Urinary Catheter Management

1. PURPOSE:

 1.1 The purpose of urinary catheterization is to facilitate urinary drainage when medically necessary
   and should be evaluated every day for need and removed promptly when no longer necessary.
 1.2 To implement protocols that are evidence based for optimal prevention of CAUTIs and are bundled for
   maximized efforts toward these device-associated infections.

2. POLICY:

 2.1 Urinary catheters should be inserted only when medically necessary and should be evaluated daily
   for need.
 2.2 Urinary catheters should be placed only under the direction of a physician order. However, if the patient’s
   nurse does not deem the urinary catheter meets the indications for placement, the patient’s nurse should
   question the need.
 2.3 Island Home Health Care will implement Best Practices for Prevention of CAUTI using evidence-based
   guidelines to prevent and eliminate these infections and comply with ZERO tolerance for preventable
   HAI’s.

3. DEFINITION:

 3.1 Indwelling catheter - is a drainage tube that is inserted into the urinary bladder through the urethra, is left in
   place, and is connected to a closed collection system; also called a Foley catheter.
 3.2 Catheter Associated-UTIs (CAUTI) are captured if the resident had an indwelling urinary catheter at the
   time of or within 2 days before onset of the event.
 3.3 Intermittent catheters – catheters that are temporarily inserted into the bladder and removed once the
    bladder is empty.
 3.4 Condom/External catheters – a urinary containment device that fits over the penis and is attached to a
   urinary drainage bag. It is used to channel male urinary leakage and protect the skin.

4. PROCEDURE:

 4.1 Patient Preparation:
  4.1.1 Consent should be obtained from the patient for indwelling catheterization before
     starting the procedure. It is imperative that the health care professional has a good understanding of
     the principles of the aseptic procedure as this will help to reduce the risk of urinary tract infection
     (UTI). It is essential to ask the patient if they have any sensitivity for Chlorhexidine,
     lignocaine/lidocaine or latex before commencing the procedure.

 4.2 Urethral Catheter - Female and Male Insertion Procedure
  4.2.1 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.
  4.2.2 In case of inability to negotiate the catheter past the U-shaped bulbar urethra use a coude tip catheter
     or hold the penis in an upright position to straighten out the curves.
  4.2.3 When inserting the urethral catheter use a sterile single-use packet of lubricant jelly.
     4.2.3.1 Routine use of antiseptic lubricants for inserting the catheter is not necessary.
  4.2.4 Indwelling, straight, and supra-pubic urinary catheters should be inserted using aseptic technique and
     sterile equipment.
     4.2.4.1 Sterile gloves drape, and sponges; an appropriate antiseptic solution for peri-urethral cleaning
       and a single-use packet of lubricant jelly should be used for insertion.
     4.2.4.2 Use the non-touch technique for indwelling urethral catheterization.
     4.2.4.3 After the catheter has been inserted using aseptic technique, it should immediately be
       connected to the sterile bag, because an aseptic closed drainage system minimizes the risk of
       catheter-associated urinary tract infections.
  4.2.5 The smallest bore catheter possible should be utilized to minimize urethral trauma and irritation.
  4.2.6 Indwelling catheters should be properly secured after insertion to prevent
     movement and urethral trauma.
  4.2.7 External/Condom catheters insertion does not require aseptic technique rather
     clean technique can be used.
     4.2.7.1 Soap and water to wash penis and dry.
     4.2.7.2 Clip the hair or shave the area near the base of the penis to avoid attachment.
     4.2.7.3 Inspect the penis for any broken or reddened skin prior to application.
     4.2.7.4 Wrap the sheath holder around the condom at the base of the penis then connect to the tube
       of the urine bag. Ensure appropriate tightness of the sheath holder for it might impair blood
       circulation.

