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Catheter Care in Residential Settings Policy

Aims of Policy

This policy is intended to set out the values, principles and policies underpinning this care service’s approach to catheter care.

Principles of Catheter Care

A catheter is a sterile tube of rubber or plastic that can be inserted into the bladder. There are two main types of urinary catheter.

1. Intermittent catheters: catheters that are temporarily inserted into the bladder and removed once the bladder is empty. These types of catheters might be self-administered.
2. Indwelling catheters: catheters that remain in place for many days or weeks and are held in position by a water-filled balloon in the bladder. These are usually inserted by trained healthcare professionals, who will also be responsible for overseeing the subsequent catheterisation process.

Urinary catheterisation is the procedure for releasing urine from the bladder when the normal outflow channel is blocked, commonly (in males) by enlargement of the prostate gland, or when normal urination cannot occur for any other reason.

A person with continence difficulties will be helped to maintain normal bladder function for as long as possible. Where all other alternative methods of continence management have been explored, a GP or responsible medical practitioner will consider the insertion of an indwelling urethral catheter.

If a catheter is inserted, the clinical need for continuing it should be reviewed regularly and it should be removed if the need no longer exists. Catheters should not be changed unnecessarily or as part of routine practice without a review being carried out. Indwelling catheters should only be changed when necessary or according to the manufacturer’s instructions.

An appropriate healthcare professional should always assess needs to help an individual with correct urinary retention, which will include monitoring urinary output.

In spite of high standards of sterilisation and aseptic technique there is still a risk to people of developing urinary infections when a catheter is inserted (it is estimated that about 10% of those who are catheterised will develop a urinary tract infection).

The most common clinical presentation of symptomatic catheter-acquired urinary infection is a raised temperature. Staff should observe for other symptoms of rarely occurring but potentially fatal presentations of severe sepsis, or septic shock.

Catheterisation is an aseptic procedure and only staff who are adequately trained in such procedures should undertake catheterisation and catheter care. Once a catheter is inserted, all appropriate care must be taken to ensure that the user is comfortable with the device and all measures are taken to reduce the risks of urinary tract infections developing.

Insertion Procedures and After Care

In inserting catheters and their subsequent care, the following protocol will usually apply.

1. A person for whom a catheter is proposed will have the procedure and associated risk of urinary tract infection fully explained to them (with an equivalent best-interest assessment and decision-making process for someone who does not have mental capacity to consent to the procedures involved).
2. If a UTI is suspected post-insertion, NICE Quality standard QS90: Urinary Tract Infections in Adults (June 2015) updated 15 February 2023, will be followed and adults with indwelling urinary catheters will not have dipstick testing to diagnose a UTI.
3. To ensure UTIs are diagnosed accurately, signs and symptoms should be assessed to diagnose UTIs with urine culture and sensitivity testing used to support the diagnosis and guide treatment.
4. Staff will be guided by healthcare professionals, who may seek guidance from a microbiologist before commencing antibiotic prophylaxis for people with a urinary catheter who suffer from recurrent UTIs as previous antibiotic use may have led to resistant bacteria.
5. For the insertion procedure, all equipment will be gathered together and a private room/space be prepared for the procedure in order to keep the individual’s sense of dignity.
6. Choice of catheter material will depend on advice or prescription from the person’s GP, clinical experience, individual assessment and anticipated duration of catheterisation.
7. The selection of catheter type should only be undertaken by adequately trained staff and it is generally recommended clinically that the smallest gauge catheter that will allow free urinary outflow be selected.
8. The person will be encouraged to drink as much fluid as possible before and after the procedure.
9. The healthcare professional involved will wash their hands and put on sterile gloves.
10. The urethral area should be cleaned prior to the insertion of the catheter.
11. An appropriate lubricant from a single use container should be used to minimise urethral trauma and infection. Local anaesthetic such as lignocaine should be used, especially in males.
12. The appropriate size of catheter should be inserted and attached to a bag to allow for drainage to a sterile closed urinary drainage system.
13. The connection between the catheter and the urinary drainage system should not be broken except for good clinical reasons, eg changing the bag in line with the manufacturer’s recommendations. Antiseptic or antimicrobial solutions should not be added into urinary drainage bags.
14. After the procedure is complete the healthcare professional should remove their gloves and wash their hands. A new pair of clean, non-sterile gloves should be put on before manipulating a person’s catheter and hands should again be washed after removing these gloves.
15. If required clinically, a urine sample should be obtained from a sampling port using an aseptic technique.
16. Urinary drainage bags should be positioned below the level of the bladder on a stand that prevents contact with the floor. Where such drainage cannot be maintained, eg during moving and handling, a clamp should be applied to the urinary drainage bag tube and this should be removed as soon as dependent drainage can be resumed.
17. The urinary drainage bag should be frequently emptied to maintain urine flow and prevent reflux. A separate and clean container should be used for each person and disposed of appropriately.
18. If clinically necessary, urine output should be measured and the volume entered on a chart or in the person’s medical records.
19. Routine personal hygiene should be maintained.
20. If indicated, bladder irrigation, instillation and washout should be performed again by trained healthcare professionals.

