Urinary catheter care skills in asepsis

1. Urinary catheter careskills in asepsis Dr.T.V.Rao MD Dr.T.V.Rao MD

2. What is a urinary catheter • Urinary catheter is any tube placed in the body to drain and collect urine from the bladder Dr.T.V.Rao MD

3. Urinary CatheterDr. Frederick Foley • Developed in the 1920s by Dr. Frederick Foley • The urinary catheter was originally an open system with the urethral tube draining into an open container. • In the 1950s, a closed system was developed in which the urine flowed through a catheter into a closed bag.

4. Urinary Catheter Utilization • About 15-25% of patients during their hospitalization will have an urinary catheter placed • Many are placed either in the intensive care or Emergency Department • 40% - 50% of these patients do not have a valid indication for urinary catheter placement

5. What is a Foley's catheter Dr.T.V.Rao MD

6. Purpose of Catheterization Catheterization is carried out for a number of reasons and can either be a temporary or permanent solution to a number of problems. Problems include physical disease and damage, psychological issues and a way to help to improve the quality of life to someone who is bed ridden. Good regular catheter care involves good hygiene, observation, monitoring well-being and prevention of problems associated with catheterization. Dr.T.V.Rao MD

7. Urinary tract infection (UTI) causes over 40% of hospital-acquired infections Most infections due to urinary catheters 25% of inpatients are catheterized Leads to increased morbidity and costs Urinary Catheter-related Infection: Background

8. Catheterization is a skill in Medicine • The ability to insert a urinary catheter is an essential skill in medicine. • Catheters are sized in units called French, where one French equals 1/3 of 1 mm. Catheters vary from 12 (small) FR to 48 (large) FR (3-16mm) in size. They also come in different varieties including ones without a bladder balloon, and ones with different sized balloons - you should check how much the balloon is made to hold when inflating the balloon with water! Dr.T.V.Rao MD

9. Caution on catheterization • The potential for contact with a patient's blood/body fluids while starting a catheter is present and increases with the inexperience of the operator. Gloves must be worn while starting the Foley, not only to protect the user, but also to prevent infection in the patient. Trauma protocol calls for all team members to wear gloves, face and eye protection and gowns. Dr.T.V.Rao MD

10. Which Disinfectant Should be Used for Catheter Site Care? • Povidone-iodine (PI) is currently the most widely used agent for site disinfection • Chlorhexidine gluconate (CHG) has been compared to PI with mixed results • We performed a formal meta-analysis of published and unpublished studies to clarify relative efficacy

11. Chlorhexidine for Site Disinfection: CR-BSI Favors CHG Favors P-I (Chaiyanupruket al. Ann Intern Med 2002)

12. What is indwelling Catheter • In indwelling urinary catheter is one that is left in place in the bladder. Indwelling catheters may be needed for only a short time, or for a long time. These catheters attach to a drainage bag to collect urine. A newer type of catheter has a valve that can be opened to allow urine to flow out, when needed. An indwelling catheter may be inserted into the bladder in two ways: • Sometimes, one may insert a tube, called a suprapubic catheter, into your bladder from a small hole in your belly. This is done as an outpatient surgery or office procedure. Dr.T.V.Rao MD

13. CONDOM CATHETERS • Condom catheters are most frequently used in elderly men with dementia. There is no tube placed inside the penis. Instead, a condom-like device is placed over the penis. A tube leads from this device to a drainage bag. The condom catheter must be changed every day. Dr.T.V.Rao MD

14. INTERMITTENT (SHORT-TERM) CATHETERS • Some people only need to use a catheter on occasion. Short-term, or intermittent, catheters are removed after the flow of urine has stopped. For more information on this type of catheter, see: Clean intermittent self-catheterization. Dr.T.V.Rao MD

15. Explain the patient before doing the catheritization • Before you start tell the person what you are going to do and why. This is important for everyone, but especially if the person is confused, has memory problems as in Alzheimer's disease or dementia. If you can, assist the catheterized person with their hygiene, rather than doing it yourself. It is important to try to help the person / patient keep their skills rather than just take over for them. There are so many advantages but it can just take that bit longer. Dr.T.V.Rao MD

16. Hand washing the most important preparation before catheterization • Wash your hands before and after handling the drainage device. Do not allow the outlet valve to touch anything. If the outlet becomes obviously dirty, clean it with soap and water. Dr.T.V.Rao MD

17. Antiseptic Hand Rinses many using alcohols • 60-70% alcohol solutions • Effective against most bacteria, viruses, fungi • Protective against hand drying • Faster, increased compliance

18. Caring before the insertion of Catheter • Wash around the catheter entry site with soap and water twice each day. Clean the top several inches of the catheter too.Always wash the site after a bowel movement. Dr.T.V.Rao MD

