the infections recorded were of the urinary tract, and that 80% of these were associated with urinary catheters. The NHS Institute (2010a) updating the 1994/5 estimated additional costing of £1327 per inpatient, when it was necessary to treat a UTI, calculated that, at 2010 prices, this additional expenditure came to £1964 per inpatient.

Ten years ago, Pratt and his colleagues (2001) published guidance relating to short-term urethral catheterization in the acute sector, which are referred to as the initial Epic (evidence-based practice in infection control) guidelines. These guidelines advised that:

■ Catheters were only used when there was no other management option, reviewed and removed as soon as possible and that their insertion and care was documented

■ The type of catheter material was chosen as appropriate to the individual, that the smallest gauge catheter was inserted as appropriate to the individual’s requirements and a 10 ml balloon was used, with the exception of specific urological indications (issues further discussed in part 2 of this article).

■ The catheter was inserted as a skilled, aseptic procedure and a single-use container of lubricant was used

■ A closed system of drainage (Figure 2) was maintained, only to be broken when the drainage bag was changed in line with the manufacturers’ recommendations, the drainage bag was positioned lower than the bladder, samples were taken aseptically from a sampling port and hand decontamination and clean non-sterile gloves were used when catheter manipulation took place

■ Antiseptic meatal cleansing was unnecessary, but good routine personal hygiene should be maintained

■ Bladder irrigation/washouts (now known as catheter maintenance solutions) did not prevent catheter associated infection. Six years later, these guidelines were reviewed and

Epic2 was published (Pratt et al, 2007), in which the requirement for education of patients and their relatives

was also acknowledged. Between the publication of the two Epic guidelines, there have been a series of initiatives regarding either infection control with reference to CAUTI, or specifically relating to catheterization. NICE’s (2003) clinical guideline on infection control supplied guidelines for the care of patients with long-term catheters, and in the same year, the report ‘Winning Ways’ (Figure 3) (DH, 2003),

British Journal of Nursing, 2011, Vol 20, No 22 1421

Figure 3. The front cover of the ‘Winning Ways’ report (Dec 2003) Document available from:

Figure 4. The front cover of the initial (2005) Saving Lives, High Impact Intervention No. 5: Urinary catheter care (not now available electronically). This was later updated in the High Impact Intervention care bundle – No. 6: Urinary catheter care (DH, 2007). Document available from:



highlighted the omnipresent risk of infection, stressing that indwelling catheters should only be used when there was no other alternative and removed as soon as possible, advising the use of low allergenic catheter materials, stipulating asepsis and that the dates of insertion and removal were routinely documented in the clinical records.

Two years later, the DH (2005) commenced the Saving Lives programme (Figure 4), aimed at reducing healthcare- associated infections, in particular, methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile). However, urinary catheter care was among a list of five High Impact Intervention care bundles. These bundles provided sets of elements on catheter insertion and catheter care as outlined in the original Epic guidelines (Pratt et al, 2001), followed by a recording tool relating to good practice in catheter insertion and another regarding ongoing catheter care, allowing a percentage of compliance to be calculated.

In 2006, further guidelines in the form of ‘Essential Steps to Safe, Clean Care’ (Figure 5) (DH, 2006) similarly provided review tools enabling the monitoring of compliance and improvement. Culminating joint working between Skills for Health and the RCN carried out in 2007, the National Occupational Standards pertaining to catheter care were developed. The six catheter-related Skills for Health competencies can now be mapped into the Knowledge and Skills Framework (KSF) (RCN, 2008; Skills for Health, 2011).

More High Impact Actions In 2009, the Nursing and Midwifery Council (NMC) conducted an online survey through the NHS Institute,

asking frontline staff (nurses and midwives) to submit examples of high quality and cost-effective care and increased efficiency. They received over 600 submissions of examples of good practice in less than 3 weeks. By June 2010, these had been collated and made accessible on the NHS Institute website as ‘The Essential Collection’, representing eight key High Impact Actions, which were accompanied by two DVD of case studies and other educational material. The eighth of the key action themes was entitled ‘Protection from Infection’, but dealt exclusively with CAUTI, and illustrated how a difference can be made when staff tackled the problem with energy and enthusiasm. Three case studies were given, but other submissions can also be accessed on the website (NHS Institute, 2010b; NMC, 2010).

Case studies in High Impact Actions Brighton and Sussex Hospitals discontinued the use of short- term and female length catheters, increased staff competency and devised a ‘Ladders and Bladders’ giant floor game (now in commercial production), which allows staff teams to compete against each other’s knowledge of good catheter care (http://

Winchester and Eastleigh Healthcare NHS Trust aimed for the reduction of inappropriate catheterization, for reliable catheter care while in situ and for prompt removal when appropriate. They designed a 28-day urinary catheter assessment and monitoring form to document all insertions and ongoing urinary catheter care, allowing weekly audit.

Birmingham’s Royal Orthopaedic Hospital initiated the universal use of silver-coated Foley catheters (silver alloy coated catheters are discussed in part two of this article), a ‘Think Link’ programme (cleaning, universal precautions, hand hygiene, communication and patient power), circulated a newsletter and adopted the ANTT (NHS Institute, 2011).

