your hospitals, your health, our priority CATHETERISATION Urethral/ supra-pubic POLICY NAME: VERSION NUMBER : 1 PROFESSIONAL ADVISORY BOARD (PAB)

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1 POLICY NAME: POLICY REFERENCE: CATHETERISATION Urethral/ supra-pubic TW12/016 VERSION NUMBER : 1 APPROVING COMMITTEE: PROFESSIONAL ADVISORY BOARD (PAB) DATE THIS VERSION APPROVED: RATIFYING COMMITTEE: DATE THIS VERSION RATIFIED: AUTHOR(S) (JOB TITLE) DIVISION/DIRECTORATE: OCTOBER 2012 POLICY APPROVAL AND RATIFICATION COMMITTEE (PARC) OCTOBER 2012 UROLOGY NURSE SPECIALIST SURGICAL TRUST WIDE POLICY (YES/) Links to other Strategies, Policies, SOP s, etc. YES CATHETERISATION SOP, CATHETER PRESCIPTION MANAGEMENT Date(s) previous version(s) approved: (if known) Version: Date : DATE OF NEXT REVIEW: SEPTEMBER 2015 Manager responsible for review: N.B. This should be the Author s line manager HEAD OF NURSING SURGERY your hospitals, your health, our priority

2 Version. CONTENTS PAGE. 1 INTRODUCTION 2 2 POLICY STATEMENT 2 3 KEY PRINCIPLES 2 4 RESPONSIBILITIES: 2 5 HUMAN RIGHTS ACT: 3 6 EQUALITY & DIVERSITY: 3 7 MONITORING AND REVIEW: 3 8 ACCESSIBILITY STATEMENT: 4 APPENDICES 1 References and further information 4 2 Glossary of Terms Used 4 3 Equality Impact Assessment Form 5 4 Monitoring & Review template 6 1

3 Version. AT ALL TIMES, STAFF MUST TREAT PATIENTS WITH RESPECT AND UPHOLD THEIR RIGHT TO PRIVACY AND DIGNITY. 1. INTRODUCTION: A urethral catheter is a hollow tube inserted into the urinary bladder for the purpose of draining urine or instilling fluid as part of medical treatment. Pomfret (1996) stated that the indications for urethral catheterisation are for drainage, investigations, instillations or management of intractable incontinence. It is also used to relieve obstruction of the urethra, which could be caused by a urethral stricture or by an enlarged prostate gland 2. POLICY STATEMENT Urethral catheterisation is an Aseptic procedure and this policy is to be used along side Standard Operational Procedure for urethral / Supra-pubic catheterisation 3. KEY PRINCIPLES To inform of the most appropriate choice of urethral / supra-pubic catheter To inform of the safe insertion, the risks associated and management of urethral/ supra-pubic catheters To inform of the safe use of intravesical solutions in catheter management To inform of the alternative to catheterisation and alternative drainage systems 4. RESPONSIBILITIES 4.1 Trust Board The Trust Board delegate authority to the relevant committees The Trust Board reserves the right to approve or ratify the Policy if this is deemed appropriate 4.2 Responsibilities of relevant Clinical Director to ensure the policy is presented to the appropriate committee for required approval to be responsible for the Policy and for allocating responsibility for writing associated procedures to ensure the Policy is reviewed in the required time frame to ensure a current Policy is displayed on the intranet 2

4 4.3 Responsibility of the Author Policy Title and Number Version To ensure that the policy is updated in line with National Guidelines If updates are required during the life of the Policy, the Author will submit these amendments to the relevant Committees for approval To provide training in catheterisation to nursing and medical staff in line with Policy and SOP requirements 4.4 Responsibility of Nursing Staff/ Medical Staff All staff have a duty to read and work within the Policy and SOP requirements It is the responsibility of each individual who undertakes to insert a urethral /supra pubic catheters that they, ensure their skills are up to date and that they have had the appropriate training read the Policy and SOP and adhere to its requirements they must also stop and seek help from the Urology Nurse specialists or a member of the Urology Team if there is any problem/ difficulty carrying out the procedure All staff must know how to access the policy library and bring to the attention of the Policy author and Policy Management Co-ordinator any discrepancies within the Policy and/or SOP. 5. HUMAN RIGHTS ACT: Implications of the Human Rights Act have been taken into account in the formulation of this policy and they have, where appropriate, been fully reflected in its wording. 5. EQUALITY & DIVERSITY: The Policy has been assessed against the Equality Impact Assessment Form from the Trust s Equality Impact Assessment Guidance and, as far as we are aware, there is no impact on any Equality Target Group 6. MONITORING AND REVIEW: It will be available for all staff to access on the intranet and anyone who attend a catheterisation study day will be directed to actively seek out the policy/guidance The catheter prescription and management form which must be completed for each patient will be used to audit and monitor the policy, The care indicators will be included in the ward to board audit tool and any areas failing will be referred to urology nurse specialist for update on catheter policy and discussed at PAB Individuals are responsible for their own actions when catheterising patients 3

5 Version. 7. ACCESSIBILITY STATEMENT: This document can be made available in a range of alternative formats e.g. large print, Braille and audiocassette. For more details, please contact the HR Department on (3766) or equalityanddiversity@ 4

