Clinical guideline for insertion and removal of an intermittent urethral catheter

Transcription

1 Document level: Clinical Service Unit (CSU) Code: CC5 Issue number: 1 Clinical guideline for insertion and removal of an intermittent urethral catheter Lead executive Lead Clinical Director Author and contact number Continence Lead Type of document Target audience Document purpose Guidance All clinical staff within CCWC This guideline is intended to serve as an evidence based guide for Competent Practitioners employed by Cheshire and Wirral Partnership NHS Foundation Trust (CWP), in the aseptic insertion and the removal of an intermittent urethral catheter for both male and female patients. This guideline also gives Competent Practitioners a guidance on how to teach patients how to perform clean intermittent urethral self-catheterisation. Please note this guideline is intended for adult patients only. Document consultation CCWC services Approving meeting CSU - Goverance and Risk Group 24-Aug-12 Ratification Document Quality Group (DQG) 14-Sep-12 Original issue date Sep-12 Implementation date Sep-12 Review date Sep-17 CWP documents to be read in conjunction with HR6 IC2 GR29 IC3 IC8 CP3 CC7 MP16 GR26 MH13 Trust-wide learning and development requirements including the training needs analysis (TNA) Hand decontamination policy and procedure Waste management policy Standard (universal) infection control precautions policy policy for the procedure for aseptic non touch technique ANTT Health records policy Clinical guidelines for urethral indwelling catheterisation Non-medical prescribing policy Policy for the safe manual handling of people and loads Part IV and IVA - MHA - Consent to treatment Training requirements Financial resource implications Yes - Training requirements for this policy are in accordance with the CWP Training Needs Analysis (TNA) No Equality Impact Assessment (EIA) Initial assessment Yes/No Comments Does this document affect one group less or more favourably than another on the basis of: Race No Ethnic origins (including gypsies and travellers) No Page 1 of 12

2 Initial assessment Yes/No Comments Nationality No Gender No Culture No Religion or belief No Sexual orientation including lesbian, gay and bisexual people No Age No Disability - learning disabilities, physical disability, sensory impairment and mental health problems No Is there any evidence that some groups are affected differently? No If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? N/A Is the impact of the document likely to be negative? No If so can the impact be avoided? N/A What alternatives are there to achieving the document without the impact? N/A Can we reduce the impact by taking different action? N/A Where an adverse or negative impact on equality group(s) has been identified during the initial screening process a full EIA assessment should be conducted. If you have identified a potential discriminatory impact of this procedural document, please refer it to the human resource department together with any suggestions as to the action required to avoid / reduce this impact. For advice in respect of answering the above questions, please contact the human resource department. Was a full impact assessment required? What is the level of impact? No Low Monitoring compliance with the processes outlined within this document Please state how this document will be Auditing the number of Competent Practitioners monitored. If the document is linked to the attending the CWP catheterisation study day and NHSLA accreditation process, please number of staff competent to catheterise. Continence complete the monitoring section below. Advisory Service Auditing Yearly. Document change history Changes made with rationale and impact on practice 1. External references References 1. Cochran S. Care of the Indwelling Urinary Catheter: Is It Evidence Based? Journal of Wound, Ostomy & Continence Nursing May / June; 34(3): Continence Advisory Service (CAS). Continence Prescribing Formulary March March. 3. Gilbert R, Henderson S; 2005, Catheter specimens of urine: an audit of practice. 2005;101(47), Lin K, Fajardo K. Screening for asymptomatic bacteriuria in adults: evidence for the US Preventive S 5. National Institute for Clinical Excellence (NICE). Clinical Guideline 139 Infection Prevention and control of healthcare-associated infections in primary and community care March. 6. NHS Quality improvement Scotland (NHS QIS). Urinary Catheterisation & Catheter care. Best statement June 7. Nursing and Midwifery Council (NMC). The Code - Standards of conduct, performance and Page 2 of 12

3 References ethics for nurses and midwives Ramakrishnan K, Mold J W. Urinary Catheters: A Review. The Internet Journal of Family Practice. 2005;3(2). 9. Tenke P, Kovacs B, Johansen T, et al. European and Asian guidelines on management and prevention of catheter-associated urinary tract infections. International Journal of Antimicrobial Agents. 2008;31S:S68 S Trautner B. Management of catheter-associated urinary tract infection. Current Opinion in Infectious Diseases. 2010,23(1), Turi MH, Hanif S, Fasih Q, et al. Proportion of complications in patients practicing clean intermittent self-catheterization (CISC) versus indwelling catheter. J Pak Med Assoc 2006;56: Wyndaele J, Intermittent catheterization: which is the optimal technique?, Spinal Cord. 2002;40(9), Page 3 of 12

