Hi-R-Ed Online

Best Practice Recommendations (continued)

•Use smallest diameter of catheter to minimize trauma to bladder neck and urethra

•Provide each patient with a separate

container for urine

emptied from drainage

bag

•Do not allow the spigot

of the drainage bag to

touch anything

There are also some things that should be avoided. Let's call those our Thou Shalt Nots. It's important to avoid:

–Routine catheter or bladder irrigation with antimicrobial agents

–Routine instillation of antimicrobial agents into the drainage bag

–Cleaning the periurethral area with antiseptics to prevent CAUTI

–Disconnecting the catheter from drainage tubing

–Replacing the catheter and bag at routine, fixed intervals

–Routine use of systemic antimicrobials to prevent CAUTI

–Routine use of silver-coated or antimicrobial-coated catheters

–Routine screening or treatment for asymptomatic bacteriuria

–Clamp prior to catheter removal

The guidelines provide specifics of practices that we should not use, some of which, such as changing urinary catheters and drainage bags every 30 days are ones that may be seen in long-term care practice. In the past, in acute care the use of drainage bags with a port for instilling hydrogen peroxide every shift was done. These practices do not reduce the risk of CAUTI and in many cases actually increase the risk of infection and MDR organisms.

Closed systems for catheter irrigation may be used after TURP’s for example. Clinical assessment should drive the decision to change the catheter and drainage bag.

Specially-coated catheters are indicated only when all other attempts to reduce CAUTI rates have been attempted and failed. A meta-analysis of randomized clinical trials (RCTs) demonstrated that bacteriuria was most effectively decreased when silver-alloy coated catheters were used vs. latex catheters when catheters were in place for less than one week. Once the catheter is in place for longer than one week the results are no longer statistically significant. Studies show a greater risk of bacteriuria in patients whose catheters were clamped prior to discontinuation, and has no clinical benefit in “training” the bladder.

Catheter Alternatives

Organizations committed to preventing CAUTI and/or reducing CAUTI rates need to provide readily available alternatives for their staff to use in patient care. The use of bladder scans to assess for urinary retention has been demonstrated to reduce catheterization rates by 30-50%. In addition, there is a saving of nursing time: 2-3 minutes for the scan vs. 15-20 minutes for the catheter insertion. In-and-out catheters for those with spinal cord injuries, bladder emptying problems or a neurogenic bladder provide intermittent catheter use and allows patients to be more mobile. Studies show a reduce risk of infection with in-and-out catheters. External urinary collection devices or condom catheters are an appropriate alternative as long as the patient does not have any issues related to urinary retention or bladder outlet obstruction. Research indicates a lower risk of bacteriuria and symptomatic UTI using these devices vs. an indwelling urethral catheter. Patients report that these devices are more comfortable as well.

Catheter Characteristics

•Duration

•Design and materials

•Size

•Shape

There are several catheter characteristics that can be taken into consideration to match the need for indwelling catheters, including duration of need, the catheter design and size, catheter shape, and even the materials used in the catheter.

For instance, hydrophilic catheters are preferred over standard catheters for intermittent (in-and-out) use. Hydrophilic catheters in this patient care scenario decreases pain, bleeding and is associated with a decreased risk of CAUTI. Silicone catheters have been shown to decrease encrustations and subsequent obstruction in patients who require catheters long term. Silicone catheters also decrease irritation. Studies show no significant difference in bacteriuria between latex vs. silicone catheters.

Antimicrobial-impregnated catheters have been shown to decrease catheter-associated bacteriuria vs. standard catheter. Once the catheter is in place longer than one week, the results are no longer statistically significant. A 2008 Cochrane Review indicates that short term use catheters coated with antiseptic, antibiotic or silver alloy may reduce CAUTI incidence in hospitalized patients and that more studies are needed.

Use the smallest catheter lumen(14-18 French) possible with a 5 ml balloon in order to prevent urethral trauma and irritation to the mucosa--all of which increase CAUTI risk. Contrary to popular belief a larger lumen catheter with a larger balloon may cause more leakage due to an increase in bladder spasms. Constipation and fecal impaction can cause spasms and leakage so provide nursing interventions to prevent these two preventable problems.

The Coude catheter, with its curved tip up may be used to navigate around an enlarged prostate or around scar tissue.

Rick Fields-Gardner