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Urinary catheters and quality control
Article · August 2016
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Urinary catheters and quality control
Authors
Abdelmohaymin Abdalla Abufatima Abdalla*, Ahmed El-Tahir Medani El- Shibly*, Ahmed Mahgoub Sharif El tohami*, Mohamed SalahEldin Mohamed Ali*, Raghda Hatim Abalhaleem Adlan+, Mohamed Siddig Eltayeb Muneer^, Mohamed Ahmed Sidahmed Abdelrahim*, Ibrahim Jamal Mubarak Mohamed^, Ihab B. Abdalrahman*
*Department of Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
+Institute of Endemic diseases, University of Khartoum, Khartoum, Sudan
^ Faculty of medicine, University of Khartoum, Khartoum, Sudan
Corresponding Author
Abdelmohaymin Abdalla Abufatima Abdalla
Al Qasr Street, P.O. Box 102, Faculty of medicine, University of Khartoum, Khartoum, Sudan.
Lead Consultant
Ihab B. Abdalrahman, Department of medicine, Faculty of medicine, University of Khartoum, Khartoum, Sudan.
The Online Journal of Clinical Audits. 2016; Vol 8(3).
Published August 2016
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Abstract
Aims – The aim of the study was to assess the appropriateness of urethral catheterization use in Soba university Hospital July 2015.
Methods – The audit was conducted at Soba university hospital. The standard used in the assessment of IUC care in this audit was obtained from the National Institute for health & Care Excellence (NICE) (CG139). The study was conducted after quick piloting which pointed out necessary modifications to the standard. The study population included all patients admitted to Soba university hospital (in all hospital wards) with indwelling urethral catheter. Ethical approval was obtained from the Department of Internal Medicine at the Soba University hospital. Verbal consent was taken from the patients who agreed to be part of the study.
Results – The study included 78 patients from all specialties. Majority of patients with IUCs were admitted to surgical departments and most of them for pre- and post- operative bladder drainage. About 5% of the patients had no known indication and 7% of patients had their IUC for inappropriate reasons.
In 37% of the patient’s files, the indication and the date of insertion were documented; otherwise the documentation process was bad and most of the information was taken from the patients and family members. 5% of patients were educated about hygiene. 90% of urinary bags were placed below the level of the bladder, but at the same time 63% of them were in contact with the floor. Antibiotic prophylaxis following long term IUC was considered and given adequately, but some patient with short term catheters were covered with antibiotic also with no clear reason.
Conclusions – 12% of catheterized patients had an unknown or an inappropriate indication. About one- third of the patients files contained only the date and indication of insertion documented. Other
parameters were poorly documented. IUC-hygiene education was poorly implemented by healthcare providers.
Urinary catheters and quality control
Introduction
Indwelling urethral catheters (IUC) are widely used in clinical practice. Despite the benefits of IUC they are often implicated in causing recurrent urinary tract infections (UTI)(1) The majority of these UTIs are associated with the use of an IUC. A more recent study that was undertaken in the Australian state of Victoria showed that catheter-associated UTI (CAUTI) was the third most common preventable hospital- acquired complication, with the two most common being pressure sores followed by in- hospital falls(2) .The balance between benefits and morbidity of IUC should always be carefully considered; depending upon clinical-sense and individual patient scenarios.
Recurrent urinary tract infections result in the need for antibiotic administration, which ultimately facilitates the emergence of drug-resistant bacteria.(3)
Several interventions have been suggested in an attempt to achieve reduction of catheter related infections. These interventions have ranged from the simple education of doctors and nurses to complex changes of policies affecting whole hospital funding.
As an illustration of the former, an audit was conducted in the use of IUC in a local hospital (4). After observing that a large proportion of IUCs were inserted in their emergency department, they decided to run education sessions for doctors and nurses regarding the use of IUCs, including indications and risks associated with use and other
reasonable alternatives, as well as implementation of a checklist to clarify the indication for IUC insertion. The intervention resulted in an almost 80% reduction in the number of IUCs inserted in that emergency department. An intervention illustrating the other end of the spectrum involved a decision made by the Centre for Medicare and Medicaid Services (CMS) to withhold funding to hospitals for the costs incurred for the treatment of a preventable complication (for example, the development of a UTI and/or urosepsis after the inappropriate use of an IUC) (5)
Ø Key issues in the prevention of CAUTIare: (6)
§ Assessing the need for catheterisation.
