Go with the Flow: Working together to improve bladder health and reduce urinary tract infections Transcript of video Trial Without Catheter Suzanne McPhee, Lead Continence Specialist Nurse, NHS Ayrshire & Arran It s quite a nice way to finish. Obviously we ve heard a lot about continence, catheters, why we shouldn t have the in and hopefully now we ll speak about taking them out and hopefully keeping them out for good. But, again I think we have to remember - the only thing that worries me slightly as a urology nurse is we have had situations where folk come to these study days and obviously we re desperate to get them out but actually don t think about the repercussions we need to make sure there s a planned care of action there because we ve had folk get catheters out and nobody s actually scanned or whatever and they ve come in with chronic retention so please be very careful when considering this that there have to be considerations. But we ll speak about this as we go through. When I was Googling to get a funny picture, I just put in trial without catheter in images and this is what came up. It reminded me it tends to be older men - we work in urology we do see a lot of men with prostate problems that come in for trial without and that kind of reminded me of them waddling to the toilet with their bottle under their arm maybe a bit worried that they re going to dribble so they ve got their googles on. Obviously we ve to put a wee bit humour in. Again, remove Foleys where possible and I think that s the theme of the day and obviously we re here to try and prevent CAUTIs. Again, consideration prior to removing catheters. A lot of this is repetitive I ll try to sort of not repeat myself too often because a lot of it s been said already today but you need to consider before you 1
remove the catheter why was it in? Was it in for an acute retention or a chronic - you know there s a complete difference. Acute retention is when somebody s got a painful retention and they come in quite often quite unwell, because they re absolutely desperate to pee and they can t and you tend to find they ve got residual urines of usually below a litre. On the other hand an insidious chronic retention which can be up to - the urology staff are here today - but the highest I ve seen is 5 litres. If any of you have any advance on that? But these are patients who have insidious, a slow building chronic retention and quite often they re in hydronephrosis. If we put catheters in they can end up with fluid imbalance and some often need renal dialysis if things are so bad. So again we have got to consider that. When we re making our first reasons for taking out the catheter we need to know why it s in in the first place so we re pre-empting if there s going to be problems. Past medical history as well, medication, constipation, there s no point - we get 2 to 3 trial without catheters most days to surgeries and there s no point taking a catheter out if that patient s constipated. Because that s probably why it s gone in in the first place. And in urology we get many patients who come in on a monthly basis with retention due to constipation and once the constipation is sorted out you tend to find that the patient passes urine much better. So that s definitely something that needs to be looked at. When the patient s present for a trial without or you re considering it have they got a sepsis as we ve heard earlier, cause if they ve got the signs - like a pyrexia they obviously would need some sort of antibiotic cover before they take it out because you could end up making them extremely unwell. It s just points to consider before taking it out. Post removal we re going to go into that in a little more depth going into fluid intake, bladder scanning, voided volumes. I m not going to labour the point I think we ve laboured it enough about fluids and hopefully you ll all be going home tonight to buy water bottles and be filling up. 2
But seriously as a urology nurse I can t emphasise the issues that there is surrounding fluid and Leslie was right - a lot of the problems we see in urology is because of lack of fluids in a lot of cases. And the same with catheters. So, the catheter comes out - the patient needs to be well hydrated. Some patients think if they drink a glass of water they should be peeing straight away, so they start to get quite concerned within an hour or two. I ve no peed yet and can get a bit uptight about it. But actually if they ve come in very dry and we find that in day surgery quite a bit - a lot of these patients are elderly and they maybe haven t drunk a lot so they re coming in a bit dehydrated so it can take a good few hours till we start to consider them ready to pass urine. So you re wanting to keep them to 2, 2 and a half litres a day - but if they re having a trial without - at least 1 to 2 glasses an hour if they can to keep them hydrated. Better water or diluting juice or obviously a tea or coffee if it s tea time. But you want to limit that in case there is a bit of bladder irritation etc. You may be aware there really is limited benefit - but Cranberry juice is still up there. Does it help, does it not? At the end of the day, if it not going to do