CATHETERISATION - INSERTION AND MANAGEMENT GUIDELINE

Policy Details NHFT document reference Version Date ratified

ICPg002 01.07.2013 03.09.2013

Ratified by Implementation date Responsible Director Review date:

Trust Policy Board 09.09.2013 Director of Nursing 01.09.2015 Infection Prevention and Control Framework – ICP000; Hand Hygiene Policy – ICP001; Standard Precaution Policy – ICP002; Cleaning and Disinfection Policy – ICP003; Decontamination Policy – ICP004; Aseptic NonTouch Technique Guideline – ICPg006 Guideline

Related Policies & other documents

Freedom of information category:

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 1 of 43 Implementation Date:09.09.2013 Guideline

TABLE ON CONTENTS 1 2 3 4 5 6

DOCUMENT CONTROL SUMMARY ................................................................ 3 INTRODUCTION................................................................................................ 5 PURPOSE.......................................................................................................... 5 DEFINITION ....................................................................................................... 6 DUTIES .............................................................................................................. 6 PROCESS.......................................................................................................... 7 6.1 Who can catheterise? ................................................................................. 7 6.2 Indications/need for catheterisation ............................................................ 7 6.3 Consent ...................................................................................................... 8 6.4 Catheter Selection ...................................................................................... 8 6.5 Catheter Insertion ..................................................................................... 10 6.6 Documentation.......................................................................................... 11 6.7 Drainage bags .......................................................................................... 11 6.8 Catheter Care ........................................................................................... 11 6.9 Bag emptying ............................................................................................ 12 6.10 Catheter maintenance solutions ............................................................... 12 6.11 Catheter Maintenance Solutions ............................................................... 13 6.12 Suprapubic catheters ................................................................................ 14 6.13 Catheter Troubleshooting ......................................................................... 15 6.14 Catheter Blockage .................................................................................... 18 6.15 Urethral Discomfort ................................................................................... 19 6.16 Unable to Tolerate the Catheter................................................................ 19 6.17 Paraphimosis ............................................................................................ 19 7 TRAINING ........................................................................................................ 19 7.1 Mandatory Training ................................................................................... 19 7.2 Specific Training not covered by Mandatory Training ............................... 19 8 MONITORING COMPLIANCE WITH THIS DOCUMENT ................................ 20 9 REFERENCES................................................................................................. 21 10 RELATED TRUST POLICY ............................................................................. 21 Appendix 1 - Equality Analysis report ........................................................................ 23 Appendix 2 - Procedure for Female Catheterisation .................................................. 26 Appendix 3 - Procedure for Male Catheterisation ...................................................... 29 Appendix 4 - Procedure for Removing a Catheter ..................................................... 32 Appendix 5 - Procedure for emptying a Catheter Bag ............................................... 34 Appendix 6 - Procedure for collection of a Catheter Specimen of Urine (CSU) ......... 35 Appendix 7 - Procedure for the Care and Management of Indwelling Catheter ......... 37 Appendix 9 - Competency Assessment Tool for a Catheterisation ............................ 41

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 2 of 43 Implementation Date:09.09.2013 Guideline

1

DOCUMENT CONTROL SUMMARY

Document Title Document Purpose (executive brief)

Status:- New/Update/Review Areas affected by the policy Policy originators/authors Consultation and Communication with Stakeholders including public and patient group involvement.

Archiving Arrangements Equality Impact Assessment (including Mental Capacity Act 2007) Training Needs Analysis Monitoring Compliance and Effectiveness Meets national criteria with regard to: NHSLA NICE NSF Mental Health Act CQC Other

Catheterisation Insertion and Management Guideline The aim of this policy is to provide nursing and care staff with research based evidence to reduce as much as possible the infection risks involved with catheterisation and catheter use. Review Trust wide Infection Prevention and Control Team Members of the Infection Prevention and Control. Comprising of representation from: Mental Health Services. Learning Disability Services. Sexual Health Services. Drug and Alcohol Services. Medical Representative. Occupational Health Service. Estates & Facilities Services. District Nurses Health Visitors Podiatrists Chairman of Northamptonshire Healthcare NHS Foundation Trust representing the Public. A central register will be held by the CGST which will hold archived copies of this policy. See appendix 1 See section 7 Compliance with this policy will be monitored through the Safer Hospitals and Environment Group. Yes: Standard 1.2.8 & 2.2.8 Yes - 2003 N/A N/A Department of Health, NPSA

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 3 of 43 Implementation Date:09.09.2013 Guideline

Further comments to be considered at the time of ratification for this policy. (i.e.: national policy, commissioning requirements, legislation)

If this policy requires Trust Board ratification please provide specific details of requirements

Health and Social Act 2008 code of practice for health and social care on the prevention and control of infections and related guidance. Infection Prevention and Control Group

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 4 of 43 Implementation Date:09.09.2013 Guideline

2

INTRODUCTION

This procedure provides Registered Practitioners and care staff with research based evidence to reduce the infection risks involved with urinary/urethral catheterisation and catheter use. Saving Lives (2007) noted that Urinary tract infections (UTI) are the largest single group of healthcare associated infections (HCAI) and account for 23% of all infections. The presence of a urethral catheter, the duration of its insertion and the quality of care are all contributory factors to the development of a urinary tract infection. The aim of this policy is to provide nursing and care staff with research based evidence to reduce as much as possible the infection risks involved with catheterisation and catheter use. Catheterisation increases the risk of acquiring a urinary tract infection, the longer the catheter is in place the greater the danger. The risk of acquiring bacteraemia is approximately 5% for each day of catheterisation. Patients who develop a urine tract infection then have a 1-4% risk of developing bacteraemia and of these, 13-30% die (Department of Health Epic Project Jan 2001). Bacteria will flourish in a urine drainage system: a non-return valve is not a sufficient barrier. Good evidence-based practice is essential to prevent ascending infection. 3

PURPOSE

The aim of this procedure is: • • • • • • •

To provide a set of measures for indwelling urethral catheterisation to be followed by all Registered Practitioners/care staff. To provide guidance to staff on interventions required to reduce the incidence of urethral catheter associated infections. To standardise practice across the Northamptonshire healthcare economy To minimise the potential risk of infections associated with indwelling urethral catheters To ensure that all staff have undertaken competency based training for the insertion and care of urethral catheterisation To ensure that the appropriate catheterisation and drainage products are used To ensure that patients are catheterised appropriately

Assessment should take account of the possible sexual, physical, social, psychological and environmental impact of catheterisation. The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 5 of 43 Implementation Date:09.09.2013 Guideline

The decision to catheterise should be made following a full holistic continence assessment with consideration given to alternative methods of management where appropriate. Catheterisation to manage incontinence should only be used when all other management strategies have been tried and failed. Review of the necessity for the catheter should be made at agreed and regular intervals. Further advice can be obtained from the Continence Nurse Specialist. Host infection risks include immune system compromise, post partum, age and debility. 4

DEFINITION

NHFT - Northamptonshire Healthcare NHS Foundation Trust. Urethral catheterisation is the insertion of a special tube into the bladder, using an aseptic technique, for the purpose of evacuating or instilling fluids (Marsden, Manual of Clinical Nursing Procedures 2001). 5