Equity and Excellence: Liberating the NHS The Coalition Government’s White Paper, Equity and Excellence: Liberating the NHS (DH, 2010) focused on outcomes and devolved power and accountability to the frontline (DH, 2011a). The DH, aiming to achieve up to £20 billion of efficiency savings by 2015, emphasized the need for quality, innovation, productivity and prevention. Aiming to achieve this, in 2010, the Quality, Innovation, Productivity and Prevention (QIPP) programme with three ‘workstreams’ (Commissioning and Pathways, Provider Efficiency and System Enablers) was launched. Within the Commissioning and Pathways workstream is the Safe Care workstream, within which there is a quality improvement programme, entitled Safety Express.

The aim of this programme is that by 2012, in four areas – hospital and community acquired pressure ulcers, blood clots (DVT and pulmonary embolism), falls in care settings and UTIs in patients with catheters – 95% of the harm caused to patients is eliminated (DH, 2011b). Safety Express aimed for a 50% reduction in CAUTI in patients with indwelling catheters by December 2012 (Brotherton and Deacon, 2011).

Safety Express has given emphasis to CAUTI that had previously been reserved for high profile infections, e.g. MRSA and C. difficile (NHS Institute, 2010a). Since January

Figure 5. The front cover of the Essential Steps to Safe, Clean Care guidelines. Document available from:

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2011, facilitators from Safety Express have been working with NHS foundation trusts and other acute providers, community providers, mental health trusts and care homes, in 100 settings across England, and it is hoped that this will be extended to another 300 before the end of the year. Improvements achieved within the ‘Safe Care’ workstream are recorded on ‘The Safety Thermometer’ (a measure to display the prevalence of ‘harm’ caused (e.g. by CAUTI) at specific times and the proportion of patients who are ‘harm free’), thereby demonstrating improvement and how rapidly this is taking place (DH 2011a; b).

Nurse-sensitive outcome indicators and Commissioning for Quality and Innovation (CQUINS) Nurse-sensitive outcome measures, indicators for quality improvement (IQI) for NHS commissioned care, use the ‘Essential Collection’ High Impact Areas, including the High Impact Action relating to CAUTI (The NHS Information Centre for Health and Social Care (NHS I.C.), 2011a; b).

The DH and NHS have listed the reduction of patients with indwelling catheters in situ as one of their set of exemplar CQUIN goals for 2010-11, that commissioners, providers and clinicians can use when agreeing local CQUIN payment framework schemes. The authors sited the quality improvement programme Safety Express and the monitoring tool, the Safety Thermometer (which they recommend is used quarterly), from the QIPP workstream Safe Care, as vehicles within which the CQUIN goal can be structured. They also recommend the ‘Essential Collection’ and the Nurse-Sensitive Indicators, the DH Saving Lives initiative, and the High Impact Intervention urinary catheter bundle as resources to achieve the CQUIN goal (NHS Networks, 2010).

Energise for Excellence in Care (E4E) Nurse-sensitive outcome measures and High Impact Actions are within ‘toolkit’ of the quality framework for nursing and midwifery ‘E4E’ (Figure 6) (DH, 2011d). E4E supports and empowers frontline staff (nurses, midwives and health visitors) to make a difference by delivering high quality, safe and effective care (including that around indwelling catheters), thereby increasing their own job satisfaction and giving patients a positive experience when accessing health care. E4E is underpinned by social movement thinking principles (people with a common cause coming together, creating a sense of belonging and sustaining the momentum of their joint ‘cause’). Nurses can enquire about or sign up to E4E by contacting

Conclusion Part one of this article has examined the reasons for urethral catheterization, Ch. size, insertion and documentation, but has concentrated on CAUTI. As demonstrated by the DH safety driving programmes discussed in this article, good practice relating to urethral catheterization has been repeatedly the focus of national initiatives, although the repetitive nature of these campaigns suggests complacency. However, the White Paper, Equity and Excellence: Liberating the NHS, aiming to achieve up to £20 billion of efficiency savings by 2015 by

devolving power and accountability to the frontline, has started to gain momentum and display positive results. The case studies in the three areas featured in the High Impact Actions have demonstrated that, when there is good practice and joint working, changes for the better can be made. The social movement thinking principles underpinning E4E reflect the same concept; nurses sustaining the momentum of their common cause by uniting like-minded others. If the financial position of the country catalyses improvements through High Impact Actions as in the reduction of CAUTI,, good will have come out of a seemingly negative situation. Part two looks at other problems related to urethral catheterization, the causes, and possible solutions. BJN

Conflict of interest: none

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Figure 6. Energise for Excellence in Care (E4E) Document available from:



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n Indwelling catheters should only be used in the absence of alternative methods of management, their use reviewed regularly and removed as soon as possible

n It has been estimated that in 2010, the additional cost of treating an inpatient for a urinary tract infection was £1964 per inpatient

n In 2006, 20% of the infections recorded in English hospitals were of the urinary tract and 80% of these were associated with urinary catheters

n A closed drainage system should be maintained, and only broken when necessary (which is usually when the drainage bag is changes as per the manufacturers’ recommendation)

n Antiseptic non-touch technique (ANTT) should always be implemented for indwelling urethral catheter insertion

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