you any harm, to me it s better taking it that not. So it s worth a thought. Certainly the limited evidence I m aware of is a couple of glasses a day and certainly any of our patients that we see with infection we would always encourage cranberry unless it s contraindicated in Warfarin and that group of drugs. So, again - trial without - get them well hydrated, the main thing about it is your accurate input, output chart and very much when the patient passes, you want to see the volume. Volume s equally important as their residual urine. And that s where I m asked on a very regular basis to get algorithms for when to put catheters back in. I think it would be an injustice to do one because not everybody fits in a box, and you have to look at the patient as a whole. It s not just about the residual volume, it s about their history but also about their voiding volume. 3
So, it s really important when you re doing a trial without catheter that the patient s been given good instruction, that when they go to pee they must use a urinal or a bedpan if it s a female. Get them in away. Let them do it themselves because if a nurse is standing over them - they ll be uptight they might not empty their bladder better so it is better if you just give them instructions when they come in or when they re in your ward or wherever and let them do it independently so they can shout on you when they ve done it and you measure. The other important thing is when they ve voided - as soon as possible you want to be doing a bladder scan. Not 2 hours later because that s not going to be accurate and if somebody s having quite a high diuresis, a high intake of fluid you might find that they will have quite a quick diuresis at some point. So, even half an hour delay could actually look as if they re starting to go back into retention. So it is important. And I know a lot of areas now it is the healthcare assistants that do that because they re the one s measuring the urine and then scanning the patient. That s just what one of the scanners looks like and again, there s competencies inside this organisation for both trained and untrained staff. There are training sessions if any of you don t feel confident at doing it. Coming on to the findings and to me that is the kind of one thing what do we do? - do we put a catheter back in because sometimes it can be the easy option, and I think that s why we re here today to think no, there is a lot more other options that we can consider for this patient. Residual urine is caused by 2 reasons. Either physical or neurological to the flow of urine or the detrusor muscle is just no longer working - you ve got a degree of detrusor failure. In finding a residual urine we need to then consider about referral if you re within an area what do we do? It s not our decision, it s not the patients - it s a group decision as to what s the next step we can do or considering we need to speak to medical staff as well. So it is a team approach. Technically, if you go in and look at text books - the ICS is International Continence Society. If you look at their definition of a residual urine - it s anything above 100ml and more whereas if you look at other ones in day to day management often the amount of 300ml comes up. Again, it depends on individual patients and we ll go through case studies at the end to try to make that a wee bit clearer because somebody with a 100ml residual for us may need to do ISC if they re triggering infection where we regularly see patients in our clinic with between 300 and 400ml residual urines that don t have UTIs that we don t actually end up doing anything for. So it s thinking about the bigger picture. 4
It must be remembered that and looking at their renal function as well. So following an ultrasound of the bladder your intervention should combine with the following. These are the things you re needing to ask: Was the residual urine significant or not. Was it below 100ml? Probably not. If they re not emptying, again, you want to just double check have they got their position right? I know it seems awful basic but I don t know if you re aware as you get older particularly females when you re sitting on the toilet seat sometimes your position can help and I m sure some of us will think about this. You think you re finished, you lean forward to get your paper to dry yourself and low and behold you get a few more dribbles. As we get older we should all practise double voiding which is where you sit on the toilet in your usual position, you think you re finished, stand up, sit down and lean forward. And quite often we see patients referred into urology with infection and actually once they start to do double voiding and empty their bladder it can sometimes stop the infection from triggering. So basic things. So is it under 100ml or over? If it is over - obviously 500ml is significant, at that stage you know you re going to need to do something. But at 500ml is the patient uncomfortable? because they may not be - you and I would probably be starting to become quite desperate at 500ml but often patients are not. So it s actually finding out that information. The other thing you want to check is their voided volume. There s no huge evidence surrounding this but what you tend to see is if somebody s got very small voided volumes - for instance they only get 50ml and 100ml but the residual urine over a few hours is starting to build up to like 200-300ml you re looking to think they re starting to go back into retention. Whereas a lot of the patients we can see is that they start to pass urine and they ve got good volumes. What is a normal bladder volume? Anybody? 