Clinical guideline for the re-insertion and removal of a supra-pubic catheter and catheter care

Transcription

1 Document level: Clinical Service Unit (CSU) Code: CC6 Issue number: 1 Clinical guideline for the re-insertion and removal of a supra-pubic catheter and catheter care Lead executive Lead Clinical Director Author and contact number Continence Lead Type of document Target audience Document purpose Guidance All clinical staff within CCWC This guideline is intended to serve as evidence based guide for Competent Practitioners employed by Cheshire and Wirral Partnership NHS FoundatioN Trust (CWP), in the removal and aseptic re-insertion of a supra-pubic catheter for both male and female patients It also povides guidance on catheter care. Please note this guideline is intended for adult patients only. Document consultation CCWC services Approving meeting CSU - Goverance and Risk Group 24-Aug-12 Ratification Document Quality Group (DQG) 14-Sep-12 Original issue date Sep-12 Implementation date Sep-12 Review date Sep-17 CWP documents to be read in conjunction with HR6 IC2 GR29 IC3 CP3 CC7 CC5 CC4 MP16 GR26 MH13 Trust-wide learning and development requirements including the training needs analysis (TNA) Hand decontamination policy and procedure Waste management policy Standard (universal) infection control precautions policy Health records policy Clinical guidelines for urethral indwelling catheterisation Clinical guidelines for intermittent catheterisation Clinical guidelines for catheter maintenance solution n-medical prescribing policy Policy for the safe manual handling of people and loads Part IV and IVA - MHA - Consent to treatment Training requirements Financial resource implications Yes - Training requirements for this policy are in accordance with the CWP Training Needs Analysis (TNA) Equality Impact Assessment (EIA) Initial assessment Yes/ Comments Does this document affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Page 1 of 23

2 Initial assessment Yes/ Comments Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems Is there any evidence that some groups are affected differently? If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? N/A Is the impact of the document likely to be negative? If so can the impact be avoided? N/A What alternatives are there to achieving the document without the impact? N/A Can we reduce the impact by taking different action? N/A Where an adverse or negative impact on equality group(s) has been identified during the initial screening process a full EIA assessment should be conducted. If you have identified a potential discriminatory impact of this procedural document, please refer it to the human resource department together with any suggestions as to the action required to avoid / reduce this impact. For advice in respect of answering the above questions, please contact the human resource department. Was a full impact assessment required? What is the level of impact? Low Monitoring compliance with the processes outlined within this document Please state how this document will be monitored. If the document is linked to the NHSLA accreditation process, please complete the monitoring section below. Document change history Changes made with rationale and impact on practice 1. Auditing the number of patients with a catheter in situ, catheter related infections and the reason for catheter insertion on a monthly basis within the boundries of Western Cheshire. Auditing the number of Competent Practitioners attending the CWP catheterisation study day and number of staff competent to catheterise. Auditing catheter care training attendence provided to private and social care providers. Continence Advisory Service Auditing Yearly. External references References 1. Cochran S. Care of the Indwelling Urinary Catheter: Is It Evidence Based? Journal of Wound, Ostomy & Continence Nursing May / June; 34(3): Continence Advisory Service (CAS). Continence Prescribing Formulary March March. 3. Dougherty L, Lister S. The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Wiley-Blackwell. Eight Edition, Gilbert R. Procedure to undertake a trial without catheter. Nursing Times Oct;102(42): Hagen S, Sinclair L, Cross S. Washout policies in long-term indwelling urinary catheterisation in adults. Cochrane Database of Systematic Reviews 2010, Issue Inelmen EM, Sergi G, Enzi G. When are indwelling urinary catheters appropriate in elderly Page 2 of 23

3 References patients? Geriatrics Oct;62(10): Lin K, Fajardo K. Screening for asymptomatic bacteriuria in adults: evidence for the US Preventive Service Task Force reaffirmation recommendation statement. Annals of Internal Medicine. 2008;149(1),W20-W National Institute for Clinical Excellence (NICE). Clinical Guideline 139 Infection Prevention and control of healthcare-associated infections in primary and community care March. 9. National Patient Safety Agency (NPSA). Rapid Response Report NPSA / 2009 / RRR005: Minimising risks of suprapubic catheter insertion (adults only) July. 10. NHS Quality improvement Scotland (NHS QIS). Urinary Catheterisation & Catheter care. Best statement June 11. Nursing and Midwifery Council (NMC). The Code - Standards of conduct, performance and ethics for nurses and midwives Robinson J. Selecting a urinary catheter and drainage system. British Journal of Nursing. 2006;15(19): Royal College of Nursing (RCN). Catheter care. RCN guidance for nurses. Royal College of Nursing, London Tenke P, Kovacs B, Johansen T, et al. European and Asian guidelines on management and prevention of catheter-associated urinary tract infections. International Journal of Antimicrobial Agents. 2008; 31S:S68 S Trautner B. Management of catheter-associated urinary tract infection. Current Opinion in Infectious Diseases. 2010,23(1), Tzortzis V, Gravas S, Melekos MM, de la Rosette JJ. Intraurethral lubricants: a critical literature review and recommendations. J Endourol May;23(5):821-6 Page 3 of 23