4 Content 1. Introduction Definitions Qualification and training Assessment Risks associated with catheterisation Patient consent and information Review Equipment required Procedure aseptic intermittent catheterisation Procedure clean intermittent self-catheterisation Female clean intermittent self-catheterisation Duties and responsibilities Clinical Director Continence Advisory Service Line managers Clinical staff Appendix 1 - Competency document Female / Male intermittent urethral catheterisation Page 4 of 12

5 1. Introduction This guideline is intended to serve as evidence based guide for registered nurses and assistant practitioners employed by CWP in the aseptic insertion and the removal of an intermittent urethral catheter for both male and female patients. This guideline also gives registered nurses and assistant practitioners guidance on how to teach patients / carers how to perform clean intermittent urethral selfcatheterisation. Please note this guideline is intended for adult patients only. If a Registered Nurse or Assistant Practitioner is performing intermittent catheterisation an aseptic technique must be used (see Procedure 9.1.and 9.2.). If the patient carries out the procedure on themselves a clean technique can be used (Wyndaele, 2002) (see Procedure 10.1.and 10.2.). 2. Definitions To provide guidance for registered nurses in: Caring out a catheter assessment and review; The education, teaching and support of the patient regarding clean intermittent urethral self-catheterisation; The insertion and removal of an intermittent urethral catheter using an aseptic technique; The delegation and supervision of intermittent catheterisation to Assistant Practitioners, patients or carers. To provide guidance for assistant practitioners in The insertion and removal of an intermittent urethral catheter using an aseptic technique; Support of the patient regarding clean intermittent urethral self-catheterisation. 3. Qualification and training This guidance applies to all clinical staff employed by CWP: Registered nurses who are currently registered with the Nursing and Midwifery Council (NMC); Assistant practitioners who have completed a recognised assistant practitioner s course. Following the catheterisation study day, the registered nurse or assistant practitioner needs to complete a minimum of 3 supervised practices till they feel confident and competent in: Female intermittent catheterisations This should be recorded in the Competency document female / male intermittent urethral catheterisation (appendix 1). If the registered nurse or assistant practitioner is already competent in female urethral indwelling catheterisation (leaflet), he / she should be supervised for a minimum of 1 female intermittent catheterisation. Male intermittent catheterisations This should be recorded in the Competency document female / male intermittent urethral catheterisation (appendix 1). If the registered nurse or assistant practitioner is already competent in male urethral indwelling catheterisation (leaflet), he / she should be supervised for a minimum of 1 male intermittent catheterisation. The supervision of these practical procedures can only be undertaken by a registered nurse who has: Attended the catheterisation study day within the last three years; Is confident and experienced in inserting and removing a urethral intermittent catheter in male and female adult patients; Competency document female / male intermittent urethral catheterisation (appendix 1). In order to maintain knowledge and skills the registered nurse or assistant practitioner should attend a catheterisation update study day every three years. Page 5 of 12