§ Selection of catheter type and system.
§ Catheter insertion.
§ Catheter maintenance.
§ Education of patients, relatives, and healthcare workers.
Ø Urinary catheterisation should be avoided whenever possible, in view of the associated risks. Indications include(7)
§ To empty the urinary bladder prior to a specific procedure (e.g. surgery).
§ To allow urinary drainage in specific perioperative cases (e.g. urological surgery, need for perioperative
§ Monitoring of urine output).
§ To relieve urinary retention when medical management has failed and surgery is not suitable or is awaited.
§ To measure output accurately in critically ill patients (e.g. in shock) (a urimeter drainage bag should be used in this case).
§ To allow healing of perineal or sacral wounds in incontinent patients.
§ In cases of deep sedation or paralysis.
§ To relieve incontinence when no alternative is possible.
The following are not appropriate indications for urinary catheter use: (8)
§ Incontinence without an appropriate indication.
§ Diuresis.
§ Frequent measurement of urinary output.
§ Nurse’s concern for patient comfort.
§ Preference of patient.
§ A substitute for nursing care.
§ Prolonged post-operative care.
Ø Types of urinary catheterisation (7)
A urinary catheter may be in situ short-term (1–14 days), short- to medium-term (2–
6 weeks) or medium- to long term (6 weeks–3 months). A urinary catheter may be urethral or suprapubic, indwelling or used intermittently. Intermittent self- catheterisation is recommended over long-term catheterisation in some conditions including voiding dysfunction.
Ø Key themes in quality care of patients with an IUC (7)
§ Insertion: aseptic, gentle; clean meatus with normal saline, use sterile lubricant that is also ideally anaesthetic, after urine starts flowing insert at least another 4 cm before inflating balloon.
§ Records: insertion date and operator, review, date for removal, amount of water in balloon, care provided, and education given.
§ Maintenance of a sterile closed system.
§ Hand hygiene and gloving when manipulating catheter.
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§ Position of bag and tubing: tube attached to leg, no obstruction/kinking, all tubing and bag always below bladder level (or clamped for short time); tubing allows hanging without touching the floor, no pulling on tubing.
§ Hygiene: daily with soap and water and after bowel movement.
§ Bag emptying: without contamination, clean port with spirit and avoid contamination of port, use of personal protective equipment (PPE), usually 8 hourly and before full.
§ Changing of catheter and bag: every 7 days (or per manufacturer’s instructions)
§ Balloon inflated with 10 mL of sterile water (adult) or 5 mL (child).
§ Size: Smallest possible size catheter used, i.e. 12–14 (adult).
§ Daily review for signs and symptoms of any complications including fever, swelling, pain, nausea.
§ Fluids: intake – adult at least 2 L daily – and output all recorded.
§ Equipment available: aseptic packs, hand washing equipment, IUC procedure, including single-use lubricant.
§ Patient and relatives’ education including fluids, hygiene, bag position, lifestyle adaptation.
§ Aseptic method of obtaining CSU (catheter specimen of urine).
§ Remove IUC as soon as possible.
§ Education and supervision of healthcare workers.
In Sudan, hospital policies contain recommendations regarding appropriate indications for catheter insertion; however, the final decision as to whether or not to insert an IUC is left up to the treating clinician, and there is no system in place to ensure policies are being followed. It would be quite reasonable to admit we are at a loss as to how urinary catheters are being used in the general hospital setting, including all of critical care, medical, obstetrics, paediatrics and surgical wards. There is no published literature on how IUCs are being used within Sudan hospitals, and for this reason, we conducted an audit of urinary catheter use in our hospital.
Aims
The aim of the study was to assess the appropriateness of urethral catheterization use in Soba university Hospital July 2015.
Audit Standards
The standard used in the assessment of IUC care in this audit was obtained from the National Institute for health & Care Excellence (NICE); March, 2012 clinical guideline for Infection prevention and control (CG139: Healthcare-associated infections:
prevention & control in Primary and community care; Long-term urinary catheters) (appendix).
Methods
The audit was conducted at Soba university hospital, which is a tertiary hospital in Khartoum south-east with many specialties. All patients were referred from different parts of the country and most of them –if not all- required admission to the wards or critical care centre. This fact illustrates the large number of patients requiring
catheterization.