4 Content 1. Introduction Definitions Qualification and training Assessment Risks associated with catheterisation Patient consent and information Review Trial without catheter (TWOC) Equipment required Selection of catheter Selection of drainage systems and securement devices Local anaesthetic gel Catheter Maintenance Solutions Procedure for re-insertion of a supra-pubic catheter Procedure for removal of a supra-pubic catheter Procedure - catheter drainage system Emptying a leg drainage bag Changing a sterile leg / night drainage bag Applying of a single use, non-sterile night drainage bag to a leg bag Applying of a single use, non-sterile night drainage bag to a catheter valve Removal of a night drainage bag from either leg bag or catheter valve Procedure - Catheter specimen of urine (CSU) Duties and responsibilities Clinical Director Continence Advisory Service Line Managers Clinical staff Appendix 1 - Competency document supra-pubic catheterisation Appendix 2 - Assessment form for indwelling catheter Appendix 3 - Record of urinary catheter changes Appendix 4 - Information on autonomic Dysreflexia Page 4 of 23

5 1. Introduction This guideline is intended to serve as evidence based guide for registered nurses and assistant practitioners employed by CWP in the removal and aseptic re-insertion of a supra-pubic catheter for both male and female patients. It also provides guidance on catheter care. Please note this guideline is intended for adult patients only. 2. Definitions To provide guidance for registered nurses in: Caring out a catheter assessment and review; The re-insertion of a supra-pubic catheter; The removal of a supra-pubic catheter; How to empty and change the drainage bags; Taking a urine sample via a catheter sample port using an aseptic technique; Patient education regarding catheter care; The delegation and supervision of any catheter related procedures to assistant practitioners, patients or carers. To provide guidance for assistant practitioners in: The re-insertion of a supra-pubic catheter; The removal of a supra-pubic catheter; How to empty and change the drainage bags; Taking a urine sample via a catheter sample port using an aseptic technique; Patient education regarding catheter care. 3. Qualification and training This guidance applies to all clinical staff employed by CWP: Registered Nurses who are currently registered with the Nursing and Midwifery Council (NMC); Assistant Practitioners who have completed a recognised assistant practitioner s course. Following the catheterisation study day, the registered nurse or assistant practitioner needs to complete a minimum of 3 supervised practices till they feel confident and competent in: Supra-pubic catheterisations. This should be recorded in the Competency document supra-pubic catheterisation (appendix 1). The supervision of these practical procedures can only be undertaken by a Registered Nurse who has: Attended the catheterisation study day within the last three years; Is confident and experienced in inserting and removing a supra-pubic catheter; Completed the document Competency document for supra-pubic catheterisation (appendix 1). In order to maintain knowledge and skills the registered nurse and assistant practitioner should attend a catheterisation update study day every three years. 4. Assessment Initial supra-pubic catheterisation and the first change of the supra-pubic catheter will be carried out by a specially trained heath care professional in a hospital setting using Ultrasound. As there is a small risk of the following complications (NPSA, 2009) Peritoneal perforation with or without bowel perforation; Infection; Haematuria; Fistula; Incisional hernia around the site of the supra-pubic catheter. Page 5 of 23

6 Subsequent changes can be carried out in the patients home, health centre or GP practice by a registered nurse or assistant practitioner, providing she / he meets the criteria set in section 3 Qualifications and training in this guidance In this guideline supra-pubic catheterisation can be used for the following reasons: To relieve retention of urine; If patient needs a long-term catheter and is sexually active; Surgery; As a last resort, to manage urinary incontinence. It is the Registered Nurse s responsibility to be aware of the medical and / or surgical history, physical and mental health, social environment and the reasons for catheterisation. This will ensure that no contra-indications exist prior to catheterisation as well as identify any known allergies. If the practitioner has any concerns prior to re-catheterisation medical advice should be sought. (NHS QIS, 2004; NICE, 2012) Please see the assessment form for indwelling catheter appendix 2. Factors that need to be considered before teaching a patient / carer how to look after the catheter and how to empty, change and position the drainage system: Cognitive ability; Dexterity; Home / social environment; Compliance with catheter care. 5. Risks associated with catheterisation Catheterisation carries a high clinical risk, which may involve some or all of the following: (Hagen, 2010; Inelmen et al, 2007): Bleeding; Infection; Bowel perforation; Catheter obstruction or leakage; Urinary tract stones; Chronic renal inflammation; Renal failure; Bladder cancer; Autonomic dysreflexia (see appendix 4); In extreme cases death can occur. Urinary Tract Infections (UTI) are the commonest source of acquired infection, particularly when inserting a catheter into the bladder. Most catheter-associated infections are derived from the patient s own colonic flora. (NICE, 2012) A major risk factor for the development of catheter-associated bacteriuria is the duration of catheterisation. To reduce this risk the catheter system should remain closed and the duration of catheterisation should be minimal as most episodes of short-term catheter-associated bacteriuria are asymptomatic and are caused by a single organism. Further organisms tend to be acquired by patients catheterised for more than 30 days (Tenke, et al, 2008). Routine urine culture in an asymptomatic catheterised patient is not recommended because treatment is generally not necessary, except for some special cases. Antibiotic treatment is recommended only for symptomatic infection (Gilbert, 2005; Lin, 2008; Tenke P, et al, 2008; Trautner, 2010). Antibiotic prophylaxis when changing catheters should only be considered for patients with a history of symptomatic urinary tract infection following catheter change or experience trauma during catheterisation. (NICE, 2012) Page 6 of 23