6 A registered nurse who can demonstrate competence to this professional level may delegate those procedures to assistant practitioners, patients or carers as appropriate. However it is the registered nurse s responsibility to ensure that the assistant practitioners and patient / carer competencies are assessed and reviewed. 4. Assessment A full continence assessment of the individual and their needs is required before intermittent catheterisation is contemplated. Following assessment the best approach to catheterisation should be selected that takes account of clinical need, patient preference and risk of infection. (NICE, 2012) Intermittent catheterisation is the preferred choice to indwelling urethral catheterisation. (NICE, 2012) This is because it can reduce complications such as urinary tract infection, bacteraemia, local infections such as epididymitis and prostatitis. It also avoids risks associated with long-term catheterisation, i.e. calculus disease, bladder spasms, leakage, blockage of the catheter and renal damage (Turi, 2006; Ramakrishnan, 2005): Intermittent catheterisation can be used for the following reasons: To relieve retention of urine; To determine residual volumes of urine; To perform bladder instillation; To manage urinary incontinence; Management of urethral strictures. It is the registered nurse s responsibility to be aware of the medical / surgical diagnosis and the reasons for catheterisation. This will ensure that no contra-indications exist prior to catheterisation as well as identify any known allergies. If the registered nurse has any concerns prior to initial catheterisation medical advice should be sought. Factors that need to be considered before either performing intermittent catheterisation or before teaching patient / carer intermittent self catheterisation (ISC): Patient s physical independence; Cognitive ability; History of urethral trauma; Compliance; Patient s preference (Turi, 2006). 5. Risks associated with catheterisation Urinary tract infections are the commonest source of acquired infection, particularly when inserting a catheter into the bladder. Most catheter-associated infections are derived from the patient s own colonic flora. Intermittent catheterisation is a safer practice with fewer complications and lower infection rates than with indwelling catheters (Turi, 2006). Routine urine culture in an asymptomatic catheterised patient is not recommended because treatment is generally not necessary, except for some special cases. Antibiotic treatment is recommended only for symptomatic infection (Gilbert, 2005; Lin, 2008; Tenke P, et al, 2008; Trautner, 2010). 6. Patient consent and information Prior to intermittent catheterisation the permission of the GP should be obtained and documented in the patient s records. The consent of the patient must be verbally obtained and documented following a full explanation of the procedure, potential complications and alternative options. To support any verbal explanation the appropriate manufacturers leaflet, relevant to that brand of intermittent catheter should be provided. Page 6 of 12

7 It is the registered nurse or assistant practitioner s responsibility to assess, and teach the patient and / or his carer on hand decontamination policy and procedure and how to perform meatal cleaning prior to performing clean intermittent self-catheterisation (NICE, 2012). 7. Review If the registered nurse or assistant practitioner is performing intermittent catheterisation on a patient, the registered nurse or assistant practitioner should review the following: Depending on the residuals (more than 100ml) intermittent catheterisation might need to be repeated. It is advisable to keep a record of the amount of urine the patient passes and the amount that is drained via an intermittent catheter. This will enable registered nurses to make a clinical decision on how often the patient needs to be catheterised intermittently; Any complications (urinary tract infection, bleeding, urethral tear or false passages). If the patient is performing clean intermittent self-catheterisation the registered nurse should review the following: How often the patient will need to self-catheterise, this will depend on the residual volumes; Signs of any complications (urinary tract infection, bleeding, urethral tear or false passages); Still using the correct technique? Is the patient compliant? Does the catheter meet the patient s current needs? Once the patient / carer is deemed to be competent and confident to perform clean intermittent selfcatheterisation, it is the registered nurse s responsibility to review the patient every 12 months or sooner if the need should arise. 8. Equipment required To prescribe the most cost-effective intermittent catheter, please refer to the most up-to-date Continence Prescribing Formulary. It is the registered nurse and assistant practitioner s responsibility to use the products that are available in this formulary, unless they are contra-indicated for the patient. If you are prescribing outside this formulary the reason should be documented. Catheters for intermittent use can either be single use pre-lubricated or reusable. 9. Procedure aseptic intermittent catheterisation This is an aseptic technique and must be used when a registered nurse or assistant practitioner performs this procedure on behalf of the patient refer to policy for the procedure for aseptic non touch technique ANTT. 10. Procedure clean intermittent self-catheterisation This procedure must only be used when the patient catheterises him / herself. Equipment: - Intermittent catheter: standard length for male patients. If the catheter is not pre-lubricated, use a sterile single use sachet of lubricant i.e. Aqua gel or Sutherland lubricating Jelly 5g sachet, Reusable intermittent catheters should be cleaned with water and stored dry in accordance with the manufacturer s instructions. (NICE, 2012) - Soap, water; - Cloth / wipe to wash genital area; - If procedure is carried out on the bed: towel and jug. Page 7 of 12