DUTIES Trust Board Has the overall responsibility for infection prevention and control. Chief Executive Has the ultimate responsibility for the management of all aspects infection prevention and control and provision of adequate resources. Director of Infection Prevention and Control Has the strategic responsibility for Infection Prevention and Control within NHFT. Infection Prevention and Control Team (IPCT) Has the responsibility for supporting staff in carrying out infection prevention and control procedures through:• Training and education • Policy development • Advising on the management of patients with infections • Advice and support for developing surveillance programmes and action plans • Advise regarding new builds/renovations • Carry out a programme of audits Managers Must ensure that the standard of infection prevention and control precautions are followed at all times in their area of responsibility. This policy must be

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 6 of 43 Implementation Date:09.09.2013 Guideline

drawn to the attention of all staff including locum staff and students. Managers should also ensure that all staff who may be exposed to blood or body fluids are trained in standard infection prevention and control precautions when joining as new employee or when undertaking new roles and through regular updates. Staff Staff must safeguard themselves and others whilst at work under the health and safety legislation. This means attending relevant training following recommended procedures (standard precautions), making proper use of equipment provided such as protective equipment and reporting any concerns regarding safety to the manager. Consultation and Communication with Stakeholders Commissioners were involved in the development of this policy through their representation on the Infection Prevention and Control Group. 6

PROCESS 6.1 Who can catheterise? Any Registered Practitioner can catheterise a patient provided they have received appropriate training in the procedure and have completed and had signed off the recognised competency/scope of practice. A Health Care Assistant (HCA) can catheterise an intended female urethral catheterisation, (stable and known to the case load) provided they have received appropriate training in the procedure and have completed and had signed off the recognised competency/scope of professional practice, been deemed competent in their knowledge and skills and from a member of the Continence Advisory Service, or a competent Registered Nurse within their own Team. They are to be delegated this task for named patients on their own caseload only. Only those HCA's, in a hospice or community setting, can carry out a known to the caseload, adult male catherisation, if they have undertaken an NVQ at level 3/Foundation Degree and holds an additional signed off NVQ/Competency on male catherisation. 6.2 Indications/need for catheterisation Assessment should take account of the possible sexual, physical, social psychological and environmental impact of urethral catheterisation. The decision to catheterise should be made following a full holistic continence assessment with consideration given to alternative methods of management where appropriate. Urethral catheterisation would be carried out for the following reasons:

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 7 of 43 Implementation Date:09.09.2013 Guideline

• • • • • • • •

To relieve retention of urine To determine residual urine To measure urine output accurately To allow irrigation of the bladder To instil medication into the bladder To allow bladder function tests to be carried out To relieve incontinence when no other means is practicable To aid patient comfort at end of life

Review of the necessity for the catheter should be made at agreed and regular intervals. 6.3 Consent Informed consent must always be obtained in accordance with the national guidelines for consent including any issues relating to the patients capacity to consent. This should be documented in the patients’ medical notes. Consent from the covering GP for catheterisation must also be obtained and documented. 6.4 Catheter Selection The choice of catheter material is determined by the expected maximum duration that the catheter is to be in situ. Catheters are generally categorised as being for short-term (maximum of 28 days duration) or long-term (maximum of 12 weeks duration). If the catheter is regularly requiring changing after less than 4 weeks, discuss with the Continence Nurse Specialist. For urethral drainage select the smallest gauge catheter possible usually 1012Ch for a female, or 12-14Ch for a male, with a 10ml balloon. Occasionally patients with urological conditions may require a larger gauge catheter and balloon. Smaller gauge catheters minimise the risk of urethral trauma and residual urine volumes, which pre-dispose to UTIs. Larger sizes may cause pain and discomfort, pressure ulceration, blockage of the para urethral ducts and abscess formation. Three lengths of catheter are available to meet the needs of different patients and individual patient assessment is paramount. Single use self lubricating hydrophilic catheters are the recommended choice for intermittent self-catheterisation. Check if patients have a latex allergy and reflect this in catheter and equipment choice. The use of latex is avoided for children with spina bifida. The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 8 of 43 Implementation Date:09.09.2013 Guideline

Female only catheters (20-26cm) can cause severe haemorrhage if used in males

trauma

and

http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/female-urinarycatheters/ Standard catheters (40 to 45cms) can be used for males and females Shorter catheters (20 to 26cms) are for females only Paediatric length for children until age of adolescence or/ deemed appropriate for adult size, also Paediatric catheter size 6-10cms

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 9 of 43 Implementation Date:09.09.2013 Guideline

6.5 Catheter Insertion Catheter insertion should only be undertaken by a practitioner who has received training in the procedure and is deemed to be competent. Catheterisation is an aseptic procedure and, therefore, an aseptic technique must be used. The perineum will require cleansing with soap and water before commencing aseptic technique. To minimise introduction of bacteria on catheterisation the urethral meatus should be cleaned prior to catheter insertion using sterile normal saline. If patients are MRSA positive Octenilin cleaning solution can be used instead of normal saline. For both male and female patients, a lubricant and anaesthetic gel from a single use container must be used and inserted directly into the urethra and left for the recommended time. Check for contraindications and if they apply contact the continence service or pharmacy department for an alternative product. For certain individuals the GP may advise that prophylactic antibiotics are required at catheter insertion (RCN 2012). Check this prior to catheterisation. Intermittent self catheterisation is always an aseptic technique when undertaken by a health care practitioner. When undertaken by the patient, it is a clean technique where gloves are not required, but strict hand hygiene should be used. An audit should be undertaken by managers to monitor compliance and to ensure an aseptic technique is used. A record of staff training and audit should be available. Staff will maintain their competency in catheterisation through annual re-assessment within the clinical area (appendix 7).

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 10 of 43 Implementation Date:09.09.2013 Guideline

6.6 Documentation The following details should be documented in the patient’s notes (use adhesive label if provided by manufacturer). • • • • • • • • • •

Amount of urine drained Any problems or patient discomfort Reason for catheterisation Date of insertion Catheter size, type, length Balloon size, batch no. expiry date Lubricant used; lot number and expiry date Type of cleansing lotion used Date catheter change is due Signature

6.7 Drainage bags Drainage bags may be body-worn, i.e. leg bag, or free standing. There should be effective fixation of the catheter and drainage bag to prevent trauma. Maintenance of a closed system is essential to prevent infection. Two litre drainage bags should be added for overnight drainage in patients with body worn (leg bag) systems using a no touch Clean Technique. Body worn (leg bag) systems should be changed weekly (or in line with manufacturer’s instructions) (Appendix 4) 6.8 Catheter Care The catheter closed drainage system should only be opened for the connection of a new bag every 7 days as per manufacturer’s instructions. More frequent changes always increase the risk of infection. When opening the closed system to fit a new bag, a rigorous no touch clean technique is essential. The tip of the new drainage tube must not be touched before inserting into the catheter. Catheter valves are sometimes used for patients with urological conditions as an alternative to a leg bag. They need to be changed every 5-7 days as per manufacturer’s instructions using a rigorous no touch clean technique. Position the urine drainage bag below the level of the bladder to allow good drainage, incorrect positioning even for a short time is linked to higher rates of infection. The bag must be kept off the floor. For mobile patients a leg bag should always be used, held in place with a strap to minimise trauma to the bladder neck. The leg bag needs to be the correct size to allow emptying when 2/3 full and the inlet tube needs to be the correct length to prevent kinking and/or pressure on the bladder neck. The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 11 of 43 Implementation Date:09.09.2013 Guideline