7 6. Patient consent and information Prior to re-catheterisation the consent of the patient must be verbally obtained and documented following a full explanation of the procedure and potential complications. To support any verbal explanation a leaflet on catheter care should be given to the patient. It is the registered nurse or assistant practitioner s responsibility to assess, and teach the patient and /or his carer on hand decontamination policy and procedure, how to attach, empty and remove either a leg / night bag or a catheter valve and how to clean the insertion site (NICE, 2012) as indicated in this guideline (section 12 Procedure catheter drainage systems ). 7. Review It is the registered nurse s responsibility to review the patient when the catheter is due to be changed. The review can be carried out earlier if identified problems occur (see appendix 3). This review may include assessment for the following: Symptoms of a symptomatic urinary tract infection (cloudy or bloody urine, which may have a foul or strong odour, Low fever, pain or burning with urination, pressure or cramping in the lower abdomen (usually middle) or back, strong need to urinate often, even right after the bladder has been emptied); Bowel perforation (abdominal pain, localised peritonitis, being systematically unwell). Medical help should be sought immediately (NPSA, 2009); How often is the catheter being changed? Problems with catheter leakage blockage (see clinical guideline on the use of a catheter maintenance solution); Is the patient / carer maintaining the closed system and using a clean technique when emptying or changing the drainage system (NICE, 2012); Observation of the supra-pubic site; Ensure the patient / carer is using correct hand decontamination before and after manipulation of the catheter (NICE 2012). For common catheter problems and possible solutions, please refer to Continence Prescribing Formulary (CAS, 2012). Catheter maintenance solutions are not for routine use and are prescription only medication. For more information on catheter maintenance solutions, please refer to clinical guideline on the use of a catheter maintenance solution. 8. Trial without catheter (TWOC) If a suprapubic catheter is present, a catheter valve can be used to stop continuous drainage, if appropriate. The supra-pubic catheter acts as a safety valve to prevent distension of the bladder if urethral voiding is difficult (Robinson, 2006). If voiding is satisfactory and the residual is low, the catheter can be removed (RCN, 2012). Patient education can assist in a successful outcome of a trial without catheter. For example the patients / carers should record and document fluid intake, urine output and sensation to void. The registered nurse or assistant practitioner should advised patients to report immediately any of the following symptoms: Discomfort when they pass urine; Sensation of incomplete emptying; Inability to pass urine; Lower abdominal pain; Haematuria; Symptoms of Urinary Tract Infection; Frequency / urgency (may indicate a Urinary Tract Infection, residual volume or overactive bladder); Incontinence. Page 7 of 23

8 9. Equipment required To prescribe the most cost-effective catheter and drainage system, please refer to the most up-to-date Continence Prescribing Formulary. It is the registered nurse or assistant practitioner s responsibility to use the products that are available in this formulary, unless they are contra-indicated for the patient. If you are prescribing outside this formulary the reason should be documented (please see appendix 3). The equipment for the insertion / removal supra-pubic catheter and the equipment for the attachment, emptying and removal of leg / night bag or catheter valve is listed in the related procedures set in section 12 (Procedure catheter drainage system ) in this guidance. 9.1 Selection of catheter When choosing a catheter the registered nurse or assistant practitioner needs to be aware that the catheter is licensed for supra-pubic use and take into consideration the following: Duration of the catheterisation: Short term catheter: licensed for 28 days; Long term catheter: licensed for 3-12 weeks. (Robinson, 2006) The length of the catheter: Standard male catheters (40-45cm) should be used for supra-pubic catheterisation.. Catheter material Polytetrafluoroethylene (PTFE) (licensed for 28 days): o Highly elastic; o Inexpensive; o Prone to encrustation (Cox et al, 1988); o Unsuitable for patients who are allergic to latex. Silver Alloy Hydrogel Coated Latex (licensed for 28 days): o Inhibits bacterial growth. (Newman, 2007); o Biocompatible and low surface friction which aids patient s comfort and reduces irritation; o Unsuitable for patients allergic to latex. All silicone (licensed for 3-12 weeks): o Suitable for patients with a latex allergy; o Reduced irritation (Madeo et al, 2009); o Wider lumen inside, therefore allowing better drainage (Dougherty et al, 2011; Newman, 2007); o Formation of a cuff on deflation of the balloon of all silicone catheters causes difficulty in removal (Parkin, 2002); o Silicone is semi permeable which may lead to deflation of the balloon and premature failure of the catheter (Getliffe, 1993; Newman, 2007). Silicone Elastomer Coated Latex (Teflon) (licensed for 3-12 weeks): o Smooth internal and external surfaces resistant to encrustation (Newman, 2007); o Coating reduces water absorption, irritation and tissue damage (Newman, 2007); o Unsuitable for patients with a latex allergy. Hydrogel coated silicone (licensed for 3-12 weeks): o Suitable for patients allergic to latex; o Reduced irritation (Madeo et al, 2009); o Hydrogel coating enhances comfort and may reduce resistance to blockage; o Silicone is semi permeable which may lead to deflation of the balloon and premature failure of the catheter (Getliffe, 1993); Page 8 of 23

