It has never been the most glamorous piece of medical equipment, but a growing older population, rising rates of obesity and a higher number of surgical procedures mean that the demand for catheters has never been greater. And, it doesn’t end here; the global catheter market is expected to rise 8.1% between 2017 and 2023 (Global urinary catheter market 2017–2023, 2017).

Catheters have been used to drain poorly emptying bladders for 3,500 years (Feneley et al, 2015). Indwelling catheters are inserted into the bladder via the urethra, whereas suprapubic catheters are inserted into the bladder via the abdomen, just above the pubic bone. While the design has moved on somewhat since Egyptian times, the catheter design that most nurses are familiar with has remained basically the same since it was designed by Frederic Foley in 1929 — a long flexible plastic tube with an inflatable balloon that holds the catheter in place in the bladder.

A catheter should only ever be used as a last resort after the nurse has undertaken a thorough assessment to identify the cause of the patient’s bladder dysfunction. In most cases, catheters are employed for short-term use and can be left in situ for anything from a few minutes to a few days. However, in 2015, figures showed that 90,000 people required an indwelling catheter for three months or more (BBC news, 4 July 2015 — ‘Industry “must do more” to improve urinary catheters’). For patients with permanent conditions which can result in the patient having no bladder control, such as spinal cord injury or multiple sclerosis, the use of an intermittent catheter may be a lifelong measure.

And yet, despite its prevalence in both hospital care and in the community, there is still controversy surrounding catheter use. This mainly focuses on when catheters should be used and for how long, how to manage them in situ and how to ensure patients who are fitted with a catheter are made comfortable and assisted to retain their dignity. While many of these issues are the result of poor clinical assessment, the lack of innovation in the design of catheters themselves is also a concern. A catheter should only ever be used as a last resort after the nurse has undertaken a thorough assessment to identify the cause of the patient’s bladder dysfunction. In most cases, catheters are employed for short-term use and can be left in situ for anything from a few minutes to a few days. However, in 2015, figures showed that 90,000 people required an indwelling catheter for three months or more (BBC news, 4 July 2015 — ‘Industry “must do more” to improve urinary catheters’). For patients with permanent conditions which can result in the patient having no bladder control, such as spinal cord injury or multiple sclerosis, the use of an intermittent catheter may be a lifelong measure.

TREADING WATER

Unlike drugs, which are often redesigned and rebranded, or medical equipment such as scanning or diagnostic equipment, which is regularly modernised to increase patient comfort, the basic design of the catheter has changed very little in the past 80 years. In 2015, Mandy Fader, professor of continence technology at the University of Southampton, called on ‘industry to wake up and invest more heavily in new catheter designs and materials that resist infection’ (BBC news, 4 July 2015 — ‘Industry “must do more” to improve urinary catheters’).

Updating the basic catheter design isn’t just about aesthetics. As well as the potential trauma involved in encrustation and subsequent blockages, catheters present a very real infection risk. Catheter-associated urinary tract infections (CAUTIs) are one of the most common healthcareassociated infections (Nicolle, 2014), costing the NHS £1–2.5 billion per year and accounting for around 2,100 deaths (Feneley et al, 2015).

However, it’s not only a lack of innovation that accounts for the risks involved in catheter care: patient education and the role of nurses in passing on best practice also has a case to answer.

According to National Institute for Health and Care Excellence (NICE) guidelines, the risks associated with catheters are greatly reduced with best practice (NICE, 2017). This includes nurses understanding when a catheter is appropriate; being familiar with catheter maintenance; and knowing that the catheter should be removed when it is no longer necessary. Nurses also need to be aware of the advice that they need to pass on to patients. For example, the catheter must be kept clean during bowel movements, especially in those people who have less control over their bowels and risk faecal matter coming into contact with the catheter.
Karen LoganCatheters are internal devices which can cause considerable harm and risk to patient safety. However, some people require them in the short term following surgery, or long term due to an inability to empty the bladder. When catheters block, they cause an emergency situation, impacting on the patient’s wellbeing and nursing resources. Catheterisation and catheter care is every nurse’s business and is a significant component of the community nurse’s work, with large numbers of catheterised patients on caseloads. Hospital nurses can be challenged by this aspect of care and fail to remove catheters in a timely fashion, or to plan adequately for the discharge of the catheterised patient. The introduction of catheter passports is a welcome development and should be embraced by hospital and community nurses alike to improve discharge communication, documentation and outcomes for patients. Used in conjunction with evidence-based catheter care bundles, they have the potential to significantly improve practice, and thus contribute to the campaigns to reduce CAUTIs and unplanned admissions, facilitate timely reviews, and expedite early catheter removal — in short, to improve general catheter management and outcomes for patients.