Overnight drainage bags connected to a leg bag should be single use. The washing out/reuse of bags is prohibited; it is unacceptable practice. There are infection control risks. Night bags should be used once and thrown away. There is no research-based evidence to substantiate the use of antiseptic or antibacterial solutions for cleaning urine drainage bags. Do not change catheters unnecessarily, but if the catheter is frequently blocking, bypassing, etc., refer to local policy or discuss with the Continence Nurse Specialist. Routine personal hygiene is all that is needed to maintain meatus cleanliness, i.e. a daily bath or shower. For patients who are unable to bath or shower daily, staff should wash the urethral meatus at least twice daily with soap and water and following a bowel movement. Hand washing and wearing non-sterile gloves when performing catheter care is always essential by nurses/carers 6.9 Bag emptying Research suggests that this procedure carries a risk of healthcare associated infection. Where possible educate and encourage the patient to empty their own drainage bag. A rigorous no touch clean technique is required for this procedure Staff should wear a disposable apron Good hand washing and wearing a pair of non-sterile latex or vinyl gloves is essential prior to emptying or changing the drainage bag; this procedure always carries a high risk to the patient. Hands must always be washed before and after the procedure The bag should be emptied when 2/3 full The outlet port should be swabbed with a 2% Chlorhexidine & 70% isopropyl alcohol wipe (Clinell wipes for medical devices) before and after opening. In any healthcare setting, a separate single use clean container should be used for each patient to empty the urine into and then emptied and disposed of appropriately, e.g. macerater or clinical waste In the patient’s own home a designated container can be reused to empty the urine into. This must be washed thoroughly after use with detergent and hot water and dried Always avoid contact between the urine drainage bag tap and the container 6.10 Catheter maintenance solutions The use of catheter maintenance solutions may be indicated as part of an individualised care plan to prolong the catheter life, remove debris and encrustation in identified patients, and for recurrent catheter blockage. The decision to use a catheter maintenance solution must be made following a risk The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 12 of 43 Implementation Date:09.09.2013 Guideline

assessment and advice should be sought from the Continence Nurse Specialist. Evidence of encrustation should always be seen prior to deciding to use a catheter maintenance solution. Long term use of such solutions is not recommended and their use and effectiveness should be reviewed on a regular basis. (See Appendix 7) 6.11 Catheter Maintenance Solutions Frequent catheter changes to avoid blockage may be unacceptable to some patients and carers (Getliffe, 2002). In this situation, a catheter maintenance solution may be considered in order to extend the life of the catheter. Catheter maintenance solutions must NOT be used to unblock a blocked catheter. A blocked catheter should be replaced. Routine, long term use of catheter maintenance solutions should be avoided due to the risk to the epithelial lining of the bladder and risk of infection from disrupting the closed drainage system. Catheter maintenance solutions must not be used to prevent catheterassociated infection (NICE, 2003). There are four main catheter maintenance solutions available. These are on a prescription only basis. Normal Saline

Solution G (3.23% citric acid) (SubyG)

Solution R (6% solution of citric acid)

Chlorhexidine 0.02%

Can be used to irrigate catheters that contain pus, blood clots or debris. It is effective for patients with reconstructed bladders that produce a large amount of mucus. It is ineffective against encrustation. Works by dissolving the crystals that form within the lumen of the catheter. There is conflicting evidence as to the efficacy of the solution. Effective at dissolving severe encrustation due to its acidic nature. Should only be used after solution G has been tried and been found to be not effective. Previously used as an antiseptic washout, it is no longer considered effective. Current literature suggests its use may be detrimental. It should not be used.

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 13 of 43 Implementation Date:09.09.2013 Guideline

There is no indication for any prophylactic use of catheter maintenance solutions and the aim of any treatment is to decrease and cease use as soon as possible. 6.12 Suprapubic catheters The insertion of a self-retaining catheter directly into the bladder via the anterior abdominal wall under aseptic conditions. Indications for Suprapubic Catheterisation

Short-term: following urological, gynaecological, or other types of surgery Long term: as an alternative to urethral drainage: • in sexually active adults • in those for whom a urethral catheter has proved problematic or intolerable • in some wheelchair bound people • in those patients for whom urethral route is not possible.

Catheter selection

Catheter Management The main principles of care and management of the suprapubic catheter are similar to those for urethral catheters. Prevention of Infection is the primary aim with adherence to aseptic technique.

For long-term drainage the catheter used is: • Hydrogel coated latex 16-18Ch 10ml balloon • standard length • for patients with a latex allergy - all silicone catheter. • A dry dressing may be required for the first 24/48 hours after initial insertion. • The catheter, as it emerges, must be supported at right angles to the abdomen. Clothing must therefore not be too tight. • If a dressing is used as part of routine care, it should be sterile. Dressings are not usually required unless there is a discharge.

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 14 of 43 Implementation Date:09.09.2013 Guideline

First and Subsequent Routine Catheter Change Follow inserting urologist plan of care

• •

•

Within 6 weeks the supra pubic tract should be established. Catheter changes for long term catheters can be undertaken 12 weekly by a practitioner who has received training and has been assessed as competent Drainage system. As for urethral catheter, although a holster appliance may be more comfortable.

6.13 Catheter Troubleshooting Bleeding/Haematuria A few specks of blood may indicate trauma to the urethra on catheterisation. Haematuria may also be caused by trauma due to traction on the catheter, infection or renal/bladder pathology. Consider the use of a catheter retaining device and ensure that the catheter bag is properly supported. If it is severe medical referral should be made immediately and the patient monitored for signs of clot formation and catheter blockage. The patient may require further medical investigation e.g.: cystoscopy. Infection Symptoms of infection include cloudy offensive smelling urine, burning pain and elevated temperature. Obtain a specimen of urine and dipstick the urine (Appendix 5). If positive to nitrates, leucocytes, protein, blood, send fresh urine sample for microscopy, culture and sensitivity and inform the patient’s medical team. If antibiotics are commenced than current advice is to change the catheter as impregnation of catheter bio-film is unlikely to occur with antibiotics No Urine Drainage This may be due to: • Kinked tubing • Constipation • Drainage bag positioned above waist level • General condition - is patient dehydrated or in renal failure • Catheter not in urethra • Catheter not the correct length (obese female patients may require a standard length catheter as a female length may to too short) • Encrustation and blockage - see below Perform a bladder scan to see if urine is present in the bladder.