9 o Formation of a cuff on deflation of the balloon of all silicone catheters causes difficulty in removal (Parkin, 2002). Hydrogel coated Latex (licensed for 3-12 weeks): o Biocompatible; o Low surface friction improves patients comfort (Seth, 1998); o Unsuitable for patients with a latex allergy. Balloon size: 5-10ml; 30ml for post-urological procedures only and not for routine catheterisation. NICE (2012) recommends that the balloon gets inflated with 10mls of sterile water. However it is the clinician s responsibility to ensure the correct amount and type of fluid is used to inflate the catheter balloon as per manufacturer s guidelines Selection of drainage systems and securement devices Leg bag Sterile leg bags must be used with indwelling catheters. Leg bags come in different capacities the life style of the patient will determine which leg bag capacity to use. Leg bags are changed every 5-7 days as per manufacturer s recommendations. Night bag: Only sterile night bags must be used when connecting directly to a catheter. These are changed every 5-7 days; n-sterile night bags should only be used when connecting to a leg bag or catheter valve. These are single use only. Catheter valve Sterile catheter valves are connected directly to the indwelling catheter. These are changed every 5 to 7 days as per manufacturer s recommendations (NHS QIS, 2004); Some patients may need to attach a non-sterile night bag to the catheter valve at night to allow free drainage. Contra-indications for use of a catheter valve include: Those with no or limited bladder sensation; Patients with reduced bladder capacity; Patients with cognitive impairment; Those with insufficient manual dexterity to open the valve. Securement devices The catheter should be secured at the bifurcation of the tubing using a securement device i.e. an abdominal G- strap ; A leg bag should be secured to the leg with either leg bag straps or a leg bag holder, i.e. Urisleeve. This will prevent traction and will be more comfortable for the patient. 9.3 Local anaesthetic gel Over the past few years, the value of local anaesthesia during urethral catheterisation has been questioned. Strong data is lacking, and the results from different studies are contradictory. Research suggests that although anaesthetic lubricants are needed during urethral catheterisation in men; plain lubricants maybe sufficient for catheterisation in woman and supra-pubic catheterisation. (Tzortzis, et al, 2009): Page 9 of 23

10 A single use sachet of sterile plain lubricating gel can be used for supra-pubic catheterisation, i.e. Aquagel lubricating Jelly 5g sachet, Sutherland Lubricating Jelly 5g sachet. Contra-indications for local anaesthetic lubricating gel: Hypersensitivity to the active ingredients; In patients who have damaged or bleeding urethral mucosa, as this will increase the rate of absorption of lidocaine across the damaged mucosa; Use with caution in patients with impaired cardiac conditions, hepatic insufficiency, epilepsy and who are taking anti-arrhythmic drugs. 9.4 Catheter Maintenance Solutions There is conflicting data on the use of Catheter Maintenance Solutions. They are not recommended for routine use. They can be used in patients who may require frequent re-catheterisation due to blockage. Please see clinical guideline for the use of a catheter maintenance solution. 10. Procedure for re-insertion of a supra-pubic catheter Equipment: Sterile catheterisation pack containing: o Sterile gloves; o Disposable plastic apron; o Disposable bag; o Sterile non-woven swab; o Cotton balls; o Sterile towel. Sterile saline 0.9% for cleansing; Sterile lubricating gel, i.e. Instillagel, Aqua gel or Sutherland Lubricating Gel; Sterile water for injections (10ml). This is not necessary if you have a prefilled balloon or syringe; Sterile syringes (10 ml) and sterile needle if appropriate x1; Sterile syringe 10 ml for deflating the balloon; Sterile catheters. It is recommended to use a standard (male) length catheter; Sterile drainage system; Securement device for catheter and leg bag; Receiver; Sharps box if required.. Action Rationale Explain the procedure to the patient. The patient understands the procedure and 1. Obtain patient s consent and record in the gives informed consent. patient s records. Review life-time of the catheter 2. Check when the catheter was last inserted and how much sterile water was used to inflate the balloon. Page 10 of 23 To ensure same amount of fluid will be withdraw. However the amount of fluid that is withdrawn can be slightly less due to osmosis. 3. Wash hands as per hand decontamination policy, put apron and gloves on. To minimise the risk of cross infection. 4. Prepare the environment work area. To provide a clean working surface. 5. Assist patient to an appropriate position and To maintain the patients dignity and comfort. cover the patient. Empty drainage bag. Reduce risk of spillage 6. Remove disposable gloves and wash hands. Put on disposable gloves. To minimise the risk of infection.