 4.3 Maintenance
  4.3.1 Standard Precautions
     4.3.1.1 Use gloves when manipulating the catheter site and drainage system and practice
       hand hygiene before and after.
     4.3.1.2 Hand Hygiene:
        4.3.1.2.1 The World Health Organization (WHO) has developed the 5 Moments for Hand
           Hygiene in Healthcare adopted by the Centers for Disease Control and Prevention
           (CDC). The 5 Moments for Hand Hygiene are:
            4.3.1.2.1.1 Before touching a resident
            4.3.1.2.1.2 Before clean/aseptic task
            4.3.1.2.1.3 After body fluid exposure risk
            4.3.1.2.1.4 After resident contact
            4.3.1.2.1.5 After contact with resident surroundings
  4.3.2 A sterile, continuously closed drainage system should be maintained for indwelling and supra-pubic
     catheter systems.
  4.3.3 If there are breaks in aseptic technique, disconnection of tubing, or leakage from the bag, or if
     the catheter becomes contaminated, the catheter should be replaced.
  4.3.4 Drainage bags should always be placed below the level of the patient’s bladder to facilitate
     drainage and prevent stasis of urine.
  4.3.5 Urine in drainage bags should be emptied at least once each shift using a container designated for
     that patient only. Care must be taken to keep the outlet valve from becoming contaminated. Use
     gloves and practice hand hygiene before and after handling the drainage device.
  4.3.6 Patients with urinary catheters will have intake and output recorded. However, urinary catheters
     are not to be inserted simply to monitor outputs with the exception of in intensive care units when
     accurate hourly output assessment is necessary for management.
  4.3.7 Condom catheter should be changed on a daily basis.

 4.4 Catheter Secured:
  4.4.1 Indwelling catheters are to be secured using a leg strap or securement device to minimize urethral
     trauma, movement of the catheter within the urethra, and accidental dislodgment with associated
     urethral trauma.
  4.4.2 Urine drainage bags are to be positioned below the bladder utilizing gravity to facilitate drainage.
     4.4.2.1 Correct positioning of tubing using the securement clip facilitates drainage into the bag
       and prevents reflux of old urine into the bladder. Bags must never touch the floor to prevent
       contamination that can be a potential source for external biofilm formation.

 4.5 Minimum of Daily Catheter Hygiene and Meatal Care:
  4.5.1 Cleansing the meatal surface during daily bathing is appropriate.
  4.5.2 Catheter hygiene is performed daily and after any episode of incontinence/bowel movement.

 4.6 Specimen Collection:
  4.6.1 Aseptique technique
     4.6.1.1 The process of obtaining a sample of urine from a patient with an indwelling urinary catheter
       must be obtained from a sampling port. The sample must be obtained using an aseptic technique
       (DH, 2003).
     4.6.1.2 This port is usually situated in the drainage tubing, proximal to the collection bag which
       ensures the freshest sample possible. The use of drainage systems without a sampling port
       should be avoided (Gilbert, 2006).
     4.6.1.3 Specimens should not be collected from the tap from the main collecting chamber of the
       catheter bag as colonisation and multiplication of bacteria within the stagnant urine or around the
       drainage tap may have occurred.
     4.6.1.4 Aspirating urine from a sampling port has traditionally been performed using a syringe and
       needle. However, needle-free systems are commercially available, which may reduce the risk of
       inoculation injury.
  4.6.2 Generally, urine cultures should be obtained prior to starting antibiotics for patients with suspected
     urinary tract infections.
  4.6.3 The patient with urinary catheter should be monitored for signs of catheter-associated urinary tract
     infection such as fever, chills, or supra-pubic pain.

 4.7 Catheter Material:
  4.7.1 Silicone catheters (100%) is designed for long term use (more than 2 weeks)

 4.8 Suprapubic Catheter Site:
  4.8.1 Performed always good hand hygiene prior to any intervention and use protective equipment (e.g.,
     gloves).
  4.8.2 Suprapubic catheter site should be cleaned daily with soap and water. Excess cleansing is not
     required and may increase the risk of infection.
  4.8.3 Observe the cystostomy site for signs of infection and over granulation.
  4.8.4 Antimicrobial agents should not routinely or as prophylactic treatment be applied to the cystostomy site
     to prevent infection.
  4.8.5 Dressings are best avoided; if a dressing is used to contain a discharge this should be undertaken with
     strict aseptic technique to protect against infection. Wherever possible, patients should be
     encouraged to change their own dressings.