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 15 of 43 Implementation Date:09.09.2013 Guideline

Catheter Bypassing Catheters bypass for the following reasons and it is important to ascertain what the cause of the problem is as each will be dealt with in a different way: • Encrustation and blockage - see below • Twisted tubing - change position of tubing. If using a leg bag, is a shorter length tube required? • Constipation - relieve constipation, give fluid and dietary advice. • Bladder spasm - common within the first 24 - 48 hours after catheterisation, if it persists consider if the patient still needs to be catheterised, check size and balloon size of catheter as reducing the size of these may help, consider anticholinergic medication if the problem persists as it may be due to bladder spasm. Bladder calculi - is possible in patients who have a long-term catheter. This will need to be confirmed by x-ray. Causes of Bypassing Problem

Cause

Action

Drainage system

Kinks or traction in poorly supported drainage bag system

Straighten tubing, ensure bag and catheter supported properly, consider use of urisleeve or g-strap, ensure night bag is supported on a stand Empty drainage bag when ½ to 2/3 full The catheter many irritate the bladder and cause it to go into spasm. This can cause pain and bypassing. The catheter may also be expelled with the balloon intact. Reduce the charriere size of the catheter. Consider anticholinergic therapy. Long term catheterisation increased the incidence of bladder stones. Discuss with the GP the possibility of the presence of bladder stones

Overfull drainage bag Bladder problems

Bladder spasms

Bladder stones

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 16 of 43 Implementation Date:09.09.2013 Guideline

Problem

Cause

Action

Catheter problems

Wrong charriere size used

Always use the smallest size possible to reduce bladder irritation. Preferable sizes: Female – 10-12ch Male – 12-14ch Suprapubic – 16ch Only use standard (“male”) length catheters on male patients. Female length catheters and standard length catheters can be used on female patients. Standard length catheters should be used for suprapubic catheters unless otherwise indicated by the urologist. Ensure the balloon is inflated as per manufacturer’s instructions. Under inflation can cause deflection of the catheter tip, causing bladder irritation and mucosal damage, over inflated balloon can cause urine to pool beneath the catheter creating a risk of bacteriuria and spasm. Pressure from the rectum may stop the catheter draining properly. Implement bowel management programme.

Wrong length of catheter used

Over/under inflated balloon

Constipation

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 17 of 43 Implementation Date:09.09.2013 Guideline

6.14 Catheter Blockage Change catheter and inspect catheter tip for signs of debris or encrustation and document in patient records. If an in-patient was catheterised prior to admission contact the District Nurse and enquire about management. Maintain a record of catheter changes to see if a pattern emerges. Consider pre-empting blockage and changing the catheter prior to blockage if a pattern of catheter life is clear. Causes of Blockage Recurrent blockage is a common problem that occurs in 40-50% of long term catheters (Getliffe, 2002). There are a number of factors that can contribute: • • • • • •

Constipation Kinked tubing The mucosa of the bladder can get drawn into the eyes of the catheter by a build up of suction within the catheter Debris Bladder stones Encrustation

Management of Catheter Blockage When a catheter blocks a full assessment of the catheter history must be carried out. This should include – • Fluid intake • Suspected bladder spasms or stones • Constipation • Kinked tubing • Urinary tract infection • How often the catheters have been changed • Type and size of catheter, balloon size • Colour, smell, appearance of the urine • Encrustation on the outside and/or inside of the catheter tip. Over the ‘life’ of three catheters, it is possible for a pattern of blockage to emerge. NICE (2003) recommend that if a catheter blocks within a shorter interval than manufacturers protocols, the catheter should be changed more frequently prior to blockage. By monitoring the history of an individual’s catheters it is possible to decide when this pre-emptive change would be most suitable.

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 18 of 43 Implementation Date:09.09.2013 Guideline

6.15 Urethral Discomfort This can be caused by the distension of the urethra by a catheter which is too large or occlusion of the par urethral glands leading to infection, urethritis and offensive discharge around the catheter. Refer to Medical Practitioner if there is offensive urethral discharge. Consider removing the catheter or changing to a smaller size catheter. (appendix 3). 6.16 Unable to Tolerate the Catheter Psychological trauma, overactive bladder or radiation cystitis. alternatives to catheterisation.

Consider

6.17 Paraphimosis This can occur if the foreskin is not replaced following catheterisation or hygiene procedures. If the foreskin cannot be replaced into its normal position refer for medical advice. 7

TRAINING 7.1 Mandatory Training Training required to fulfil this policy will be provided in accordance with the Trust’s Training Needs Analysis. Management of training will be in accordance with the Trust’s Statutory and Mandatory Training Policy. 7.2 Specific Training not covered by Mandatory Training Ad-hoc training sessions based on an individual’s training needs as defined within their annual appraisal or job description.

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 19 of 43 Implementation Date:09.09.2013 Guideline

8

MONITORING COMPLIANCE WITH THIS DOCUMENT

The table below outlines the Trusts’ monitoring arrangements for this document. The Trust reserves the right to commission additional work or change the monitoring arrangements to meet organisational needs. Aspect of compliance or effectiveness being monitored DUTIES Infection Prevention and Control Group

Group or committee or Individual individual Method of responsible Monitoring responsible monitoring for the frequency for monitoring completing any actions TO BE ADDRESSED BY THE MONITORING ACTIVITIES BELOW. Infection The Infection Bi-annually Infection Director of Prevention Prevention Prevention Infection and Control and Control and Control Prevention audits Team; Group and Control Clinical services will be monitoring their practice against this policy. Group or committee who receive the findings or report

The Audits will be managed by the IP&CT as part of the annual plan and will be presented to the Infection Prevention and Control Group This document will be reviewed every 2 years unless relevant legislation dictates otherwise

Bi - Monthly Safer Director of Audits reports Modern are shared Matrons Hospitals and Infection with the Environment Prevention service lead Infection Group. and Control concerned as Prevention Governance well as the and Control Committee Team Infection Prevention and Control Group Training will be monitored in line with the Statutory and Mandatory Training Policy.

Infection Prevention and Control Training WHERE A LACK OF COMPLIANCE IS FOUND, THE IDENTIFIED GROUP, COMMITTEE OR INDIVIDUAL WILL IDENTIFY REQUIRED ACTIONS, ALLOCATE RESPONSIBLE LEADS, TARGET COMPLETION DATES AND ENSURE AN ASSURANCE REPORT IS REPRESENTED SHOWING HOW ANY GAPS HAVE BEEN ADDRESSED. The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 20 of 43 Implementation Date:09.09.2013 Guideline

9

REFERENCES

Department of Health (2003) Winning ways: working together to reduce healthcareassociated infection in England. Department of Health, London. [Accessed online] www.dh.gov.uk/assetRoot/04/06/46/89/04064689.pdf Date accessed 17.12.09 Department of Health (2007) Essential Steps to Safe Clean Care. Department of Health. London. [Accessed online] http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4136212. Date accessed 17.12.09 Department of Health (2007) Saving Lives Reducing Infection delivering Clean Safe Care (Oct 2009) [Accessed online] http: //www.clean-safecare.nhs.uk/ArticleFiles/Files/CleanSafeCare_ReducingInfectionsAndSavingLives_St rategy.pdf Date accessed 17.12.09 Pratt et al (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare-Acquired Infections in NHS Hospitals in England. Journal of Hospital Infection February 2007; 65S: S1-S64 The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7th edition ISBN: 978-1-4051-6999-8 Wiley-Blackwell (2008) London Association for Continence Advice Notes on Good Practice (2000) Urethral and Suprapubic Catheterisation and the use of Catheter Maintenance Solutions Department of Health The Health Act (2006) Code of Practice for the Prevention and Control of Health Care Associated Infections National Institute for Clinical Excellence (2003) Prevention of Healthcare Associated Infection in primary and Community Care. NICE London National Institute for Clinical Excellence (October 2006) Urinary incontinence, NICE clinical guideline 40, NICE London National Institute for Clinical Excellence (May 2010), Lower urinary tract symptoms, the management of lower urinary tract symptoms in men, NICE clinical guideline 97, NICE London The Association for Continence Advice (2004) ACA Notes on Good Practice: Catheter Maintenance Solutions. ACA, London. Getliffe, K. (2002) ‘Managing recurrent urinary catheter encrustation’ British Journal of Community Nursing 7(11):574-580 Hagen, S; Sinclair, L; Cross, S. (2010) ‘Washout policies in long-term indwelling urinary catheterisation in adults’. Cochrane Database of Systemic Reviews, Issue 3. The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 21 of 43 Implementation Date:09.09.2013 Guideline