11 . Action Rationale Open the outer package of the catheterisation pack. 7. Carefully open the inner package remembering no touch technique, as this is an aseptic technique. To prepare equipment and to reduce the risk of introducing infection into the bladder Then place all necessary equipment on sterile surface. Disposing of outer packaging as required. Open a single use sachet of lubricant i.e. Aqua gel or Sutherland lubricating Jelly 5g sachet, and squeeze gel over catheter. Remove previous catheter. 9. Be aware of the angle at which the catheter is removed and also the length of catheter withdrawn. Remove gloves. 10. Wash hands as per policy 11. Put on sterile gloves Cleanse around the supra-pubic stoma with 12. sterile saline Insert the catheter at the same angle into the abdominal tract within 30 to 40 minutes Advance the catheter slightly further than the length of the catheter that was removed. You may need to use a corkscrewing action. Adequate lubrication helps reduce urethral trauma and minimises the discomfort experienced by the patient. (Cochran, 2007; NHS QIS 2004; NICE, 2012) See procedure in section 11 of this guideline for the removal of a supra-pubic catheter. To aid insertion To remove any new contamination To reduce the risk of introducing infection during catheterisation. Please note that the cystostomy tract can close quickly due to detrusor contraction. (NHS QIS, 2004) To ensure safe insertion of the catheter. To aid insertion. A proper inflation is necessary for the creation of a symmetrical balloon Inflate the balloon as per manufacturer s guidelines. Withdraw the catheter slightly and connect to the new sterile drainage system. Observe for urine, which may not be immediate and might be a little bloodstained. An under-inflated balloon can result in a tearshaped balloon configuration with deflection of the catheter tip. An over-inflated balloon increases urine pooled in the bladder base with the associated risks of bladder spasms or bacteriuria. (Cochran, 2007) Maintaining a closed drainage system reduces the risk of catheter-related infection (Cochran, 2007; NHS QIS 2004; NICE, 2012; Tenke, 2008) To observe that the catheter is draining 16. Secure catheter to abdomen using an abdominal G-strap. To prevent any pulling on the catheter 17. Dispose of equipment and sharps as per policy To maintain a safe environment. 18. Wash and dry hands as per policy Reduces cross infection. Page 11 of 23

12 . Action Rationale Record information in care plan, to include: - Catheter type, size, make and batch number; - How much sterile water is used to inflate 19. the balloon; - Date of insertion; - Batch of lubricant; - Date of next catheter change and subsequent review. 20. Instruct patient / carer on effective catheter care - Wash hands before and after dealing with the catheter and drainage system (NICE, 2012) - The insertion area of the catheter should be washed with soap and water and does not require a dressing unless indicated - Check the drainage bag is below the level of the bladder - Check that catheter and drainage bag are correctly secured - Maintain closed system - Advice on when and how to change / attach drainage system - Drink at least 1.5 litres if not contraindicated - Avoid constipation - How to dispose of equipment To provide a point of reference (THIS IS ESSENTIAL). To prevent possible complications, i.e. trauma, infection, blocked catheter, Advise patient on problems that may occur, i.e. symptoms of infection, blockage, pain, haematuria, Prompt intervention 11. Procedure for removal of a supra-pubic catheter Equipment: - Disposable gloves; - Apron; - Plastic Bag; - Syringe 10ml; - Gauze.. Action Rationale 1. Explain the procedure to the patient. To ensure that the patient understands the procedure and gives informed consent. 2. Check in the patient s records how much To identify how much water is in the balloon water was used to inflate the balloon prior to deflation 3. Wash hands as per hand decontamination To minimise risk of cross infection (NICE, policy 2012) 4. Put on a disposable plastic apron To reduce the risk of cross infection 5. Prepare the environment work area. To provide a clean working surface 6. Assist the patient into a suitable position and cover the genital area. To maintain the patient s dignity and comfort. 7. Wash hands as per policy To minimise risk of cross infection 8. Put on disposable gloves. To reduce the risk of cross infection Page 12 of 23

13 . Action Rationale 9. Empty the drainage bag. To ensure urine does not leak onto bedclothes 10. Release the catheter and drainage bag support / straps For easier removal of catheter 11. Deflate the balloon using a 10 ml syringe If unable to deflate the balloon, seek medical advice To minimise trauma Gently remove the catheter To minimise trauma 12. As you withdraw the catheter from the tract; you may need to use a slight corkscrewing action (ACA, 2004) Have some gauze ready. This is maybe due to encrustation or cuffing of the deflated balloon There may be a gush of urine as you withdraw the catheter. te the angle at which the catheter is removed To aid assistance on reinsertion. 13. Clean around supra-pubic stoma To minimise risk of infection, to protect skin integrity 14. Dispose of equipment, gloves and apron To prevent environmental contamination 15. Wash hands Minimise the risk of cross infection. If supra-pubic catheter is to be reinserted, 16. please refer to the above procedure 8.1 Reinsertion of supra-pubic catheter 17. Information to be recorded in the patients - Reason for removal - Any problems on removal? 12. Procedure - catheter drainage system To provide a point of reference (THIS IS ESSENTIAL) 12.1 Emptying a leg drainage bag Leg bags: Should be emptied regularly (usually when 2 / 3 full); Be positioned below the level of the bladder; Changed every 5 to 7 days according to manufacturer s instructions. (Cochran, 2007) (NICE, 2012). Equipment: - Apron and Disposable n-sterile Gloves; - Receiver; - Tissue.. Action Rationale 1. Explain procedure to patient. To obtain patient s consent and cooperation. 2. Collect equipment. To provide a suitable working environment. 3. Wash hands as per hand decontamination policy, To reduce cross-infection and selfcontamination. (NICE, 2012) put apron and gloves on. 4. Loosen securement device, open the tap and empty all urine into receiver or toilet. 5. Close the tap; wipe it dry with the tissue, measure amount of urine (if requested), and empty into toilet. To reduce cross infection Page 13 of 23