300-400ml? round about that. If you have someone passing those volumes but they have still got 200-300ml in their bladder they might be someone who, over a day or two, is not going to need any intervention. So it s matching their small voided volumes as well as their residual urine. Certainly at 500ml if the patient s significant then we consider what else we re going to do. And what form of drainage, we ve said this on many occasions today - if someone does and they ve got a retention ISC is the gold standard it s in the NICE, it s in the European Association of Urology the EAU. 5
Most of these things are now all sort of advising ISC if he patient can do it. Sometimes that s not suitable for everybody. What I wanted to share with you and I think we have seen a change in practise over the last year or so - with patients coming in for trial without catheter, probably previously very much so - if they ve went into retention - indwelling catheters were inserted. There was odd patients that were taught ISC but now that s very much the first thing we think about. Can they manage if they go into retention rather than putting back in a catheter. This was the outcomes. It was over 83 patients I think it was and it was the girls i day surgery that done it. Within that we were successful with 66% unsuccessful was 32% - not carried out - somebody did prefer a long term catheter - and it is patient choice when comorbidities etc. I m not sure of drilling down into the data here what the reason for it was but there obviously was a very valid reason. A patient did refuse to get the catheter out as well. You do try to coerce and give them the risks and benefits but sometimes there are patients who are not going to take your advice. Can I say within that successful group was ISC as well and we ll break that down later. So these are patients that have gone through a urine retention pathway - they ve either come into Crosshouse or Ayr, with retention through the clinical decisions unit or they ve come from wards. For instance some of the women have had a stroke. For some reason they ve been discharged home with a catheter. They ve been picked up in urology and then brought back in for a trial without. Hopefully some of these patients could be dealt with before this stage happens. The come into day surgery at half 8 in the morning which is where urology is in the out patients where we work. We obviously go through a process and we have brought the paperwork if anybody s interested there is documentation for trial without catheters information here. And obviously we do the checks, make sure they don t have the symptoms of an infection, and then we ll remove the catheter. Then they have a seat and drink. Most of them are out within 5 or 6 hours probably by the mid afternoon to teatime. Within this group 93% got home the same day and 7% didn t. Sometimes there would be social reasons and things for that as well. The audit didn t go into the depth. 6
What we looked at here was successful and unsuccessful. Within this group the 53 patients that were successful 28 did ISC. So for us considering that was probably 28 urethral catheters that we avoided because these patients are home managing ISC. There still is a few went home with indwelling catheters as well. The reason for no ISC why they decided they were for a long term catheter was because they d had it and there was no way that we were going to talk them into it. Not required, not suitable, patient refused and obviously the ISC patients with urethral strictures - they had urethral strictures so there would be a difficulty with them doing it. To sum it up and make it a bit more understandable because we talk about retention but some of these patients are going home voiding but still have residuals. What do we do? Do we catheterise even though they re voiding but they ve still got residuals how can we manage them? and these are all patients seen within the last week or two when I was doing this presentation. A 78 year old man following hernia repair was found to be residually 450ml. His only symptoms nocturia twice nightly. Everything else was fine - his upper tract, his U s and E s. What would we do with this patient? He came in - got his catheter out. He did have a catheter in unfortunately but got it out, still had residual urines and he s now doing ISC. The thing is he doesn t need to do it 4 times a day - We ve probably not enlightened you - if somebody s in a proper retention - they need to do their catheter probably 4 times a day. You need to keep residuals below 400ml or it ll start to trigger infection and it can start to dilate the upper tracts. So ideally you want to keep residuals at 400. So this patient obviously was in the kind of border so he only did it at night and the thing is probably that was why he had nocturia because if he s going to bed at night with a fairly full bladder - his bladder s filling up so it s just going to top over and he s up several times at night. We ve particularly a lot of males with prostate disease often do ISC at night to drain their bladder so that they get a good night s sleep. Again just thinking about your practise some of your elderly patients that are in strike wards and rehab wards. If you ve got residual urines that might need to be what you need to consider. Certainly not be putting a catheter in. 7