National Institute for Clinical Excellence (2003) Clinical Guideline 2: Infection Control: Prevention of healthcare associated infections in primary and community care. NICE, London. Nazarko, L. (2008) ‘Effective evidence based catheter management’ British Journal of Community Nursing 13(3):110-114 The Association for Continence Advice (2004) ACA Notes on Good Practice: Catheter Maintenance Solutions. ACA, London. Getliffe, K. (2002) ‘Managing recurrent urinary catheter encrustation’ British Journal of Community Nursing 7(11):574-580 Hagen, S; Sinclair, L; Cross, S. (2010) ‘Washout policies in long-term indwelling urinary catheterisation in adults’. Cochrane Database of Systemic Reviews, Issue 3. National Institute for Clinical Excellence (2003) Clinical Protocol 2: Infection Control: Prevention of healthcare associated infections in primary and community care. NICE, London. Nazarko, L. (2008) ‘Effective evidence based catheter management’ British Journal of Community Nursing 13(3):110-114 RCN Catheter Care, Guidance for Nurses (2012) http://www.rcn.org.uk/__data/assets/pdf_file/0018/157410/003237.pdf 10

RELATED TRUST POLICY • • • • • •

ICP000 - Infection Prevention and Control Framework ICP001 - Hand Hygiene Policy ICP002 - Standard Precaution Policy ICP003 - Cleaning and Disinfection Policy ICP004 - Decontamination Policy ICP012 - Aseptic Non-Touch Technique Policy

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 22 of 43 Implementation Date:09.09.2013 Guideline

Appendix 1 - Equality Analysis report Equality Analysis Report Name of function Catheterisation – insertion and management guideline Date 12.07.2013 Assessing officers Head of Infection Prevention and Control Description of policy including the aims and objectives of proposed: (service review/resign, strategy, procedure, project, programme, budget, or work being undertaken): The aim of this policy is to provide nursing and care staff with research based evidence to reduce as much as possible the infection risks involved with catheterisation and catheter use. Evidence and Impact - provide details data community, service data, workforce information and data relating specific protected groups. Include details consultation and engagement with protected groups. Evidence base: NHFT Equality Information Report August 2012 Northampton County Council :Northamptonshire Results: 2011 Census Data Summary





Corby

Daventry

East Northants

Kettering

N’pton

South Northants

W’Boro

Northants

England

2001

53,400

72,100

76,600

82,200

194,200

79,400

72,500

630,430

49,449,700

2011

61,100

77,700

86,800

93,500

212,100

85,200

75,400

691,900

53,012,500

% rise

14.4

7.8

13.3

13.7

9.2

7.3

4.0

9.8

7.2

Ethnicity: 85.7% (White) and 14.3% (BME ) - 1.75% (dual heritage); 4.01% (Asian); 2.5%(Black including British, African and Caribbean); 0.85 % (Chinese); 6.05 % (white other EEA, polish, Gypsy & Traveller)


Gender: 49.6% males; 50.4% females (including 1% transgender)




Disabled people: 19% (including 3.5 % < aged under 18)




Faith communities: 71% Christian; 29% minority faith: (includes Hindu, Muslim, Sikh, atheists, non-belief)


Sexual orientation (gay, lesbian or bisexual): 5 - 7% (Stonewall estimate) Service Information: provide any relevant service data or information to inform the Equality Analysis including service user feedback, external consultation and engagements or research.

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 23 of 43 Implementation Date:09.09.2013 Guideline

Equality Analysis Report Name of function Catheterisation – insertion and management guideline Date 12.07.2013 Protected Groups STAGE 3: Consider the effect of our actions on (Equality Act 2010) people in terms of their protected status? The law requires us to take active steps to consider the need to:




Eliminate unlawful discrimination, harassment and victimisation Advance equality of opportunity Foster good relations with people with and with protected characteristic

Identify the specific adverse impacts that may occur due to this policy, project or strategy on different groups of people. Provide an explanation for your given response. Age

None

Disability

None

Gender (male, female and transsexual, inc. Pregnancy and maternity)

None

Gender reassignment

None

Sexual Orientation (inc. Marriage & civil partnerships

None

Race

None

Religion or Belief (including non belief)

None

Equality Analysis outcome: Having considered the potential or actual effect of your project, policy etc, what changes will take place?

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 24 of 43 Implementation Date:09.09.2013 Guideline

Equality Analysis Report Name of function Catheterisation – insertion and management guideline Date 12.07.2013

Action Plan Issue to be addressed

Action

Who

Date to be completed

Ratification - a completed copy of the Equality Analysis form must be sent to Equality and Inclusion Officer to be approved. Approving Officers Date of completion

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 25 of 43 Implementation Date:09.09.2013 Guideline

Appendix 2 - Procedure for Female Catheterisation Equipment required: • Hand sanitiser • Disposable apron • Sterile catheter dressing pack • Catheter of appropriate length, size and type • Sodium Chloride 0.9% • Instillagel 6ml syringe (lubricant/surface anaesthesia) • 10ml sterile water to fill catheter balloon unless using prefilled catheter • Syringe and blue 23G needle if not needle free system (sharps box to ensure safe disposal of sharp) • Sterile disposable gloves • Appropriate drainage system • Urine specimen container for MCS (if necessary) • Catheter Holder/ straps • Disinfectant Wipe (eg sanicloth to clean neck of ampoule Before starting the procedure: Obtain consent of patient Cleanse the genital area with soap and water. Check that the patient is not allergic to any of the products used in the catheterisation procedure (eg: latex). If latex allergic, use a 100% silicone catheter and non-latex gloves. Action Explain and discuss the procedure with the patient verbally and obtain consent

a) Assist the patient to get into the supine position with bent knees, hips flexed and feet resting about 60cm apart. b) Do not expose the patient at this stage of the procedure Ensure that a good light source is available. Decontaminate hands with either soap and water or using hand sanitiser Put on disposable apron

Rationale To ensure that the patient understands the procedure • check patient’s identity • and check any allergies • and check valid consent To enable genital area to be seen

To maintain the patient’s dignity and comfort To enable genital area to be seen clearly To reduce the risk of cross infection To reduce the risk of cross infection from micro-organisms on clothes

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 26 of 43 Implementation Date:09.09.2013 Guideline

Action Clean and prepare the trolley, placing all equipment on the bottom shelf. Take the trolley to the patient’s bed/bedside. In community setting prepare a clear area. Clean hands Open the outer cover of the catheterisation pack and slide the pack onto the top shelf of the trolley Using an aseptic technique, open supplementary packs Clean neck of ampoule with sodium chloride 0.9% solution prior to drawing up sterile water Remove cover that is maintaining the patient’s privacy and position a disposable pad under the patient’s buttocks Decontaminate hands with either soap and water or using hand sanitiser Put on sterile gloves Place sterile towels under patient’s buttocks Using gauze swabs, separate the labia minora so that the urethral meatus is seen (one hand should be used to maintain labial separation until catheterisation is completed) Clean around the urethral orifice with 0.9% sodium chloride using single downward strokes Insert the nozzle of the Instillagel into the urethra. Squeeze the gel into the urethra, remove the nozzle and discard the tube. Place the catheter, in the receiver, between the patient’s legs Remove soiled gloves, decontaminate hands prior to donning sterile gloves Introduce the tip of the catheter into urethral orifice in an upward and backward direction. Advance the catheter until 5-6cm has been inserted