14 . Action Rationale Remove gloves, wash hands as per hand To reduce risk of cross infection. (NICE, 6. decontamination policy 2012) 7. Remove and dispose of equipment. To leave a clean safe environment. Report any concerns to appropriate health Alert appropriate health staff of patient s 8. personnel, i.e. the amount of urine passed; current condition colour, odour, appearance of the urine Changing a sterile leg / night drainage bag Equipment: Sterile leg / night bag; Disposable n-sterile Gloves; Apron; Plastic Bag; Receiver.. Action Rationale 1. Explain procedure to patient. To obtain patients consent and cooperation. 2. Collect equipment. To provide an suitable working environment 3. Wash hands as per hand decontamination To prevent cross-infection and selfcontamination. (NICE, 2012) policy, put apron and gloves on and open pack which contains sterile leg / night bag 4. Loosen securement device, empty leg / night bag by opening tap and emptying all urine into Safe disposal of equipment receiver / toilet. Remove gloves, wash hands as per hand decontamination policy and put on clean gloves Disconnect leg bag from catheter and place leg / night bag in receiver for disposal, while continuing to hold catheter Remove protective cap from the new bag, being careful not to touch the connecting end, immediately insert into the end of the catheter. Secure new bag using chosen method of support. Remove gloves, wash hands as per hand decontamination policy. Report any concerns to the appropriate health professional, i.e. the amount of urine passed; colour, odour, appearance of the urine. To prevent cross-infection and selfcontamination. To prevent leakage of urine. To facilitate drainage of urine. To prevent tension on the catheter by weight or urine. To minimise risk of cross infection. For prompt response to any identified problems Applying of a single use, non-sterile night drainage bag to a leg bag A night bag can be attached to the leg bag to allow free over night drainage. The leg bag should NEVER be disconnected from the catheter to apply a night bag. (Cochran, 2007) (NICE, 2012) (NHS QIS, 2004) Equipment: - Apron and Disposable n-sterile Gloves; - n-sterile, single use, 2 litre night bag; - Receiver; - Tissue. Page 14 of 23

15 . Action Rationale 1. Explain procedure to patient. To obtain patient s consent and cooperation. 2. Collect equipment. To provide an suitable working environment 3. Wash hands as per hand decontamination To reduce cross-infection and selfcontamination. (NICE, 2012) policy, put apron and gloves on. 4. Loosen securement device, empty leg bag by opening tap and emptying all urine into To prevent leakage of urine. receiver / toilet. 5. Close the tap, wipe it dry with the tissue 6. Attach the non-sterile, single use, 2 litre night bag to the leg bag. For effective night time drainage of urine. 7. Open tap from leg drainage bag to the night bag To ensure urine drains correctly. 8. Attach night bag to equipment as agreed, i.e. To minimise risk of trauma, and promote catheter bag stand. effective drainage of urine 9. Remove gloves and apron, wash hands as To reduce risk of cross-infection. (NICE, per hand decontamination policy 2012) 10. Report any concerns to appropriate health Alert appropriate health staff of patient s personnel, i.e. the amount of urine passed; current condition. colour, odour, appearance of the urine Applying of a single use, non-sterile night drainage bag to a catheter valve Patients with catheter valves may choose to go on free drainage over night and will use a night drainage system. (NICE, 2012). Equipment: Apron and Disposable n-sterile Gloves; n-sterile, single use, 2 litre night bag; Receiver; Tissue.. Action Rationale 1. Explain procedure to patient. To obtain patient s consent and cooperation. 2. Collect equipment. To provide an suitable working environment 3. Wash hands as per hand decontamination To reduce cross-infection and selfcontamination. (NICE, 2012) policy, put apron and gloves on. 4. Open the catheter valve into a receiver or down the toilet. To empty the bladder 5. Close the catheter valve, wipe it dry with the tissue To prevent leakage of urine 6. Attach non-sterile, single use 2 litre night bag to the catheter valve For effective drainage of urine 7. Open the catheter valve. To ensure urine drains correctly. 8. Attach night bag onto the catheter night bag To minimise risk of trauma, and promote stand or holder effective drainage of urine 9. Remove gloves and apron, wash hands as To reduce risk of cross-infection. (NICE, per hand decontamination policy 2012) 10. Report any concerns to appropriate health Alert appropriate health staff of patient s personnel, i.e. the amount of urine passed; current condition. colour, odour, appearance of the urine. Page 15 of 23

