Ask yourself: does this patient really need a catheter?

The use of catheters has serious implications and nurses should constantly review the need to continue with them, says updated RCN guidance

The use of catheters has serious implications and nurses should constantly review the need to continue with them, says updated RCN guidance

  • Guidance applies to all settings, including nursing homes
  • Grounded in practice, it focuses on infection control
  • Consider alternatives – don’t see catheters as default position

Picture: SPL

Rose Gallagher has a message for nurses and other clinicians caring for patients in all health and care settings: before reaching for a catheter consider the alternatives.

‘We want to ensure that all teams focus on the patient and not the device,’ she says, adding that she wants to encourage nurses to think: ‘Do we really need to do this?’

As the RCN professional lead for infection prevention and control, Ms Gallagher was part of a team responsible for updated college guidance on catheter care. Published earlier this year, the document is comprehensive, based on the latest evidence and brings together information from a wealth of existing guidelines, including several continence or urinary infection-related publications from the National Institute for Health and Care Excellence (NICE).

Popular guidance

The guidance, aimed at nursing teams, is grounded in practice. It includes important information on the legislative position around catheter care, the need for consent, the competencies required and relevant knowledge of anatomy. There are also sections on documentation, reasons for considering catheterisation, risk assessment and catheter-related equipment and how to look after it.

There is a strong focus on infection control, with catheter care for particular patient groups also considered, including a section on catheter guidance for the end of life, which has been expanded for the latest edition.

Ms Gallagher hopes the updated guidance will persuade nurses to consider alternatives rather than turn to catheters as the default position. ‘This has been a popular piece of guidance, and given how much our knowledge of the impact of catheterisation has increased, I’m pleased that it’s been updated,’ she says.

Cause of infection

While urinary catheters can be an important part of continence care they can also be a cause of infection, sometimes deadly, she says. These include bloodstream infections such as E. coli.

The health service has been successful in cutting rates of some infections associated with healthcare, such as MRSA, Ms Gallagher says, but she warns that it is hard to break down the factors that made the difference. That’s why it’s important not to let another organism take hold in the same way. ‘We don’t want to be in the same position with E. coli,’ she stresses.

‘It should never be about saving time – it should be about what’s best for the patient’

Rose Gallagher, RCN professional lead for infection prevention and control

She accepts that all nurses are under pressure, and that helping a patient to go to the toilet can take more time than fitting and emptying a catheter.

Time and resources

‘Elderly people coming into hospital are mostly continent. If you avoid a urinary catheter, you need more resources in terms of nursing time, but it should never be about saving time – it should be about what’s best for the patient. This can be challenging due to staff shortages, but it is unacceptable to put them in for that reason. But we have to acknowledge that continence takes time and resources.’

She hopes all nurses will read the guidance and reflect on it as part of revalidation, and also incorporate it in their practice. She also advises looking at new RCN guidance on bowel care.

‘This is relevant for all care settings, including nursing homes’

Sue Hill, independent continence specialist nurse

Sue Hill, an independent continence specialist nurse who was involved in reviewing the guidance, says nurses will be able to use it to implement positive change in their organisations.

Getting it right

‘This is relevant for all care settings, including nursing homes,’ she says. ‘Nurses can go to the guidance to check information if there’s something they’re not sure about, but they can also use it to develop local policies, because it is based on the latest evidence.’

People are talking more about catheters and about bladder care generally than in the past, says Ms Hill, which is positive for patient care, but she would still like to see more education and training around it for all nurses. Getting it right – or not getting it right – can have a big effect, she says.

Ms Hill cites the case of one patient living at home who was fitted with a catheter and was plagued by frequent infections. ‘She was a lady in her seventies and she had constant infections, and it affected her quality of life. It seemed that every time the catheter was changed she got an infection. She now comes to the clinic to have it changed on a planned basis and the number of infections has reduced dramatically. Her life has improved overall.’