Rationale To reserve top shelf for clean working spaces

To prepare equipment To reduce risk of introducing infection into the urinary tract To reduce cross infection

To ensure urine does not leak onto bedclothes Hands may become contaminated by handling outer packaging To reduce the risk of cross infection To create a sterile field This manoeuvre provides better access to the urethral orifice and helps to prevent labial contamination of the catheter Inadequate preparation of the urethral orifice is a major cause of infection following catheterisation. To reduce the risk of cross infection. Adequate lubrication helps to prevent urethral trauma. Use of local anaesthetic minimises the patient’s discomfort. To provide a temporary container for urine as it drains To reduce cross infection The direction of insertion and the length of catheter inserted should bear relation to the anatomical structure of the area

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 27 of 43 Implementation Date:09.09.2013 Guideline

Action a. Advance the catheter 6-8 cm. b. Inflate the balloon according to the manufacturer’s directions, having ensured that the catheter is draining adequately. c. Withdraw the catheter slightly and allow urine to flow before connecting the drainage system. d. Support the catheter. Ensure it does not become taut when the patient is mobilising. Make the patient comfortable and ensure the area is dry. Measure the amount of urine

Send a urine specimen for laboratory examination if required Dispose of equipment in appropriate waste bag/double bag and seal before moving the trolley for cleaning Decontaminate hands with either soap and water or hand sanitiser Document procedure/catheter type and size. Volume of water in balloon, lot number and expiry date in medical notes.

Rationale This prevents the balloon from becoming trapped in the urethra. Inadvertent inflation of the balloon within the urethra is painful and causes urethral trauma.

To maintain patient comfort and to reduce the risk of urethral and bladder neck trauma. If the area is left wet or moist, secondary infection and skin irritation may occur. To be aware of bladder capacity for patients who have presented with urinary retention. To monitor renal function and fluid balance. To detect presence of bacteria To prevent environmental contamination

Reduce the risk of cross infection To provide a point of reference or comparison in the event of later queries.

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 28 of 43 Implementation Date:09.09.2013 Guideline

Appendix 3 - Procedure for Male Catheterisation Equipment required: • Hand sanitiser • Disposable apron • Sterile catheter dressing pack • Catheter of appropriate length, size and type • Sodium Chloride 0.9% • Instillagel 11ml syringe (lubricant/surface anaesthesia) • 10ml sterile water to fill catheter balloon unless using prefilled catheter • Syringe and blue 23G needle if not needle free system • Sterile disposable gloves • Appropriate drainage system • Urine specimen container (if necessary) • Catheter holder or leg straps • Disinfectant Wipe (eg sanicloth to clean neck of ampoule Before starting the procedure: Cleanse the genital area with soap and water. Check that the patient is not allergic to any of the products used in the catheterisation procedure (eg: latex). If latex allergic, use a 100% silicone catheter and non-latex gloves. Action Explain and discuss the procedure with the patient verbally and obtain consent.

Assist the patient to get into the supine position with the legs extended. Do not expose the patient at this stage of the procedure. Decontaminate hands with either soap and water or hand sanitiser. Put on disposable plastic apron Clean and prepare the trolley, placing all equipment required on the bottom shelf. Take the trolley to the patients bedside. In community setting prepare a clear area. Open the outer cover of the catheterisation pack and slide the pack onto the top shelf of the trolley, in community setting a clear area.

Rationale To ensure that the patient understands the procedure • check patient’s identity • And check any allergies • and check valid consent. To ensure patient’s privacy.

To reduce the risk of cross infection. To reduce the risk of cross infection The top shelf acts as a clean working surface.

To prepare equipment.

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 29 of 43 Implementation Date:09.09.2013 Guideline

Action Clean neck of ampoule with sodium chloride 0.9% solution prior to drawing up sterile water Using an aseptic technique, open the supplementary packs. Remove cover that is maintaining the patient’s privacy and position a disposable pad under the patient’s buttocks and thighs. Decontaminate hands with soap and water or hand sanitiser. Put on sterile gloves Place sterile towels under patient’s buttocks. Wrap a sterile swab around the penis. Retract the foreskin, if necessary and clean the glans penis with 0.9% sodium chloride. Insert the nozzle of the Instillagel into the urethra. Squeeze the gel into the urethra, remove the nozzle and discard the tube. Massage the gel along the urethra. Squeeze the penis and wait approximately 5 minutes. Remove soiled gloves, decontaminate hands prior to donning sterile gloves to insert sterile catheter Grasp the penis behind the glans, raising it until it is almost totally extended. Maintain grasp of penis until the procedure is finished. Place the receiver containing the catheter between the patient’s legs. Insert the catheter for 15-25cms until the urine flows. Do not inflate balloon until urine flow is seen in tubing If resistance is felt at the external sphincter, increase the traction on the penis slightly and apply steady, gentle pressure on the catheter. Ask the patient to strain gently as if passing urine.

Rationale To reduce cross infection To reduce the risk of introducing infection into the bladder. To ensure urine does not leak onto the bedclothes. Hands may have become contaminated by handling the outer packaging. To reduce the risk of cross infection To create a sterile field. To reduce the risk of introducing infection to the urinary tract during catheterisation.

Adequate lubrication helps to prevent urethral trauma

To prevent anaesthetic gel from escaping and allow it to take effect. To reduce cross infection This manoeuvre straightens the penile urethra and facilitates catheterisation. Maintaining a grasp of the penis prevent contamination and retraction of the penis. The male urethra is approximately 18 cm long. Ensuring correct placement will prevent trauma of urethra and allow patency of the catheter. Some resistance may be due to spasm of the external sphincter. Straining gently helps to relax the external sphincter.

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 30 of 43 Implementation Date:09.09.2013 Guideline

Action a. When urine begins to flow advance the catheter almost to its bifurcation. b. Gently inflate the balloon according to the manufacturer’s directions c. Withdraw the catheter slightly and attach it to the drainage system. d. Support the catheter. Ensure that the catheter does not become taut when patient is mobilising or when the penis becomes erect. Ensure that the catheter lumen is not occluded by the fixation device or tape. e. If catheter cannot be advanced Stop procedure and seek further medical advice immediately Ensure that the glans penis is clean and then reduce or reposition the foreskin.

Make the patient comfortable. Ensure the area is dry. Measure the amount of urine

Take a urine specimen for laboratory examination if required. Dispose of equipment in appropriate waste bag and seal before moving the trolley. Perform hand hygiene Document procedure/catheter type and size. Volume of water in balloon, lot number and expiry date in notes.

Rationale Advancing the catheter ensures that it is correctly positioned in the bladder. Inadvertent inflation of the balloon in the urethra causes pain and urethral trauma. To maintain patient comfort and to reduce the risk of urethral and bladder neck trauma. To prevent further trauma and injury

Retraction and constriction of the foreskin behind the glans penis (paraphimosis) may occur if this is not done. If the area is left wet or moist, secondary infection and skin irritation may occur. To be aware of bladder capacity for patients who have presented with urinary retention. To monitor renal function and fluid balance.