 
Karen Logan OBE, nurse consultant, Aneurin Health Board
June RogersIntermittent catheterisation — the reusable debate Intermittent urethral catheterisation has a very long history, however it was not until 1949, at Stoke Mandeville, that it began to be performed by nurses as a matter of routine as a sterile ‘no touch’ procedure (Guttmann and Frankel, 1966). Intermittent catheterisation continued to be undertaken as a sterile procedure until 1970 when Lapides (1972), after finding that a patient had admitted dropping her catheter which was therefore no longer ‘sterile’, realised that using a ‘clean’ technique only did not apparently increase the infection risk.

The initial catheters used for clean intermittent catheterisation (CIC) were reusable plastic or rubber ones, with a water-based lubricant applied as necessary, and washed in between use. This practice of reusing catheters continued until the 1980s when the first hydrophilic single-use catheters were produced. Later on, a wide range of catheters for single-use were developed and this soon became the norm, particularly within the UK.

However, in some countries, the spiraling costs meant that singleuse catheters were not becoming a viable option and many reverted to reusing catheters. This caused a debate as to whether single-use catheters were worth the extra cost, as there was an opinion that there was no difference of increased risk of infection between single- or reusable catheters.

To try and address this issue, Cochrane carried out a review in 2014 to evaluate and compare the infection risk of the two methods of catheterisation (Prieto, 2014). They concluded that: ‘... there is still no convincing evidence that the incidence of UTI is affected by use of aseptic or clean technique, coated or uncoated catheters, single (sterile) or multiple-use (clean) catheters, self-catheterisation or catheterisation by others, or by any other strategy.’

However, in 2017, this review was withdrawn following peer review feedback which felt that their own clinical experience did not reflect the findings of the review (Christison et al, 2017). Christison et al (2017) also voiced concerns regarding the handling of cross-over and multi-arm trials, as well as corrections and clarifications of data used. These issues are currently being addressed, as well as changes that are required to reflect current methodological standards.

It is now suggested that until evidence can conclusively demonstrate that catheter reuse is as safe as single-use, healthcare professionals should advocate the latter. This is important, as currently there is no standardised and universally accepted cleaning method for catheters, which would be the prerequisite for safe multiple use — the debate continues!

 
June Rogers MBE, specialist continence advisor, Bladder & Bowel UK
As well as the risks involved in having a catheter in situ, many people are embarrassed by the lack of dignity involved. This can impact on a person’s quality of life, leaving them isolated at home and fearful of socialising in case they experience a leak or find that their drainage bag is visible under their skirt or through their trousers, for example.

Everyday activities such as swimming or sexual intercourse may have to be put on hold for the duration of the catheterisation, which can add to an individual’s distress. In December 2017, a nursing home in High Wycombe was put into special measures due to ‘undignified care practices’. One male resident was discovered walking around with his trousers rolled up to his knees and his drainage bag clearly visible; another resident sat in a chair with their drainage bag resting on the carpet (http://bit.ly/2Bz2VtN).

Following best practice in catheter care is literally a matter of life and death. In December 2017, an 87-year old woman living in a nursing home in Clacton, Essex, died after staff failed to notice her catheter was blocked. She was found to have retained two litres of urine (http://bit. ly/2C0RJHJ).
 