Implications for Care Homes

A care home should have a policy for those circumstances in which people make use of catheters and where they are expected to be involved in some way with their catheter care. The following should apply.

1. Care workers who are expected to help with catheter care and catheterisation processes should have this part of their role written into their job descriptions.
2. The precise tasks which they are expected to carry out should be detailed on the person’s plan of care. These are likely to involve the emptying, changing and replacing of catheter bags and ensuring bags are correctly positioned and in working order. In some cases, care staff will be expected to monitor and record urinary output.
3. Care staff will not normally be expected to engage in the insertion of an indwelling catheter, which should be always carried out by a qualified healthcare professional. If there are exceptions made, it will be as a result of decisions by the responsible healthcare professionals, taking into account a comprehensive risk assessment, to delegate and train others to the level of equal competence. They will provide oversight for the practice of those who receive such training.
4. Care staff should only assist with the insertion of intermittent catheters, which are sometimes used on a self-administration basis. If this has been explicitly agreed, they are trained and competent in the procedures involved and they are supported and supervised by the responsible healthcare professional.
5. All catheter care tasks carried out should be recorded on the care plan and applicable monitoring forms.
6. No care staff should carry out any catheter care task without the necessary instruction and training in those procedures.
7. No care staff should be expected to carry out any procedure that is beyond their level of responsibility and competence.
8. All care staff who work with users who have catheters should have an understanding of the catheterisation process, irrespective of their involvement in any catheter care.
9. All care staff should be able to observe and report to the designated healthcare professional responsible for the person’s catheterisation and/or to their supervisor/line manager, if the user has any problems or difficulties with the catheters, if they are distressed or uncomfortable, if there appear to be risks of infection from catheter use and if there appears to be any incorrect use of the devices. For example, care staff involved in catheter care will need to make sure that:
   a. urine is flowing out of the catheter into the urine collection bag
   b. the catheter tubing does not become twisted or kinked
   c. the urine collection bag is kept below the level of the bladder
   d. the urine collection bag does not drag and pull on the catheter
   e. (where appropriate) they check for inflammation or signs of infection in the area around the catheter, such as pus or irritated, swollen, red or tender skin
   f. the area around the catheter is cleaned twice a day with water and dried with a clean towel afterward
   g. they do not apply powder or lotion to the skin around the catheter
   h. they do not tug or pull on the catheter
   i. the urine collection bag is hung in a safe place, such as on the side of the bed at night.
10. All care staff who work with users who have catheters must be rigorous about handwashing before and after they carry out any personal care task in order to prevent and reduce the risks of the user developing a urinary tract infection. This becomes of paramount importance when they are involved directly in catheter care procedures.
11. Care staff who provide personal care to someone who uses a catheter must ensure that he or she is able to keep their sense of dignity at all times.

Training

All care staff should read and understand the service’s catheter care policy and associated protocols and procedures. Catheter care issues will be included in the service’s induction programme where relevant. Training in any specific procedures to be used will be provided, which will include supervised practice.

Training will cover basic information about catheter care and general principles of catheter maintenance.

To be competent in the different aspects of catheter care, selected staff will be given the relevant training and refresher courses as appropriate and which are identified in individual appraisal and learning plans.

All care staff should be aware of the signs of sepsis, be able to recognise deterioration and have the confidence to escalate concerns appropriately.

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