EVIDENCE-BASED PRACTICE PROTOCOL



EVIDENCE-BASED PRACTICE PROTOCOL

Management of Long-Term Indwelling Urinary Catheters

|Definitions |Long-term: > 30 days |

| |Indwelling: drainage tube inserted into the urinary bladder through the urethra, left in place, and connected to a drainage |

| |system |

| |Catheter-related urinary tract infection (CAUTI): |

| |Must meet one of the following criteria: |

| |1) 2 of the following AND urinalysis or culture not done |

| |-Fever (2-4 degrees F or 1 degree C above baseline) or chills with no other source |

| |-Flank pain OR suprapubic pain OR tenderness OR frequency OR urgency |

| |-Worsening mental or functional function |

| |-Changes in character of urine (blood, foul odor, increase sediment, etc.) |

| |2) One of the following AND urinalysis/culture done |

| |-Fever* or chills |

| |-Flank pain OR suprapubic pain OR tenderness |

| |(re: urinalysis/culture: bacteriuria – positive culture or positive nitrite assay; |

| |pyuria – 10 or more wbc/hpf on urinalysis or positive leukocyte esterase assay) |

|Indications |-Bladder outlet obstruction or retention |

| |-Healing sacral wound (pressure ulcer on trunk) in incontinent pts. |

| |-Palliative end-of-life |

|Types of catheters |-Antimicrobial catheters not supported for effectively preventing CAUTIs |

| |-Use smallest size (caliber) |

| |-Silicone may be preferred in long term catheterized patients to prevent obstruction |

|Maintenance |Maintain closed system – minimize disconnections; if change to leg bag, disinfect tubing with 70% alcohol |

| |Routine hygiene (daily bathing; no antiseptics; see patient/family education) |

| |Keep drainage bag &connecting tubing below level of bladder and off the floor |

| |Proper securing to prevent movement & urethral traction |

| |Empty bag regularly when 1/3-1/2 full making sure not to touch the spigot to the container or toilet – clean spigot with alcohol|

| |Empty bag before bedtime |

| |No regular use of topical antiseptic or antibiotics, chronic antibiotic suppressive therapy, routine cultures, saline irrigation|

|Changing the catheter (or |Antiseptic conditions |

|drainage bag) |Adequate lubricant |

| |Inflate balloon with sterile H20 and amt. determined by manufacturer’s recommendations |

| |Routine changing of catheter monthly based on Medicare beneficiaries and/or physician order; note that changing the catheter at |

| |regular intervals is not fully supported – need to adapt to individual patient based on infection, obstruction or when closed |

| |system compromised |

| |Change drainage bag when catheter changed or more frequently for clouding, odor, or discoloration |

|Cleaning the drainage bag |Bleach solution method preferred (decrystalizes sediment and inhibits bacterial growth) (mix daily): MUST TEACH SAFE HANDLING |

| |OF BLEACH |

| |Wash hands before & after; disconnect bag from catheter; rinse tubing with tap water using a soft, plastic squirt bottle or |

| |turkey baster; mix 4 oz. bleach with 1 gallon tap water; pour solution into tubing/bag; avoid wetting the air vent located at |

| |top of drainage bag; agitate for 30 seconds; drain; air dry; store in closed container |

| |Vinegar solution method if cannot use bleach safely: Follow directions above; instead, use ½ c. vinegar to 1 ½ cups tap water |

|Infection Related |Most S&S for CAUTI are nonspecific; only obtain specimens if patient exhibits S&S since treatment should target symptomatic |

| |patients |

| |No prevention for biofilm (layer resistant to acidic irrigants & antibiotics |

| |Change catheter, then get urine specimen – 1) disinfect port with 70% alcohol & pat dry prior to withdrawing specimen; 2) can |

| |obtain specimen from newly inserted catheter by letting urine drain directly into cup before connecting tubing; 3) if catheter |

| |already connected to tubing, and no port, disconnect and disinfect with 70% alcohol; Do not obtain urine culture from drainage |

| |bag |

| |Transport urine culture according to recommendations (room temperature with chemical preservation and test within 24-72 hours) |

| |Urine culture before antibiotics |

| |Treatment is based on symptoms (criteria) and organism |

| |Use SBAR-CUS when communicating assessment findings to healthcare provider |

|Patient/family Education |Wash hands with soap & running water |

| |Avoid tension on the catheter and kinks; anchor catheter appropriately |

| |Drainage bag below level of bladder |

| |Fluids – 6-8 glasses/liquid/day – keep urine yellow |

| |Avoid irritants such as caffeine, ETHO, etc. |

| |Avoid constipation |

| |Daily perineal cleaning with soap and water; front to back in females; start at tip in men; wash away from body down catheter |

| |Shower unless contraindicated |

| |Teach self-management – emptying the drainage bag; changing the drainage bag; switching from drainage bag to leg bag; cleaning |

| |and storing drainage bag; complications |

|Other |-If urethral catheter for > 10 years, screen for bladder cancer |

| |-Discuss possible transition to subrapubic catheter |

| |-May consider belly bag |

|Documentation |Urinary NDP |

| |Narrative: if appropriate, catheter changed without difficulty; next change (once individualized) |

| |Plan for next visit: culture results, teaching |

NOTE: With silicone catheters, check the balloon inflation every 2 weeks

References:

Association of Professionals in Infection Control and Epidemiology (APCI). (2008). Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs) Developing and Applying Facility-Based Prevention Interventions in Acute and Long-Term Care Settings. APIC: Washington, DC.

Healthcare Infection Control Practices Advisory Committee (HICPAC). (2009). Guidelines for the Prevention of Catheter-Associated Urinary Tract Infections. CDC: Atlanta, GA.

Hooton, T. M., Bradley, S. F., Cardenas, D. D., Golgan, R., Geerlings, S. E., Rice, J. C., Saint, S., Schaeffer, A. J., Tambayh, P. A., Tenke, P, & Nicolle, L. E. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the infectious diseases society of America. CID, 50, 625-663.

National Association for Continence. (2010). When The Drainage System Is Changed Frequently. Accessed from .

National Guideline Clearinghouse. (2009). Catheter-associated urinary tract infections. In: Guidelines on urological infections.

Smith, J. M. (2003). Indwelling Catheter Management: From Habit-based to Evidence-based Practice. Wound Ostomy Management, 49(12). Access from .

Urinary catheters. Accessed from .

VNAA genitourinary policies (i.e., Decontamination of Vinyl Urinary Drainage Bag; Sterile Urine Specimen Collection from a Foley Catheter; Urinary Catheter Care).

Wound Ostomy and Continence Nurses Society. (2009). Indwelling urinary catheters: Best practices for clinicians. Mt. Laurel, NJ: WOCN.

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