MORE IS NOT NECESSARILY MERRIER

Not all catheters are necessary. Approximately one-quarter of patients admitted to hospital are fitted with a catheter and in 30–50% of cases, the clinical rationale is unclear (Loeb et al, 2008). Often, as a result of lack of knowledge and poor assessments, catheterisation is treated as a routine intervention, undertaken as casually as inserting a cannula or recording a patient’s blood pressure.

The first question a nurse needs to ask when considering a catheter, particularly an indwelling catheter, is: ‘Does my patient need this?’ Nurses need to investigate whether a less invasive alternative could be used, for example, would conservative methods such as pelvic floor exercises, bladder retraining, or teaching a patient or carer to employ intermittent self-catheterisation, be more effective?

Of course, this is not easy — properly assessing a patient’s suitability for a catheter requires the completion of a full assessment including measurements of the patient’s post-void residual urine and a frequency/volume chart. But, while nurses are all busy, there is no excuse for failing to perform a comprehensive assessment before considering such an invasive procedure as a catheterisation. After all, it is thought that improved catheter care can reduce the rate of CAUTIs by 30% (Academic Health Science Network [AHSN], 2016).
Brenda CheerThe child’s perspective
The incidence of Foley catheter use in children is far less than in adult practice, but the risks from improper use are the same, if not more significant.

Excellent paediatric leg bags are now available, so why do we still see children on hospital wards with adult-sized, long-tube leg bags, or even worse, night bags or urometers trailing behind them as they walk down the ward? For those of us who work in the field, using a paediatric product is obvious:
  • It promotes acceptance in the child – e.g. child-friendly images on bags places them reassuringly in the same category as toys, rather than scary hospital equipment
  • It reduces clinical risk — as the child recovers and becomes more active, a long loop of inadequately secured tubing is highly likely to get caught in a toy/buggy/cot side.
So, why are paediatric leg bags not universally used? I’m guessing at least in part because of ignorance; general nurses simply don’t know they are available. However, it is the responsibility of specialists in the field to share their knowledge and awareness of products.

Although in recent years we have seen some children’s catheter accessories coming onto the market, what is apparent to us at ERIC is that there is very little investment in the field of paediatric continence; it is the ‘poor relation’ that attracts little interest or support. With regard to catheters themselves, the only concessions toward child users are smaller charrière sizes and shorter lengths. Is that sufficient? If manufacturers respond to Professor Fader’s criticism of their attention to innovation and improvement, will they remember that children are not just little adults?

 
Brenda Cheer, ERIC nurse, The Children’s Bowel & Bladder Charity
Determining whether a patient requires a catheter is the first step in improving care. There are protocols designed for this very purpose, for example, nurses can use the HOUDINI anagram to identify the reasons why a catheter should be used (Houghton, 2017):
  • If none of these factors are involved, the nurse should consider removing the catheter. If the nurse decides that a catheter is necessary, it should be removed as soon as possible and not left in situ simply because it is more convenient for the healthcare staff.
  • H: haematuria
  • O: obstruction (urinary)
  • U: urology surgery
  • D: pressure ulcer (open sacral or perineal wound in an incontinent patient)
  • I: input and output monitoring being performed
  • N: not for resuscitation; nursing management for end-of-life care
  • I: immobility.
If none of these factors are involved, the nurse should consider removing the catheter. If the nurse decides that a catheter is necessary, it should be removed as soon as possible and not left in situ simply because it is more convenient for the healthcare staff.

PASSPORT TO IMPROVING CARE

Catheter passports are documents that provide information for patients on how they should care for their catheter at home, as well as including a section for healthcare staff and carers to record catheter changes and maintenance. Catheter passports can improve communication between primary and secondary care services, where often the rationale for a catheter insertion has not been adequately communicated. Catheter passports can also promote self-care among patients, improve communication between patients and nurses and help patients to adjust to living with a catheter (Jaeger et al, 2017). One study found that using a catheter passport not only helped patients to cope at home, but also assisted nurses who wanted to increase their catheter care knowledge (Jaeger at al, 2017).