The study was conducted after quick pilot study. The purpose of this pilot study was to ensure the ability to meet the original objectives of the clinical audit project from the data collected and to reveal whether the tool was appropriate and can be implemented.
The pilot study report modified the standard that was used to assess the checklist and moreover, the pilot study was useful to identify any problem at an early stage. The study population consisted of the patients admitted to Soba university hospital (in all
wards) with an IUC. Any other patient, including those with history of catheterization, was excluded.
Collected data were analysed and processed using the Statistical Package for Social Sciences (SPSS).
Ethical approval was obtained from Department of Internal Medicine at the Soba hospital. Verbal consent was taken from the patients who agreed to be part of the study.
Results
The study included 78 patients from all wards; figure (1).
Figure (1): The percentages of patients recruited in the study in each department
Indication: (Figure 2.)
• About 5% of the patients had no known indication (4 patients).
• 7% of patients had their IUC for inappropriate reasons (5 patients), three of them for measuring urinary output in ambulant patients and two for patient’s preference.
• Pre- & post-operative bladder drainage was the dominant appropriate indication (42%).
32.1 47.4
7.7 12.8
0 10 20 30 40 50 60 70 80 90 100
Medicine Surgery Paeditrics Obstetrics and
Gynaecology
DEPARTMENTS
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Documentation: (table 1)
• In only one third of the patient’s files, the indication and the date of insertion were documented. This fact directed the work towards seeking an appropriate indication for the rest of the patients from other sources, which is summarized in table 2
• The overall documentation procedure was the major problem, since the majority of important information was completely missed in all patients’
files.
Table (1): The Percentage of documented data
Variable Percentage
Date of Insertion 38.5%
Time 00.0%
Name of the Health-worker who inserted the catheter 12.8%
Role 02.6%
Indication 35.6%
Catheter size 02.6%
Catheter type 01.3%
Catheter balloon volume 00.0%
Catheter duration 00.0%
latex allergy 00.0%
Consent 00.0%
Difficulties and attempts 00.0%
Draining urine 00.0%
Appearance 00.0%
Volume 01.3%
Dipstick 01.3%
Specimen sent 00.0%
Table (2): The Source of knowing the Indication of Catheterization
The Source of Knowledge Percent
Patient file 35.6
Patient himself 17.8
Family member 41.1
Nursing staff 5.5
Maintenance:
§ Although the overall process was adequate regarding hygienic aspects, patient's education; which is a very important part, was seriously missed, since only 5%
were educated.
§ Most of the urine bags were placed below the level of the bladder, but in the same time, a considerable percentage of urine bags were in contact with the floor.
§ Antibiotic prophylaxis following long term IUC was considered and given adequately, but some patient with short term catheters were covered with antibiotic also with no clear reason.
§ The variables of catheter maintenance were shown in table (3).
Table (3): Percentage of yes answer to questions related to catheter maintenance
Specific question about catheter care %
Was any indwelling catheter connected to a sterile closed urinary drainage system or catheter valve?
93.6%
Was the connection between the catheter and the urinary drainage system
broken? 15.4%
Before manipulating the patient’s catheter, were the hands decontaminated? 62.8%
Before manipulating the patient’s catheter, were the new pair of clean non sterile gloves put on?
88.5%
Before manipulating the patient’s catheter, were the gloves removed? 80.8%
After manipulating the patient’s catheter, were the hands decontaminated? 55.1%
Was the patient educated about the need for hand decontamination before and after manipulation of the catheter?
5.1%
Was the carer(s) educated about the need for hand decontamination before and after manipulation of the catheter?
17.9%
Were urine samples obtained from a sampling port using an aseptic technique? 19.2%
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Conclusions
• 12% of catheterized patients had an unknown or an inappropriate indication.
• Most parameters of documentation were poorly written in the records.
• Regarding hygiene:
- Most of the healthcare providers approach regarding placing a closed-sterile circuit was satisfactory.
- Patient’s (and Care-provider's; if appropriate) IUC-hygiene education was poorly implemented by healthcare providers.
- 25.1% were educated about washing the urethral meatus daily.
- Although about 90% of urine bags were below bladder-level, 62% were in contact with the floor.