6 Version. REFERENCES AND FURTHER INFORMATION: APPENDIX 1 Please list any references and/or further information relevant to the policy Royal College of Nursing Catheter care guidance for Nurses (March 2008 ) The Association for Continence Advice (2004). tes on Good Practice. London. NMC (2002). Exercising Accountability. London NMC. NMC (2002) Guidelines for Professional Practice. London. NMC. 5

7 Version. GLOSSARY OF TERMS APPENDIX 2 Ch/FG SP ISC Haematuria UTI POM ph Cystoscopy Charier / French gauge the abbreviations used for measurement of internal lumen Supra pubic catheter Intermittent Self Catheterisation Blood in urine Urinary Tract Infection Prescription only medication Measurement of urine acidity using lab stix Inspection of bladder under local anaesthetic using a endoscope 6

8 Version. EQUALITY IMPACT ASSESSMENT FORM STAGE 1 INITIAL ASSESSMENT (PART 1) APPENDIX 3 FOR USE WITH POLICY S AND SOP S Division: Title of Person(s) Completing Form Surgical Urology Nurse Specialist Department: New or Existing Policy? urology new Title of Policy being assessed: catheterisation Implementation Date (Policy) What is the main purpose (aims / objectives) of this policy? Will patients, carers, the public or staff be affected by this policy? Please delete as appropriate. Patients Carers Public Yes Yes Staff Yes If staff, how many individuals / Which Groups of Staff are likely to be affected? Nursing and Medical Staff Have patients, carers, the public or staff been involved in the development of this policy? Please delete as appropriate. Patients Carers Public Staff yes If yes, who have you involved and how have they been involved: Urology nurses, urology consultants, quality improvement team What consultation method(s) did you use? How are any changes / amendments to the policy communicated? For example: focus groups, face-to-face meetings, questionnaires etc. Quality improvement group For example: Meetings / Focus / etc. QUESTIONS YOU MUST CONSIDER when completing the following Equality Impact Assessment Table: Are there any barriers which could impact on how different groups might benefit from this policy? Does this policy promote the same choices for different groups as everybody else? Could any of the following group s experience of this policy be different? Does this policy address the needs and potential barriers of these groups? 7

9 Version. EQUALITY IMPACT ASSESSMENT TABLE POLICIES (PART 2) Equality Group Positive Impact Negative Impact Reason/Comments for Positive Impact Reason/Comments for Negative Impact Resource Implication Men Women Younger People (17-25) and Children Older People (60+) Race or Ethnicity Learning Difficulties Hearing Impairment Visual Impairment Physical Disability Mental Health Need Gay/Lesbian/ Bisexual Transgender Faith Groups (specify) Marriage & Civil Partnership Pregnancy & Maternity Carers High Low ne High Low ne (Why it could benefit any / all of the Equality Groups) (Why it could disadvantage any / all of the Equality Groups) no Yes / no high low high For patients whose first language is not English Catheterisation information not available in other languages If not accompanied by carer or relative Catheterisation information may be difficult to understand Loop system not readily available in all wards and departments no no yes no yes no Other Group (specify) Applies to ALL Groups 8

10 High: Low: ne: (a) Policy Title and Number Version. There is significant evidence of a negative impact or potential for a negative impact. Likely to have a minimal impact / There is little evidence to suggest a negative impact. A Policy with neither a positive nor a negative impact on any group or groups of people, compared to others. INITIAL ASSESSMENT (PART 3) In relation to each group, are there any areas where you are unsure about the impact and more information is needed? (b) How are you going to gather this information? (c) Following completion of the Stage 1 Assessment, is Stage 2 (a Full Assessment) necessary? Have you identified any issues that you consider could have an adverse (negative) impact on people from the following Equality Groups? Age (Younger People (17-25) and Children / Older People (60+) Gender (Men / Women) Race Disability (Learning Difficulties / Hearing Impairment / Visual Impairment / Physical Disability / Mental Illness) Religion / Belief Sexual Orientation (Gay / Lesbian / Bisexual) Gender Re-assignment Marriage & Civil Partnership Pregnancy & Maternity Carer Other (Please delete YES/ as appropriate) Any other comments Assessment completed by (Job Title) : Date Completed : If IMPACT is identified Action: further documentation is required. If YES IMPACT is identified Action: Full Equality Impact Assessment Stage 2 form must be completed. Refer to link below: PLEASE RETURN A COPY OF THE COMPLETED ASSESSMENT FORM (STAGES 1, 2 & 3) VIA TO: DEBBIE JONES, EQUALITY AND DIVERSITY PROJECT LEAD (for Service related policies) debbie.jones@wwl.nhs.uk EMMA WOOD, EQUALITY AND DIVERSITY PROJECT LEAD (for HR / Staffing related policies) emma.wood@wwl.nhs.uk 9

11 POLICY MONITORING AND REVIEW ARRANGEMENTS Appendix 4 NAME OF POLICY/SOP or CLINICAL GUIDELINE: catheterisation policy Para Audit / Monitoring requirement Method of Audit / Monitoring Responsible person 6 Ref to catheter prescription management form Frequency of Audit Monitoring committee Type of Evidence Part of ward to board audit Matrons Monthly PAB Completed catheterisation management forms Location where evidence is held Urology nurses your hospitals, your health, our priority