8 No. Action Rationale 1. Explain the procedure to the patient and To ensure that the patient understands the provide the appropriate manufacturer s procedure and gives informed consent. leaflet, relevant to that brand of catheter. 2. Advise patient to try and empty their bladder if possible. To ascertain residual volumes 3. Advise patient to gently pull the foreskin back and wash the glans of the penis with water. 4. Advise patient to wash hands with soap and water (NICE, 2012) To minimise risk of infection. 5. Discuss with the patient different positions in which intermittent catheterisation can be performed, i.e. - Sitting on the toilet; To ensure a comfortable and safe position - Standing over the toilet; - On the bed. 6. If the patient catheterises himself on the bed, advise him to put a towel under the buttock and thighs. To ensure urine does not leak onto bed clothes If the catheter is not attached to a bag, advise the patient to put a jug between the legs. Advise patient to open packaging and to lubricate catheter as per manufacturer s guidelines. Advise the patient retract any foreskin and to raise the penis into an upright position. Advise the patient to remove catheter from packaging using a no touch technique Advise the patient to insert the intermittent catheter into the urethra for 15 25cm until urine flows. Advise the patient that he might feel some resistance at the external sphincter; ask him to cough or to strain as if passing urine and advise to continue inserting the catheter gently. If he is unable to insert the catheter, stop the procedure and seek medical advice. When urine begins to flow, advise to advance the catheter another 2-3 cm. When the flow stops, advise the patient to slowly remove the catheter Advise the patient to dry the glans penis and to return any foreskin to its normal position. Measure the amount of urine drained if required Reduces risk of spillage. Adequate lubrication helps reduce urethral trauma and minimises the discomfort experienced by the patient. (Cochran, 2007; NHS QIS 2004; NICE, 2012) Retraction of the foreskin prevents contamination. Raising the penis in un upright position straightens the penile urethra. To minimise risk of infection. Male urethra is approximately 18cm long. Some resistance may be due to spasm of the external sphincter. To avoid trauma to the urethra. To ensure a good drainage of the bladder To minimise trauma Reduces the risk of infection, irritation and paraphimosis. If you are unable to return the foreskin to its normal position seek medical advise. Depending on the residual volume, i.e. more than 100mls, an ongoing plan of care should be implemented. This can be discussed with the Continence Advisory Service. Page 8 of 12

9 No. Action Rationale 16. Dispose of catheter in household rubbish, advise patient not to flush it down the toilet. To prevent environment contamination. 17. Advise patient to wash hands with soap and water (NICE, 2012) To minimise risk of infection. 18. Leave a contact number with the patient 19. Information to be recorded in the patient s record: - Consent; - Catheter type, size, manufacturer and batch number; - Amount of urine drained if required Female clean intermittent self-catheterisation Equipment: - Intermittent catheter: standard or female length To enable the patient to have easy access to advice and support To provide a point of reference to ensure accurate record keeping (THIS IS ESSENTIAL). If the catheter is not pre-lubricated, use a sterile single use sachet of lubricant i.e. Aqua gel or Sutherland lubricating Jelly 5g sachet. Reusable intermittent catheters should be cleaned with water and stored dry in accordance with the manufacturer s instructions. (NICE, 2012). - Soap, water; - Cloth / wipe to wash genital area; - If procedure is carried out on the bed: towel and jug. No. Action Rationale Explain the procedure to the patient and provide the appropriate manufacturer s leaflet, relevant to that brand of catheter. Advise patient to try and empty their bladder if possible. Advise patient to spread labia apart and wash the genital area from front to back with water. Advise patient to wash hands with soap and water (NICE, 2012) Discuss with the patient different positions in which intermittent catheterisation can be performed, i.e. - Sitting on the toilet - Standing over the toilet - On the bed If the patient catheterises herself on the bed, advise her to put a towel under the buttock and thighs. To ensure that the patient understands the procedure and gives informed consent. Evidence of consent by signature on the care plan. To ascertain residual volumes To reduce the risk of post catheterisation infection. To minimise risk of infection. To ensure a comfortable and safe position To ensure urine does not leak onto bed clothes. If the catheter is not attached to a bag, advise the patient to put a jug between the legs. Reduces risk of spillage. Page 9 of 12