We ve got staff from nursing homes. There are several nursing homes in Ayrshire that the staff actually do the catheter for the patient. They re obviously not able to do it themselves either cognitively or functionally but I know one particular man I was involved with fairly recently where he kept pulling his catheter out and he was getting really quite aggressive and it was actually easier for the staff to do a catheter in and out twice a day rather than the trauma of him constantly pulling it out. Probably twice wasn t enough he should have needed it more but it s the balance - the quality versus the risk and it s considering all these things looking at the bigger picture. So that s one. So the next one was a 90 year old man and we have got them in their 90s still that do ISC complained of urinary incontinence, frequency nupturia and hesitancy - he d 600ml in his bladder but it was starting to affect his upper tracts and his kidneys. He had a degree of dilatation in his kidneys and his U s and E s were starting to go off. So we knew that we needed to do something. Rather than put in a catheter he was taught ISC twice a day - morning and night to keep his residuals down - he would still pass urine during the day but it would take his residuals down and obviously hopefully - which I m sure it did - resolve his hydronephrosis. So again it s just trying to highlight areas that you could think about. Female, 56 year old female she had a stroke and history of recurrent UTI even before her stroke she had a history of UTIs but never had it properly investigated. Following her catheter removal she had 300ml residual but she was passing fairly good amounts. This lady had quite a dense hemiparesis and the first thought was - is she really going to manage? But she actually was quite a character and was very determined. A bit like Margaret actually and I would say that s one of the big things about ISC it s motivation.if they re like Margaret you re never going to fail but there are others you have to coerce. Hopefully if you take anything from today about ISC your dribble initial reaction when you say to patients is oh no hen, I m not going to do that. And we get that probably on a date basis. But usually it;s enough if you - I tend to give them scenarios and I probably do give them the worst scenarios with indwelling catheters and once you start to have that dialogue with them and give them the book and time to think about it sometimes they will start to come round. However this woman wasn t she was determined. I was negative thinking she s not going to manage this but as you see with Lorna s things we ve got there are aids and adaptations and that lady eventually - she stayed overnight - to make sure she was competent at doing it - but she managed it very well eventually and got home. 8
What you sometimes find and what the positive thing is with some of these people is that once they actually start to empty their bladder with ISC their residuals resolve over a few days. And we give them our numbers and quite often within a few days of going home and being taught it they re phoning up to say I m hardly getting anything from my catheter because I m starting to pee naturally myself. Whereas, if they had indwelling catheters put back in they would never have known that. So it s a bit of food for though in your areas that you work. We ve got community nurses here I would say community s far better than acute. The minute they get patients with catheters, nursing home as well they are starting to think why is this in?, can we get this out?, because I think someone alluded to this earlier, it s a huge issue with call outs and overnight services with catheters blocking etc. So it s just making sure we consider these things. Just to finish off - an indwelling catheter should only be placed where there is a clear indication - a catheter is a last resort when all other options fail. And it s not for the comfort of the nursing staff. I hope thee days are by and gone but I ve heard that often - not recently I have to say - but it certainly is something - an intermittent catheter is preferable obviously to indwelling. This resource may be made available, in full or summary form, in alternative formats and community languages. Please contact us on 0131 656 3200 or email altformats@nes.scot.nhs.uk to discuss how we can best meet your requirements. NHS Education for Scotland 2017. You can copy or reproduce the information in this resource for use within NHSScotland and for non-commercial educational purposes. Use of this document for commercial purposes is permitted only with the written permission of NES. 9