Indwelling Urinary Catheters: Procedures, Risks, and Infection Prevention

Introduction

In the medical field, the use of indwelling catheters has become a common patient care intervention (Clinical Review, 2009). This intervention, however, carries substantial risks, the most common of which is infection. Nurses can assist in preventing catheter-associated urinary tract infections (CAUTIs) by incorporating aseptic methods during insertion, following best practice by changing catheters promptly when indicated, and maintaining hand hygiene when inserting or handling catheters. Because catheterization is a painful process, patients should provide informed consent after being made fully aware of the associated benefits and risks.

Urinary catheterization is the practice of inserting a hollow tube into the bladder using an aseptic method to enable drainage of urine or instillation of fluids as a medical intervention. Some 3,000 years ago, owing to inadequate resources and knowledge, people used reeds to drain the urinary bladder. This clinical practice applies only when it is medically significant, and the catheter should remain in position for the shortest necessary period. Leaving the catheter in place beyond what is required risks the development of catheter-associated complications such as UTI (Robinson, 2007).

This paper outlines the procedure of catheterization and draws from research on the topic to develop an analytical report. Its aim is to evaluate current practice in relation to indwelling catheters and urinary catheterization. In part, the analysis draws on a hospital-based prospective study to offer alternatives to the overuse of indwelling catheters in acute hospital settings (Bhatia et al., 2010).

Urinary tract infections (UTIs) have a substantial impact and account for a significant percentage of all healthcare-associated infections (Leaver, 2007). UTIs are also the most common nosocomial infections in the intensive care unit. Urinary catheters are frequently used in ICUs for regular and precise monitoring of urinary output. Once inserted, catheters tend to remain in place beyond the point at which appropriate indications exist for their continued use. Urinary tract infections in critically ill patients prolong hospital stays and increase mortality rates.

Background and Clinical Guidelines

In a bid to prevent CAUTIs, medical practitioners have adopted several strategies involving catheter materials, drainage systems, insertion techniques, and anti-infective agents. Among all these approaches, the most significant intervention is discouraging the continuous use of catheters, as prolonged catheterization raises the risk of infection and other complications that may increase mortality in critically ill patients. Beyond limiting indwelling catheter use, health practitioners should also remove catheters as soon as there is an indication that their use is no longer clinically required (Pomfret).

CAUTIs are healthcare-associated infections acquired during the course of receiving treatment for other health conditions within a healthcare setting (Robinson, 2009). Research confirms that CAUTIs qualify as infections resulting from catheter interventions. Approximately 10–12% of hospital patients and 4% of patients in the community have urinary catheters. Nosocomial UTIs develop in almost 5% of patients who undergo catheterization in the United States, and an estimated 80% of those cases are attributable to urinary catheters. Complications arising from catheterization include fever, pyelonephritis, urinary tract stones, and renal inflammation.

UTIs also prolong hospital stays and increase the costs involved in managing disease (Leaver, 2007). One essential reason for inappropriate catheterization is the absence of widely accepted guidelines regarding indwelling urinary catheter placement. Catheters are used following chemotherapy, to increase comfort in critically ill patients, to manage incontinence, to measure urine output in critically ill patients, pre- or post-bladder surgery, and after radiological investigations (Dailly, 2011). Professionals who perform, teach, or advise on urinary catheterization should follow evidence-based regulations:

Despite limited research on this topic, Newman (2007) suggests that health professionals should rely on their practical knowledge to recognize that without any form of catheter securement, damage to the urethra and meatus must occur (Bhatia et al., 2010). Constant tension will also inflict discomfort on the patient (Wilson, 2008). Gray (2008) suggests that it is important to recommend and implement regular securement in patients with both short- and long-term indwelling urinary catheters (Mangnall, 2011). Newman (2007) further suggests that the best method of stabilizing urinary catheters has not been definitively established; however, it is important to select a device that suits the individual patient's needs.

To improve quality of life, catheter securement devices should be both comfortable and secure (Fisher, 2010). Current research indicates a growing number of devices available on prescription or for purchase that enable securing of urinary catheters. Much of the earlier literature notes that both adhesive and non-adhesive devices are widely available (Fisher, 2010). Despite the challenges of inserting catheters in patients who require them, a literature review reveals that no thoroughly tested devices are currently available to assist nurses with this procedure (Pelter and Stephens, 2008).

Step one: This involves evaluating the patient's situation to determine whether the intervention is required. In a community setting, the district nurse should carry out the evaluation as part of a single assessment process (Clarkson and Booth). Community staff nurses can then take over in maintenance assessment and catheter monitoring. Nurses must keep accurate records in the patient's notes clearly showing:

Catheterization Procedure

Step two: This step involves considering alternatives to catheterization that may deliver the same clinical results. These include referral to a continence advisor, appropriate toileting regimens, and bladder retraining. Referral to uro-gynecology may also be appropriate.

Step three: If no other option is available, it is necessary to determine the type of catheterization required — long-term or short-term (Clarkson and Booth).

Step four: At this stage, the nurse should discuss the procedure with the patient using appropriate language. Discussion should cover the benefits and risks, with consideration of the patient's age, ability, and mental status. Catheterization is frightening and painful; it also carries risks of infection and trauma (Clarkson and Booth). It is important to engage the patient in the decision-making process at this step.

Step five: The nurse should involve another person — either a family member or another nurse — in the decision-making process. Where family members already use catheters, their involvement can be especially valuable (Bhatia et al., 2010). Within primary care, health promotion and appropriate training will enhance patient self-management.

Step six: The nurse should evaluate whether the patient is able to provide valid consent. Legal implications, such as Trust policy, must be considered. The patient's consent should be documented, whether verbal or written; however, written consent is preferable for a first catheterization (Bhardwaj, Pickard and Rees, 2010).

Step seven: The device selected should relate to the agreed type of catheterization. Nurses must follow the manufacturer's guidelines for all medical equipment (Clarkson and Booth), use internationally standardized measures, and carry out the procedure using aseptic technique — including in the patient's home. Trusts provide sterile catheterization kits for the procedure, which typically contain:

Step eight: The procedure should be undertaken by a competent practitioner; anyone who is inadequately trained should not undertake it unsupervised. The Trust will provide a competency framework within which practitioners should operate (Clarkson and Booth).

Step nine: On completion of the procedure, the catheter bag will hold draining urine. The nurse must complete all documentation and the patient's record, including the product name, other products used, lot number, batch number, Charrière size, balloon size, expiry date, and date of next change (Booth and Clarkson).

Conclusion and Recommendations

There is a need for health practitioners to evaluate patients carefully to confirm a genuine clinical requirement for catheterization before proceeding with the intervention. This is especially important for women and for patients catheterized in the emergency setting. Physicians should maintain aseptic standards throughout the procedure (Bhatia et al., 2010). Hand washing, in particular, is essential for maintaining hygienic standards and minimizing the incidence of infection. Overall, CAUTI is preventable through careful patient selection and the consistent application of aseptic techniques in catheter use.