Recommendations
• The authors should inform the head departments of the hospital about the results of the audit.
• The audit team should take serious steps to make IUC insertion limited to appropriate indications
• The documentation process should be part of a training session given periodically to working staff.
• The education of nurses and other paramedics about patient education of hygiene and catheter position is an integral part to reduce the risk of recurrent UTIs.
• The audit team should distribute the audit report in a leaflet to the medical staff so as to increase the awareness about the practice of IUC and patients education.
References
1. Tambyah PA. Catheter-associated urinary tract infections: diagnosis and prophylaxis.
International journal of antimicrobial agents. 2004;24 Suppl 1:S44-8.
2. McNair P.D. JTJ, Borovnicar D.J. The U.S. Medicare policy of not reimbursing hospital-acquired conditions: What impact would such a policy have in Victorian hospitals? The Medical Journal of
Australia. 2010; 193(1),: 22-5.
3. Becknell B, Schober M, Korbel L, Spencer JD. The diagnosis, evaluation and treatment of acute and recurrent pediatric urinary tract infections. Expert review of anti-infective therapy. 2015;13(1):81-90.
Is the urine drainage bag positioned below the level of the bladder? 89.7%
Is the urine drainage bag in contact with the floor? 62.8%
Is the meatus washed daily with soap and water? 25.6%
Is there a patient-specific care regimen? 3.8%
Were approaches such as reviewing the frequency of planned catheter changes
and increasing fluid intake considered? 30.8%
Was any catheter blockage documented? 2.6%
Was a bladder instillation or washout used to prevent catheter-associated
infections? 6.4%
If the patient has a long-term indwelling urinary catheter, was antibiotic prophylaxis
offered when the catheter was changed? 17.9%
If the patient has a history of symptomatic urinary tract infection after catheter change or experiences trauma during catheterization in case of UTI, was antibiotic prophylaxis considered when the catheter was changed?
10.3%
Was antibiotic prophylaxis given when the catheter was changed? 10.3%
4. Gokula RM, Smith MA, Hickner J. Emergency room staff education and use of a urinary catheter indication sheet improves appropriate use of foley catheters. American journal of infection control.
2007;35(9):589-93.
5. Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections. Jama. 2007;298(23):2782-4.
6. Madeo M, Roodhouse AJ. Reducing the risks associated with urinary catheters. Nursing standard. 2009;23(29):47-55; quiz 6.
7. Savage A. Evidence-based practice in relation to indwelling urinary catheters. Africa Health;Jan2014. 2014;36 ( Issue 1,):, p25.
8. Elpern EH, Killeen K, Ketchem A, Wiley A, Patel G, Lateef O. Reducing use of indwelling urinary catheters and associated urinary tract infections. American journal of critical care : an official publication, American Association of Critical-Care Nurses. 2009;18(6):535-41; quiz 42.
Appendix: The tool used to assess the catheter maintenance
No. Question Yes No
1 Was any indwelling catheter connected to a sterile closed urinary drainage system or catheter valve?
2 Was the connection between the catheter and the urinary drainage system broken?
Before manipulating the patient’s catheter, were the following done:
3 • Hands decontaminated?
4 • A new pair of clean, non-sterile gloves put on?
After manipulating the patient’s catheter, were the following done:
5 • Gloves removed?
6 • Hands decontaminated?
7 Was the patient educated about the need for hand decontamination before and after manipulation of the catheter?
8 Was the carer(s) educated about the need for hand decontamination before and after manipulation of the catheter?
9 Were urine samples obtained from a sampling port using an aseptic technique?
10 Is the urine drainage bag positioned below the level of the bladder?
11 Is the urine drainage bag in contact with the floor?
12 Is the meatus washed daily with soap and water?
13 Is there a patient-specific care regimen?
14 Were approaches such as reviewing the frequency of planned catheter changes and increasing fluid intake considered?
15 Was any catheter blockage documented?
16 Was a bladder instillation or washout used to prevent catheter-associated infections?
17 If the patient has a long-term indwelling urinary catheter, was antibiotic prophylaxis offered when the catheter was changed?
If the patient has a history of symptomatic urinary tract infection after catheter change or experiences trauma during catheterisation:
18 • Was antibiotic prophylaxis considered when the catheter was changed?
19 • Was antibiotic prophylaxis given when the catheter was changed?
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