10 No. Action Rationale 7. Advise patient to open packaging and to lubricate catheter as per manufacturer s guidelines. Page 10 of 12 Adequate lubrication helps reduce urethral trauma and minimises the discomfort experienced by the patient. (Cochran, 2007; NHS QIS 2004; NICE, 2012) This prevents contamination of the catheter and provides better access to the urethra. 8. Separate the labia minora so that the urethral meatus can be seen. 9. Advise the patient to remove catheter from packaging using a no touch technique To minimise risk of infection. Advise the patient to insert the catheter into 10. the urethral orifice in an upward and The female urethra is approximately 4 cm backward direction for 5 6cm or until urine long. flows 11. When urine begins to flow, advise the patient to advance the catheter for a further 2-3cm. To ensure a good drainage of the bladder 12. When the flow stops, advise the patient to slowly remove the catheter To minimise trauma 13. Ensure the genital area is dry. For patient s comfort Depending on the residual volume, i.e. more 14. Measure the amount of urine drained if than 100mls, an ongoing plan of care should required be implemented. This can be discussed with the Continence Advisory Service. 15. Dispose of catheter in household rubbish, advise patient not to flush it down the toilet. 16. Advise patient to wash hands with soap and water (NICE, 2012) 17. Leave a contact number with the patient 18. Information to be recorded in the patient s record - Consent; - Catheter type, size, manufacturer and batch number; - Amount of urine drained if required. 11. Duties and responsibilities To prevent environment contamination. To minimise risk of infection. To enable the patient to have easy access to advice and support To provide a point of reference to ensure accurate record keeping (THIS IS ESSENTIAL) Clinical Director Clinical Director is responsible for development, implementation and review of approved documents, which fall within their remit. The clinical director will take a uniform approach towards the complex issues in this guidance. They will ensure training is implemented across CWP through their monthly managers meeting Continence Advisory Service Continence Advisory Service is responsible for: Offering advice and support to registered nurses and assistant practitioners in all aspects of catheterisation; Ensuring the guideline is evidence based and reviewed on a 5-yearly basis or earlier if necessary; Providing evidence based education and training in male and female catheterisation; Auditing the implementation of the guideline Line managers Line Managers have the responsibility to Highlight the guidance to all clinical staff Providing evidence that the guideline has been cascaded within their team or department;

11 Where appropriate, ensuring the new guideline is effectively implemented; Ensuring that staff attend all training identified in respect of this guideline Clinical staff It is the responsibility of clinical staff Ensuring that the guidance contained herein is adhered to and followed; Complying with The code: Standards of conduct, performance and ethics for nurses and midwives (NMC, 2008); Attending a catheterisation study day, organised by CWP Continence Advisory Service, before completing any supervised practices and the competency document; Sending their completed competency document to the CWP Continence Advisory Service, when they are confident and competent in carrying out male and / or female urethral intermittent catheterisation; Updating their skills every three years by attending a catheterisation study day, organised by CWP Continence Advisory Service, or sooner if required; Reporting any accidents, incidents and near misses in relation to this processes and procedures contained herein via Datix-system. Page 11 of 12

12 Appendix 1 - Competency document Female / Male intermittent urethral catheterisation Prior to completing this document the registered nurses or assistant practitioner must have attended the Continence Advisory Service s catheterisation study day. The practical procedure should be carried out as directed per Clinical Guideline for the insertion and removal of an intermittent catheter. In order to complete this document the registered nurses or assistant practitioner will need to undertake a minimum of 3 supervised practices in female urethral intermittent catheterisation or until the practitioner feels confident and competent to carry out the procedure. Please note if the registered nurse or assistant practitioner has completed the competency document in female or male indwelling urethral catheterisation, only 1 supervised practice is required if they feel confident and competent. It is the registered nurse or assistant practitioner s responsibility to keep up to date by attending the Continence Advisory Service s catheterisation study day every 3 years. On completion of this competency document, please return to: Continence Advisory Service, Hope Farm Clinic, Hope Farm Road, Great Sutton, CH66 2RQ. A certificate will be forwarded to you. The document will then be returned to be kept in your professional portfolio as evidence. Practitioners name Base Designation The nurse should be able to demonstrate competency in the following elements and work within CWP guidelines and policies - Assess and review the need for catheterisation - Assess if the patient could carry out the procedure her/himself - Identify medical / surgical history and any known allergies - Explain procedure and potential adverse effects and symptoms to the patient, using manufacturer s catheterisation document - Gain consent - If the registered nurse or assistant practitioner has to insert an intermittent catheter, it should be an aseptic technique - Work within CWP s Infection Prevention Control (IPC) policies as outlined in the catheterisation guidelines - Prepare area - Check equipment and materials to ensure they are safe and fit for purpose before usage. Check type, size, expiry date of catheter - Prepare equipment - Insert and remove catheter - Know when not to proceed or abandon urethral catheterisation and what actions to take - Dispose of clinical waste appropriately. - Record information in patient care plan Date Initial Date Initial Date Initial Page 12 of 12