To prevent environmental contamination. Reduce the risk of cross infection To provide a point of reference or comparison in the event of later queries

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 31 of 43 Implementation Date:09.09.2013 Guideline

Appendix 4 - Procedure for Removing a Catheter Equipment required: • Hand sanitiser • Sodium Chloride 0.9% • Disposable apron • Sterile dressing pack • Disposable gloves • Needle and syringe (if urine specimen is required) • Sharps disposal unit • Syringe for deflating balloon • Waste bag (NB Catheters should be removed early in the morning so that any retention problems can be dealt with during the day). Action Explain the procedure to the patient and inform him/her of potential post catheter symptoms (e.g. urgency, frequency and discomfort which are often caused by irritation of the urethra by the catheter).

Rationale To ensure that the patient understands the procedure • check patient’s identity • and check any allergies • and check valid consent.

Decontaminate hands with either soap and water or using hand sanitiser. Put on disposable plastic apron and gloves. Clamp below the sampling port until sufficient urine collects; take a catheter specimen of urine using the sampling port if clinically indicated. Remove gloves and decontaminate hands with either soap and water or using hand sanitiser Put on gloves then use the sodium chloride 0.9% solution to clean the meatus and catheter, always swabbing away from the urethral opening. In women, never clean from the perineum/vagina towards the urethra. Release leg support Having checked the volume of water in the balloon, use syringe to deflate balloon. Do not cut catheter. If balloon will not deflate do not add

To obtain an adequate urine sample and to assess whether post catheter antibiotic therapy is needed. For easy removal of catheter To reduce the risk of cross infection

To reduce the risk of infection

For easy removal of catheter To confirm how much water is in the balloon. To ensure the balloon is completely deflated before removing catheter.

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 32 of 43 Implementation Date:09.09.2013 Guideline

Action anything to current volume in balloon seek help. Ask patient to breathe in and then out: as patient exhales gently - but quickly remove catheter. Male patients should be warned of discomfort as the deflated balloon passes the prostate gland. Clean meatus. Place all used equipment in an appropriate coloured waste bag. Make patient comfortable. Remove gloves and apron and decontaminate hands Complete documentation as per local policy

Rationale

To relax pelvic floor muscles

Hands should always be washed after removal of gloves to reduce risk of cross infection For audit purposes

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 33 of 43 Implementation Date:09.09.2013 Guideline

Appendix 5 - Procedure for emptying a Catheter Bag Equipment required: • Disposable apron • Non-sterile gloves • Swab (70% isopropyl alcohol + 2% chlorhexidine impregnated) • Disposable clean receptacle Action Explain the procedure to the patient

Wash hands or use hand sanitiser prior to putting on disposable gloves and apron. Clean the outlet valve with a swab saturated with 70% isopropyl alcohol wipe and 2% chlorhexidine impregnated wipes e.g Clinell.medical devices wipe. Allow to dry. Open and allow the urine to drain into the clean receptacle (do not allow tap to touch sides of container). Close the outlet valve and clean it again with a new 70 % isopropyl alcohol and 2% chlorhexidine impregnated swab. Allow to dry. Check the tap is not in contact with the floor and that drainage is not obstructed If required, measure amount of urine and then dispose of urine Dispose of receptacle. Remove gloves and apron and dispose of appropriately Decontaminate hands with either soap and water or hand sanitiser Complete records

Rationale To ensure that patient’s identity and understanding of the procedure and give consent To reduce the risk of cross infection

To reduce the risk of infection

To empty drainage bag and accurately measure volume of contents To reduce the risk of cross infection

Bacteria can ascend up the tubing into the bladder causing infection To comply with waste policy Bacterial can thrive in dirty, wet containers To comply with waste policy Hands should always be washed after removal of gloves to reduce the risk of cross infection To provide evidence of activity

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 34 of 43 Implementation Date:09.09.2013 Guideline

Appendix 6 - Procedure for collection of a Catheter Specimen of Urine (CSU) Samples should only be taken from catheters for valid reasons such as suspected infection and should never be taken from the catheter but instead from the sample ports on the bag’s draining tubing. Equipment required: • Sterile 5 ml syringe • (if not a needle less port - a blue 23G needle is also needed) • Disposable gloves/apron • Sterile urine specimen container • 70% isopropyl alcohol and 2% chlorhexidine impregnated wipes • Laboratory request form • Clamp if necessary • Sharps box if necessary Action If there is no urine in the tubing, clamp the tubing a few centimetres below the sampling port until sufficient urine collects Decontaminate hands with either soap and water or hand sanitiser. Put on disposable apron and gloves Clean the sample port with a 70% isopropyl alcohol wipe and 2% chlorhexidine impregnated wipes e.g Clinell.medical devices wipe. Allow to dry for 20 seconds. Then either If needle less collection port system: Action Insert the sterile syringe into the port and aspirate urine and remove syringe If syringe collection port system: Action Attach needle to syringe and insert into port at 45°angle, aspirate urine and remove needle from port. Remove needle from syringe using aperture on sharps box Place urine into specimen container and dispose of syringe in sharps box Swab the sample port again and remove any clamp used

Rationale To obtain adequate sample of urine

To reduce the risk of cross infection

To reduce the risk cross infection

Rationale To obtain specimen of urine Rationale To Obtain specimen of urine

To reduce the risk of infection To reduce infection

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 35 of 43 Implementation Date:09.09.2013 Guideline

Action Label specimen container and seal securely in specimen bag Remove and dispose of gloves and perform hand hygiene Complete records

Rationale To confirm patients details and for safe transportation To reduce the risk of cross infection To provide a point of reference or comparison in the event of later queries

If specimen has to be kept overnight, this should be stored in a specimen fridge and sent to the laboratory immediately next day.

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 36 of 43 Implementation Date:09.09.2013 Guideline

Appendix 7 - Procedure for the Care and Management of Indwelling Catheter Action Wash hands thoroughly before and after any manipulation of the catheter.

Rationale To reduce the risk of cross infection when emptying catheter bags.

Wear a new pair of clean, non-sterile gloves and an apron. Use a disposable container to drain the urine Maintain closed system

Only empty the urinary drainage bag or take a urine sample when necessary

Ensure catheter is positioned below waist level to assist drainage. Use a stand and do not let the catheter bag drag on the floor. Secure catheter to prevent any trauma. Change the catheter bag every seven days including leg bag or in accordance to either the manufacturers’ recommendations or the patient’s clinical need. Maintain catheter care at least twice daily, using only soap and water. The area should be thoroughly cleansed after all bowel movements. If self-caring incorporate into daily personal hygiene. Observe for changes in colour, consistency and odour of urine. Obtain CSU as appropriate and document. Obtain urine from a sampling port using aseptic technique. Educate patient regarding fluid intake. Preferably two and a half litres a day, unless on fluid restriction. Maintain fluid balance chart. Bladder washouts must be prescribed and documented.

Maintaining a sterile continuously closed urinary drainage system is central to the prevention of Catheter Associated Urinary Tract Infections (CAUTI). Unnecessary emptying of the drainage bag or taking a urine sample will increase the risk of catheter-related infection and should be avoided Reflux of urine is associated with infection and therefore drainage bags should be positioned in a way that prevents backflow of urine. Emptying the drainage bag when necessary will maintain urine flow and prevent reflux. Catheter acquired urinary tract infections are less likely to occur when catheter bags are changed less frequently. Meatal cleansing with antiseptic solutions is not recommended, as they have not been shown to actually reduce infections. A urine sample should not be taken from the catheter bag. Specimens collected from the drainage bag may give false results due to organisms growing there. Ensure adequate fluid intake and record urine output is satisfactory.