Sharon Holroyd edited the
guidance. Picture: Neil O’Connor

Timely and needed

At Calderdale and Huddersfield NHS Foundation Trust, bladder and bowel service lead clinical nurse specialist Sharon Holroyd, who edited the updated guidance, says it is timely and much needed. ‘Continence is one of the fundamentals of nursing care, and maintaining continence can significantly increase a patient’s quality of life,’ she says.

‘Catheters can be a part of that, and we hope this updated guidance will raise awareness, encourage adoption of good practice across all NHS and independent healthcare settings, and improve the quality of care for patients.’

Age UK clinical lead for professionals and practice Lesley Carter, a nurse with many years’ experience of working with older people, believes the battle for good catheter care has not yet been won, and welcomes the new guidance. She says good catheter care remains patchy – and that poor care can be devastating for patients.

Poor outcomes

She was involved in a 2015-17 campaign in south London to reduce catheter-associated urinary tract infections (see box). It included a survey of catheter care practice. ‘Some people were getting extremely good care, but in other areas people really didn’t know what was going on,’ she says.

‘There were some cases where someone had a catheter put in when they were in A&E and then it never came out again – they were sent home with it and nobody, in terms of health professionals in the community, knew about it. I don’t think the situation will have changed that much.’

The London campaign focused minds and made people ‘get their heads down’ and think about how to improve patient care, she says.

‘It’s about avoiding catheters where possible, having them for as short a period as possible, and maintaining them well’

Lesley Carter, Age UK clinical lead for professionals and practice

Ms Carter worries that there are inequalities in healthcare, with older people more likely to be catheterised – with potentially poor outcomes. These include infections but also the risk of losing continence and losing mobility, because they are not getting up to go to the toilet. ‘We don’t think it helps their well-being.’

Shared experience

Good communication around continence issues is also important, she says. ‘We still don’t talk about it – people whisper about it.’

This is something that also concerns Ms Gallagher. She wants all nurses, including those working in community settings, to talk about catheter care and be prepared to share experience.

Summing up her advice, she says: ‘It’s about avoiding catheters where possible, having them for as short a period as possible, and maintaining them well. It’s a very important aspect of patient care, wherever you are.’

‘Good catheter care saves lives’

An initiative to improve catheter care in south London resulted in a 30% reduction in catheter-associated urinary tract infections (CAUTI) – and work continues to find new ways of driving positive change.

The No Catheter – No CAUTI campaign was run by the Health Innovation Network, the academic health science network for South London, and focused on better bladder care in acute and community trusts across the region.

The network’s clinical director for patient safety Adrian Hopper, a physician with a special interest in geriatric medicine at Guy’s and St Thomas’ NHS Foundation Trust, says the initiative encouraged clinicians in acute and community trusts to see what they could do better.

Community of practice

‘Although the programme wrapped up a couple of years ago the work continues,’ says Dr Hopper, adding that it led to a ‘community of practice’ clinicians who meet regularly to discuss how to maintain and drive further improvements.

‘We’ll be looking at nudge approaches and seeing what makes the difference’

Adrian Hopper, a physician with a special interest in geriatric medicine

There are also plans to run a further programme with funding from the charity Health Foundation looking at ‘nudge’ or persuasive methods to manage change to improve catheter care. ‘We’ll be looking at nudge approaches and seeing what makes the difference – is it catheter passports, or a checklist, or something written on a bag?’ he says.

Dr Hopper acknowledges that there is still some distance to go before every patient gets the best possible experience, and points to the transition between a hospital stay and a patient’s discharge home as being a ‘danger point’.

‘It’s not glamorous’

‘We still see patients who have been sent home without having had a trial without catheter,’ he says.

There are positive initiatives, such as out-of-hours community support teams for catheter care, although these are a work in progress. ‘What can you do if your catheter goes wrong at 2am other than call an ambulance? Community support can help keep you at home,’ says Dr Hopper.

He welcomes the greater national focus on catheter care and hopes the work of the Health Innovation Network will help take this further. ‘It’s not glamorous – which is one of the reasons I like it,’ he says. ‘But good catheter care is so important – it really does save lives.’

Jennifer Trueland is a health journalist

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