19. Health care workers should develop skills in introduction of Catheter • Introduction Femaleurethral catheterization, the insertion of a catheter through the urethra into the urinary bladder to permit drainage of urine, is a fundamental skill Insert the catheter completely into the urethra, and do not inflate the balloon until there is return of urine, to avoid trauma … Dr.T.V.Rao MD

20. Principles of placement of catheter and collecting bag Dr.T.V.Rao MD

21. The Urine collecting bag should be at a lower level to the patientto prevent retrograde flow Dr.T.V.Rao MD

22. Criteria for insertion and continuation of a F/C includes: Retention Critical I&O Comatose Paralyzed Neurogenic Bladder Pre-op placement Wound with incontinence Bladder Irrigation Physical trauma/pain with bedpan/incontinence brief Terminal illness/comfort measures Dr.T.V.Rao MD

23. Complications of catheterization • The main complications are tissue trauma and infection. After 48 hours of catheterization, most catheters are colonized with bacteria, thus leading to possible Bacteriuria and its complications. Catheters can also cause renal inflammation, nephro-cysto-lithiasis, and pyelonephritis if left in for prolonged periods. • The most common short term complications are inability to insert catheter, and causation of tissue trauma during the insertion. • The alternatives to urethral catheterization include suprapubic catheterization and external condom catheters for longer durations. Dr.T.V.Rao MD

24. UTI PYELONEPHRITIS DEATH R/T BACTEREMIA DAMAGE TO URETHRA (SCARRING AND STRICTURES) Prostatitis and epididymitis Risks / Consequences of Catheterization Dr.T.V.Rao MD

25. Indwelling Foley catheters are a major source of UTI’S. Direct relationship between duration a f/c is in the patient and incidence of infection. Risk factors: Female Advanced age Duration Diabetes Renal insufficiency Dr.T.V.Rao MD

26. Biofilm: Extracellular Polymers(Donlan, CID 2001; 33:1387–92, Liedl, Curr Opinion Urol 2001;11: 75-9) Staphylococcus aureus biofilm on an indwelling catheter. CDC Public Health Image Library Organisms attach to and grow on a surface and produce extracellular polymers Intraluminal ascent (48hours) of bacteria faster than extraluminal (72-168 hours) Most catheters used >1 week have biofilms Extraluminal more important in women

27. What is the Foley Catheter Bundle? Insert using sterile technique Hand hygiene before and after any contact with the F/C system Secure catheter to thigh at ALL times Keep catheter bag below the level of the bladder at ALL times Maintain a sterile, continuously closed system Specified criteria for insertion and continuation of a Foley catheter Peri care daily and after all incontinent stool What is “Peri Care” for a patient with a f/c? Daily wash with warm soap & water then dry. What we are doing now, is it right right things to do.Foley Catheter Bundle Dr.T.V.Rao MD

28. Collection of urine from catheterised patients • 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. • 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). • 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. Dr.T.V.Rao MD

29. Aspirating the urine with syringe and Needle • 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. Dr.T.V.Rao MD

30. Contraindications for catheterization • Foley catheters are contraindicated in the presence of urethral trauma. Urethral injuries may occur in patients with multisystem injuries and pelvic factures, as well as straddle impacts. If this is suspected, one must perform a genital and rectal exam first. If one finds blood at the meatus of the urethra, a scrotal hematoma, a pelvic fracture, or a high riding prostate then a high suspicion of urethral tear is present. Dr.T.V.Rao MD

31. Up to 25% of hospitalized patients urinary catheterization Catheter associated nosocomial UTI 5% per day ! Nosocomial UTI 40% of nosocomial infection Bacteria ascend intraluminally into the bladder within 24 to 72 hours (from Harrison’s 16th) > 1 month of catheterization Nearly all will be bacteriuic Long-term (>30 days) and short-term (<30 days) catheterization 80% of patients with nosocomial UTI have an indwelling urinary catheter Epidemiology of urinary catheterization

32. Reminder for Appropriate Urinary Catheter Use • Avoid urinary catheter use if not indicated • Try to discontinue the catheter promptly when not needed • The longer the catheter is present, the higher the risk of infection! • The urinary drainage system should always remain a closed system

33. Constant evaluation to continue to use catheter ……. • Both nurses and physicians should evaluate the indications for urinary catheter utilization. • Physicians should promptly discontinue catheters that are no longer needed. • Nurses evaluating catheters and finding no indication should contact physician to promptly discontinue catheter.

34. Should we need to remove the urinary catheter in 48~72 hours of smoothly post op patients to reduce the rate of catheter associated UTI? What’s the rate of catheter associated UTI in 48~ 72 hours? Remove urinary catheter as soon as possible! Rate of Bacteriuria in indwelling catheter patient in 48 hours post-OP: average 24% Important question when to remove

35. Programme Created by Dr.T.V.Rao MD for Medical and Health care Workers in the Developing World • Email • doctortvrao@gmail.com Dr.T.V.Rao MD