16 12.5 Removal of a night drainage bag from either leg bag or catheter valve Equipment: Apron; Disposable non-sterile gloves; Plastic bag;. Action Rationale 1. Explain procedure to patient. To obtain patient s consent and cooperation. 2. Collect equipment and prepare work area. To provide a suitable working environment. 3. Wash hands as per hand decontamination To reduce contamination and prevent cross policy, put on apron and gloves infection. (NICE, 2012) 4. Close tap on the leg bag or the catheter valve To prevent spillage of urine. 5. Remove the night bag from the leg bag or catheter valve For patient s comfort and dignity. 6. Empty the night bag into the toilet as per manufacturer s instructions Safe disposal of bodily fluids. 7. Remove and dispose of equipment To leave a safe environment. 8. Remove gloves, apron, wash hands as per To minimise risk of cross infection. (NICE, hand decontamination policy 2012) 9. Report any concerns to appropriate health Alert appropriate health staff of patient s personnel, i.e. the amount of urine passed; current condition. colour, odour, appearance of the urine. 13. Procedure - Catheter specimen of urine (CSU) Urine samples are only taken from catheters for a valid reason, such as suspected infection. A urine sample should be taken from the sample port (NICE, 2012) as per procedure in this document using a needleless device. If a patient has a catheter valve, a sample should be taken as per procedure in this document. Samples are collected from the sample port on the bag to ensure that the closed system is maintained. Disconnecting the catheter from the urine bag to obtain a urine sample increases the risk of catheter-related infection (NICE, 2012) (Dougherty et al, 2006) and this practice may cause inappropriate findings from microbiology. If the patient has a catheter valve in situ, it is recommended to use a new sterile catheter valve and to attach a sterile leg bag. The specimen of urine is then obtained using the sample port of the leg bag. Equipment: - n-sterile disposable gloves; - Apron; - Sterile syringe 10ml; - Plastic bag; - Appropriate urine specimen bottle / syringe as recommended by the laboratory; - Isopropyl alcohol 70% impregnated swab.. Action Rationale 1. Explain procedure to patient. To obtain patient s consent and cooperation. 2. Wash hands To reduce contamination and prevent cross infection. 3. Collect equipment and prepare work area. To provide a suitable working environment. 4. Label specimen bottle / syringe For identification 5. Wash hands, put on apron and gloves To reduce contamination and prevent cross infection. Page 16 of 23

17 . Action Rationale 6. Occlude drainage tubing a minimum of 3 inches below the sampling port by kinking the tubing until urine is visible under the sample port Prior to obtaining a catheter sample of urine, the port is cleaned with an isopropyl alcohol 70% impregnated swab and allowed to dry thoroughly. Insert the sterile syringe into the centre of the needle-free sample port using a non-touch technique. Press the syringe firmly and twist gently to access the sampling port. Slowly aspirate urine sample into syringe Disconnect the syringe from the sample port and empty the contents of the syringe into the specimen bottle or syringe Page 17 of 23 So there is urine available in the drainage tube Alcohol-impregnated wipes are effective for rapid disinfection. Allowing the cleaned area to completely dry facilitates coagulation of the organisms. (Dougherty et al, 2011) To avoid any needle-stick injury (Cochran, 2007) To send the specimen in the required specimen bottle or syringe to the laboratory. This is to ensure the specimen does not get contaminated 10. Dispose of syringe To leave a safe environment. 11. Unkink tubing To ensure free flow of urine 12. Put the labelled bottle into bag with the request form To identify correct patient sample 13. Wash hands as per hand decontamination To reduce contamination and prevent cross policy infection. 14. Information to be recorded in the patient s To provide a point of reference records (THIS IS ESSENTIAL) 14. Duties and responsibilities 14.1 Clinical Director Clinical Director is responsible for development, implementation and review of approved documents, which fall within their remit. The Clinical Director will take a uniform approach towards the complex issues in this guidance. They will ensure training is implemented across CWP through their monthly managers meeting Continence Advisory Service Continence Advisory Service is responsible for: Offering advice and support to Registered Nurses and Assistant Practitioners in all aspects of catheterisation; Ensuring the guideline is evidence based and reviewed on a 5-yearly basis or earlier if necessary; Providing evidence based education and training in supra-pubic catheterisation; Auditing the implementation of the guideline Line Managers Line Managers have the responsibility to Highlight the guidance to all clinical staff; Providing evidence that the guideline has been cascaded within their team or department; Where appropriate, ensuring the new guideline is effectively implemented; Ensuring that staff attend all training identified in respect of this guideline Clinical staff It is the responsibility of clinical staff Ensuring that the guidance contained herein is adhered to and followed; Complying with The code: Standards of conduct, performance and ethics for nurses and midwives (NMC, 2008); where appropriate;

18 Attending a catheterisation study day, organised by CWP Continence Advisory Service, before completing any supervised practices and the Competency Document; Sending their completed competency document to the CWP Continence Advisory Service, when they are confident and competent in carrying out supra-pubic catheterisation; Updating their skills every three years by attending a catheterisation study day, organised by CWP Continence Advisory Service, or sooner if required; Reporting any accidents, incidents and near misses in relation to this processes and procedures contained herein via Datix-system. Page 18 of 23