Irrigation, instillation and washout do not prevent infection.

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 37 of 43 Implementation Date:09.09.2013 Guideline

Action Catheters must not be changed unnecessarily or as part of routine practice except where necessary to adhere to the manufacturers guidelines.

Document all catheter management procedures

Rationale The commonest complication associated with urinary catheter insertion is infection. Co-existing factors may include trauma to the urethra, or a poor aseptic technique during catheter insertion. To provide a point of reference or comparison in the event of later queries

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 38 of 43 Implementation Date:09.09.2013 Guideline

Appendix 8 - Procedure for administration of a urinary catheter maintenance solution Check that the packaging of the urinary catheter maintenance solution is intact and the check the expiry date prior to use. The sachet of solution is supplied sterile and should not be removed from its wrapping until it is required for use. An aseptic technique will be used to prevent cross infection. The solution should be sterile and at room temperature. Equipment Disposable non-sterile gloves Disposable plastic apron Sterile, single use catheter maintenance solution at room temperature New sterile drainage system i.e. Leg bag, catheter valve Nursing procedure sheet or towel Action Rationale Verbally check name of patient by Reduce error by ensuring correct patient asking for name and date of birth Explain the procedure and gain valid To actively involve patient in health care consent, explaining risks and benefits to decisions, the procedure Check for any known allergies To reduce allergic reaction Ensure privacy within the environment To promote dignity and respect for the where care is being delivered patient Help the patient into a supine or sitting position, protect the bed and ensure To maintain patients privacy and dignity privacy Assist if necessary to remove clothing from the waist down to facilitate Maintain dignity of patient observation Reduce the risk of transfer of transient Decontaminate hands, put on apron and organisms on the healthcare workers apply non sterile gloves hands to the patient Drain bladder or empty urine bag before To accurately determine volume of fluid starting the procedure to be instilled Remove straps and lay leg bag on the To aid accessibility bed (if in use) or flat surface Remove gloves and decontaminate Reduce the risk of transfer of transient hands. Put on a pair of non-sterile organisms gloves. Check solution has been stored at room To prevent the bladder going into spasm temperature if the solution is too cold

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 39 of 43 Implementation Date:09.09.2013 Guideline

Equipment Disposable non-sterile gloves Disposable plastic apron Sterile, single use catheter maintenance solution at room temperature New sterile drainage system i.e. Leg bag, catheter valve Nursing procedure sheet or towel Action Rationale Prepare a maintenance solution as To reduce any errors. To ensure correct manufacturer’s guidelines checking administration of the solution expiry date and cross checking against prescription chart. Disconnect leg bag or catheter valve To prevent leakage of urine from catheter. Place bag or valve in a receiver for disposal, while continuing to hold the catheter Remove protective cap from the To minimise risk of infection catheter maintenance solution, being careful not to touch the connecting end. Immediately insert into the end of the catheter Instill the catheter maintenance solution To reduce the risk of damage to the as per manufacturer’s guidelines. bladder mucosa. Disconnect the catheter maintenance To minimise risk of infection solution from the catheter and dispose of the catheter maintenance solution, while continuing to hold the catheter Remove protective cap from the new To facilitate the drainage of urine sterile leg bag or catheter valve, without touching the connection. Insert the end of the bag or valve into the catheter. Secure the drainage system To prevent tension on the catheter by weight of urine Remove gloves, wash hands as per To minimise risk of infection hand hygiene policy. Record procedure including To record and evaluate procedure
Type of solution
Rationale for use of catheter maintenance solution
Instilled amount of fluid
Batch number
Colour, odour, appearance of the urine
Frequency of catheter maintenance solution

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation - Insertion and Management 40 of 43 Implementation Date:09.09.2013 Guideline

Name: .................................................................

Job Title: ...............................

Band: .................................................

Work Place: ................................................................................................................

Date Assessed: .................................

Date of attending theoretical session: ............................................................................................................................................ Appendix 9 - Competency Assessment Tool for a Catheterisation YES

NO

EVIDENCE PROVIDED

Materials and Equipment A working knowledge of the types of catheters, urinary drainage bags, link systems, catheter valves and support methods including garments, straps and stands that can be used with the appropriate selection to meet the individuals specific needs A working knowledge of the types and use of lubrication gels A working knowledge of the solution used to fill balloons Anatomy and Physiology An in-depth understanding of the anatomy and physiology of the male and female lower urinary tract in relation to lower urinary tract function and continence status including:• Urine production and what influences this •

Normal micturition

•

The nervous system including autonomic dysreflexia

•

Sexual function and links to catheter usage

•

The prostate gland, urethral sphincters and the urethra

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation Insertion and Management Procedure 41 of 43 Implementation Date: 09.09.2013

YES

NO

EVIDENCE PROVIDED

Applied anatomy and physiology to voiding dysfunction and how a urethral urinary catheter could be used to relieve this • Anatomy and physiology links of how common catheter related complications occur A working knowledge of how to advise individuals in the use of catheters in relation to their anatomy, its function and sensation Urethral Catheterisation A working knowledge of the causative factors which determine the need for a urethral urinary catheter A working knowledge of the reasons why individuals have planned catheter changes and how to initiate unplanned catheter changes because of blockage or other complications An in-depth understanding of the adverse effects and complications during urethral catheterisation and the appropriate actions to take An in-depth understanding of how to advise individuals using catheters in relation to lifestyle advice, maintaining catheter function, reducing infection, what to do in the event of problems with equipment and how to deal with common complications An in-depth understanding of the short and long term risks and health implications associated with urethral urinary catheterisation An in-depth understanding of why a risk assessment prior to the decision to catheterise is important and what contributes to this assessment Infection Control Related to Catheter Care A working knowledge of the causes of urinary tract invasion from bacteria and how to minimise this in all care settings A working knowledge of the importance of applying standard precautions for infection control and the potential serious life threatening consequences of poor practice •

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation Insertion and Management Procedure 42 of 43 Implementation Date: 09.09.2013

YES

NO

EVIDENCE PROVIDED

A working knowledge of how to meet standards of environmental cleanliness in the area where catheterisation is to take place to minimise the infection risk A working knowledge of when to undertake urinalysis and obtain a catheter specimen of urine Drugs and Medication An in-depth understanding of the indications, mode of action, side-effects, cautions, contraindications and potential interactions of medication, antibiotics, anaesthetic agents and associated solutions used for individuals urethral catheterisation Care and Support of the Individual A working knowledge of how to obtain valid consent and how to confirm that sufficient information has been provided on which to base this judgment A working knowledge of the importance of respecting an individuals’ privacy, dignity, wishes and beliefs’ The healthcare worker will only be assessed as competent at catheterisation if ALL elements are completed. If any one element is failed the healthcare worker must be assessed again. Assessed by competent by (Assessors name): Signature: .............................................................................

Print Name: ...............................................................................

Job Title: ...............................................................................

Work Place: ..............................................................................

Band: ....................................................................................

Click here to return to the table of contents The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version Catheterisation Insertion and Management Procedure 43 of 43 Implementation Date: 09.09.2013