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Why should I have to use a catheter?

Rethinking continence care assumptions could reduce infection rates and save the NHS millions. Jennifer Trueland reports on an ambitious campaign

Rethinking continence care assumptions could reduce infection rates and save the NHS millions. Jennifer Trueland reports on an ambitious campaign

Picture credit: Science Photo Library

The No Catheter – No CAUTI campaign urges all clinicians to keep catheter use to a minimum and ensure that when they are used, they are used properly. Supporters want a revolution in awareness, putting catheters and associated infections on the same level as, for example, handwashing and drip-line infections.

Irene Karrouze is a woman on a mission. The lead continence nurse at King’s College Hospital NHS Foundation Trust in south London is involved in a campaign to get all clinicians to think about catheters – and associated infections – as much as they do handwashing.

She believes nurses are the key to saving the NHS millions of pounds in wasted bed days as well as reducing avoidable harm and deaths to patients. That is why she is involved in No Catheter – No CAUTI (catheter-associated urinary tract infection), a campaign that aims to reduce harm from catheterisation.

Run by the Health Innovation Network (HIN) in south London, and part of its patient safety programme, the initiative focuses on catheter use. It encourages nurses and others to consider whether catheters are necessary and, where they are used, to make sure they are managed properly and removed as soon as possible.

Phase one involves five south London hospitals and linked community services; the next stage will include all hospital and community trusts in south London, with learning shared across England and beyond.

The potential economic gains are huge – across the five trusts involved, it is reckoned CAUTI-associated excess bed days cost £12.3 million a year. But it is the cost to patients that matters most to Ms Karrouze.

‘It is about changing the culture,’ she says. ‘Catheters and CAUTI are part of our job. But what we must remember is that if you don’t put the catheter in in the first place, then you won’t get to CAUTI.

‘Once a catheter is in, it can be difficult to remove it, because nurses are waiting for the doctor to say it can come out.

‘What we are trying to do is put the ownership back with nurses. We are empowering nurses to remove them, and to ensure they are discussed on ward rounds.’

 

‘We hope to revolutionise catheter care in South London, the UK and then the world’

 

HIN says CAUTI is a major problem and has made it one of its patient safety priorities. In south London HIN brings together universities, local authorities and third sector organisations, as well as health services, with a focus on improvement and innovation. Academic health science networks also host patient safety groups that drive improvements.

Each year around 93,000 patients across the five trusts have catheters inserted, and more than 7,000 of these develop urinary tract infections. Almost one third of inpatient urinary catheter days have been shown to be inappropriate, and 26% of catheters inserted in A&E are inappropriate, HIN says.

According to the network’s clinical director for patient safety Adrian Hopper, the damage caused by CAUTI is often underestimated. ‘Patients can get extremely ill and can even die. If you contrast CAUTI with the energy and enthusiasm that has gone into tackling other infections such as clostridium difficile and meticillin-resistant Staphylococcus aureus, then it is neglected.’

Information from the NHS Safety Thermometer – a point-of-care survey instrument used by the NHS in England – shows that between 15% and 18% of patients in Dr Hopper’s hospital – Guy’s in London – are catheterised at any one time. ‘If it is taken out in a couple of days then for most people it will be fine,’ he says. ‘But when there are delays in taking it out, problems tend to arise.

‘While the nursing staff are waiting for the doctor to say take it out, catheters are rarely on doctors’ radars – so it doesn’t happen.’

The campaign is being run as an improvement collaborative, and will build on the work already taking place in south London at Ms Karrouze’s trust and elsewhere.

Steps taken at King’s include improving documentation so that all catheter use is audited, introducing a policy on prompt removal of catheters, and publicising the issue and the campaign among staff. ‘I hope nurses now know that catheters are important,’ says Ms Karrouze.

Cinderella group

But why has it taken so long to get to this point? Dr Hopper thinks it might be something to do with the patient group most affected.

‘People who get really ill, and who die from catheters tend to be frail and old – that is where the septicaemia occurs. This is a Cinderella group of patients. What we need to do is nudge everyone in health care to take this seriously.’

He is hoping for a change in culture, similar to what has taken place in other areas of infection control. ‘It is a question of encouraging people to do something they might not think of doing at the moment. Remember where we were not so long ago with hand hygiene, but now we all know we have to wash our hands. Similarly with drip-line infections. Even 15 years ago people would say it was too difficult, but the situation has been transformed.’

Age UK is working with the network to raise awareness of how to look after catheters and prevent infection. The charity’s director Caroline Abrahams would like to see more openness about the issue, among older people as well as clinicians. ‘Catheters can be a taboo subject for older people, who can find talking about them uncomfortable and upsetting. If worried about their catheters, older people are often too embarrassed to raise the issue, and uncertain about who to ask for help.’

The No Catheter – No CAUTI campaign is ambitious. ‘The hope is that we are going to revolutionise catheter care in south London, the UK and then the world,’ says Dr Hopper. ‘It is an important issue and we want people to take it seriously’.

To catheterise… or not

Lead continence nurse at King’s College Hospital NHS Foundation Trust Irene Karrouze advises that patients should only be catheterised where it is clinically indicated and that the catheter should be removed when it is no longer clinically indicated.

Clinical indications for catheterisation:

  • To monitor urine output in an acutely unwell or chronically ill patient or during surgery.
  • Acute urinary retention, for example benign prostatic hypertrophy.
  • Diagnostic purposes, for example renal tract imaging.
  • Change of long-term catheter.
  • End of life care.
  • Chronic obstruction that caused hydronephrosis.
  • Initiation of continuous bladder irrigation, for example clot retention.
  • Use in conjunction with an epidural during childbirth – catheter balloon has to be deflated during pushing stage.

Contraindications for catheterisation:

  • Two failed attempts at catheterisation.
  • Patient and/or medical consent has not been obtained.
  • Never catheterise or continue catheter use for nursing convenience.
  • The patient is agitated or cognitively impaired – avoid catheterisation where possible.
  • Nurses should never base the decision solely on residual urine status, even if the amount is considerable. Where a residual volume of urine is identified, the patient’s symptom and severity profile, along with renal function and cognitive status, must be considered before catheterisation.

 

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