19 Appendix 1 - Competency document supra-pubic catheterisation Prior to completing this document the Registered Nurse or Assistant Practitioner must have attended the Continence Advisory Service s catheterisation study day. The practical procedure should be carried out as directed per Clinical Guideline for the re-insertion and removal of supra-pubic catheter & catheter care. In order to complete this document the Registered Nurse or Assistant Practitioner will need to undertake a minimum of 3 supervised practices in supra-pubic catheterisation or until the practitioner feels confident and competent to carry out the procedure. It is the Registered Nurse or Assistant Practitioner s responsibility to keep up to date by attending the Continence Advisory Service s catheterisation study day every 3 years. On completion of this competency document, please return to: Continence Advisory Service, Hope Farm Clinic, Hope Farm Road, Great Sutton, CH66 2RQ. A certificate will be forwarded to you. The document will then be returned to be kept in your professional portfolio as evidence. Practitioners name Base Designation The nurse should be able to demonstrate competency in the following elements and work within CWP guidelines and policies - Assess and review the need for catheterisation - Identify medical / surgical history and any known allergies - Explain procedure and associated risks to the patient - Gain informed consent - Work within CWP s Infection Control policies as outlined in the catheterisation guidelines - Check equipment and materials to ensure they are safe and fit for purpose before usage. Check type, size, expiry date of catheter and drainage systems - Prepare patient - Prepare environment and equipment for the catheterisation - Remove previous catheter if one in situ and observe catheter tip. - Insert catheter using an aseptic technique - Know when not to proceed or abandon the catheterisation and what actions to take - Attach drainage bag/valve and secure catheter - Give advice and support on catheter care and hand hygiene to patient/carer - Dispose of clinical waste appropriately. - Record information and contact number in patient care plan Date Initial Date Initial Date Initial Page 19 of 23

20 Appendix 2 - Assessment form for indwelling catheter Patient details Surname Forename NHS Number Date of Birth Have the risks & contra-indications of catheterisation been explained to the patient? Yes If NO, state reason: Allergies - Contra-indication for lubricant with Lidocaine Yes If YES, state reason: Reason for catheterisation Have alternatives been discussed with the patient i.e. sheath; urinal; disposable products? Urethral catheter Date of initial insertion Supra-pubic catheter Date of initial insertion of supra-pubic catheter in hospital Date of first change of supra-pubic catheter in hospital Catheter Make Type Short Term Long Term Catheter length Female Standard Charriere Amount of fluid used to inflate balloon Lubricant Single use sachet lubricant only Brand: Single use lubricant with lidocaine Brand: Drainage system - Leg bag Yes Make of leg bag Day Night Length of leg bag tube Short Long Leg bag capacity Leg bag fixation Straps Leg bag holder Catheter valve Yes Make of catheter valve Yes mls mls Night bag Yes Make of night bag Sterile night bag Night bag stand Yes n-sterile single use night bag Catheter fixation strap Yes If NO, state reason Make of catheter strap If unable to catheterise, please state reason Page 20 of 23

21 Patient details Surname Forename NHS Number Date of Birth Catheter Care Has the patient / carer been instructed on the following Maintaining the closed system? Yes If NO, state reason: Hand hygiene? Yes If NO, state reason: Maintaining a healthy fluid and diet intake? Yes If NO, state reason: Cleansing of meatal area / supra pubic site? Yes If NO, state reason: Fitting of catheter strap or leg bag strap/holder? Yes If NO, state reason: Position of drainage system below level of bladder? Yes If NO, state reason: Emptying of drainage system? Yes If NO, state reason: Changing leg / night bag or catheter valve? Yes If NO, state reason: Disposal of drainage system? Yes If NO, state reason: How to order supplies? Yes If NO, state reason: Possible complications? Yes If NO, state reason: Contact number in case of emergency? Yes Assessor Print name Designation Signature Date of assessment Patient s signature If patient unable to sign Name of Carer Relationship to Patient Signature Page 21 of 23

22 Appendix 3 - Record of urinary catheter changes Name Date of Birth NHS Number Reason for initial catheterisation Name of catheter Name of leg / night bag or catheter valve Date of initial catheterisation Type of catheter Short-term Long-term Day Frequency of change Urethral Supra-pubic Catheter length Night Female Standard Charriere Name of lubricating gel Date Time Reason for visit Can trial without catheter be considered? Yes Batch Number Catheter Expiry Date Lubricant Batch Number Expiry Date Lifespan of catheter If patient has signs of Urinary Tract Infection, has a Catheter Specimen of Urine been obtained? Yes Outcome? Print Name Signature Designation Yes Yes Outcome? Yes Yes Outcome? Yes Yes Outcome? Yes Yes Outcome? Page 22 of 23

23 Appendix 4 Information on autonomic Dysreflexia Autonomic Dysreflexia is unique to patients with spinal cord injuries at T5 and above. Autonomic Dysreflexia is a sudden and potentially lethal surge of blood pressure often triggered without warning by acute pain or a harmful stimulus. This occurs because the body is unable to lower the blood pressure therefore the blood pressure will continue to rise until the offending stimulus is removed. Spinal injury patients are usually aware of this condition and have experienced it prior to hospital discharge. Factors that can trigger Autonomic Dysreflexia: Full bladder / blocked catheter; Constipation; Skin i. e cuts, bites, burns; Sexual activity / Menstruation; Labour; Medical tests including gynaecological examination, cystoscopy. Symptoms of Autonomic Dysreflexia may be mild or severe. Patients can present with one or more of the following: Cool, clammy skin; Flushed face; Blotchiness; Sweating above level of injury; Pounding headache; Seeing spots or blurred vision; Nausea; Feeling Anxious; Increased blood pressure. Treatment for Autonomic Dysreflexia: Sit the patient up; Identify and remove irritation; Give prescribed medication for autonomic Dysreflexia; Monitor blood pressure. Page 23 of 23