Providing a catheter passport is particularly important on discharge, as many patients leaving hospital with a catheter do not have enough information about how to care for the equipment at home, which can lead to physical and psychological issues. For example, full drainage bags can ‘drag’ on the catheter, which is uncomfortable for the patient and increases the risk of the catheter being torn out. Similarly, it is essential that patients leave hospital with the correct length of drainage bag tubing; for example, men may want longer tubes so the drainage bag can be secured below the knee, while women may require a shorter tube so it fits to their thigh.

Many patients are also discharged without leg socks, which can hold the drainage bag in place more comfortably. Stabilisation devices that secure the catheter discreetly with foam anchor pads are also available.
Brenda CheerAll urologists will welcome articles such as this one that increase the awareness of healthcare professionals and patients to the correct use of urinary catheters.

It is not controversial to claim that no one wants to have a catheter, that is until you can’t pass urine! Retention of urine is not only very painful but also potentially lifethreatening. Seeing the immediate relief of pain by draining the bladder with a catheter is wonderfully satisfying for the healthcare professional who inserts it, never mind the patient. How humans managed without catheters beggars belief. Egyptians used reeds that they found along the river Nile.

Modern catheters are designed to be comfortable and avoid complications, such as infection and blockage. However, the longer a catheter is in place, the more likely problems will occur. So, this article is correct to encourage more education on the correct use of catheters, on how to avoid complications, and how to treat them should they occur. So much suffering and cost could be avoided with good training. As a general principle, catheters should be avoided unless absolutely essential. If they are used, they should be used properly and expert advice taken on how to sort out the problem necessitating their use in the first place.

 
Alan Doherty, consultant urologist, Birmingham Prostate Clinic

THE FUTURE

The catheter is here to stay, but its current design faces much criticism. Feneley et al (2015) echo Professor Fader’s insistence that there is an urgent need for the development of an alternative indwelling catheter system, which:
  • Is safe, easy to insert, either urethrally or suprapubically
  • Can be retained reliably in the bladder
  • Can empty without damage to the bladder
  • Has control mechanisms appropriate for all users.
Whether we’ll have to wait another 80 years for this to happen is yet to be seen.

References

Academic Health Science Network (2016)
Catheter care improvement programme brings about 30% reduction in infection rate. Available online: http://atlas. ahsnnetwork.com/catheter-careimprovement- programme-brings-about- 30-reduction-in-infection-rate/

Christison K, Walter M, Wyndaele JJM, et al (2017) Intermittent catheterization: The devil is in the details. J Neurotrauma 6 Nov [Epub ahead of print]

Feneley RC, Hopley IB, Wells PN (2015) Urinary catheters: history, current status, adverse events and research agenda. J Med Eng Technol 39(8): 459–70

Global Urinary Catheter Market (2017– 2023) — Increasing incidences of urinary incontinence to drive growth — research and markets. Available online: www.businesswire. com/news/home/20171115005759/en/Global-Urinary-Catheter-Market- 2017-2023---Increasing

Guttmann L, Frankel H (1966) The value of intermittent catheterization in the early management of traumatic paraplegia and tetraplegia. Paraplegia 4(2): 63–84

Houghton M (2017) Urinary Catheter Care Guidelines. Southern Health NHS Foundation Trust. Available online: www. southernhealth.nhs.uk/_resources/ assets/inline/full/0/70589.pdf (accessed 15 February, 2018)

Jaeger M, Fox F, Cooney G, Robinson J (2017) A qualitative study exploiting the value of a catheter passport. Br J Nurs 28(15): 857–66

Lapides J, Diokno AC, Silber SJ, et al (1972) Clean intermittent self-catheterization in the treatment of urinary tract disease. J Urol 107: 458

Loeb M, Hunt D, O’Halloran K, et al (2008) Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med 23(6): 816–20

National Institute for Health and Care Excellence (2017) Healthcare-associated Infections: Prevention and Control in Primary and Community Care. Clinical guideline 139. NICE, London

Nicolle LE (2014) Catheter associated urinary tract infections. Antimicrob Resist Infect Control 3: 23.

Prieto J, Murphy CL, Moore KN, et al (2014) Intermittent catheterisation for long-term bladder management. Cochrane Database Syst Rev. 2014 Sep 10;(9):CD006008


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