Evidence: care of urinary catheters and drainage systems | nursing times

A review to evaluate evidence on supporting clinical practice and ensuring best practice in the management of urinary catheter drainage systems AUTHORS Sarah Jones, MSc, FETC, RGN, is

continence adviser, West Kent PCT, and members of the South East Thames continence advisory group; Anthony Brooks, BSc, CertEd, DEN, RN, is highly specialist nurse continence adviser, East

and Coastal Kent PCT, Sue Foxley, RGN, is consultant nurse, King’s College Hospital NHS Foundation Trust, Judith Dunkin, RGN, is continence adviser, Hastings and Rother PCT. ABSTRACT Jones,

S. et al (2007) Care of urinary catheters and drainage systems. Nursing Times; 103: 42, 48–50. A question about the reuse of drainable urinary catheter night drainage bags in a patient’s

home promoted the South East Thames continence advisory group to examine the evidence for the management of urinary catheter drainage systems. The objective of this review was to establish

if there is evidence available to support clinical practice and provide recommendations to staff and patients to ensure best practice. Published and unpublished research, national and local

guidelines, and information provided by professional organisations were reviewed. The review was divided into six questions. RISKS OF CATHETERISATION Urinary catheterisation places a patient

at significant risk of acquiring a urinary tract infection (UTI) (Tew et al, 2005). Catheter-associated UTIs have been shown to prolong the length of hospital stay by 2.4 to 4.5 days

(Joanna Briggs Institute, 2000). It is estimated that the cost of treating a UTI is £1,327 per patient (Roadhouse and Wellsted, 2004), and that the minimum cost to the NHS in England of

catheters and catheter-related management products is approximately £40m a year, not taking into account the cost of associated drugs, bladder instillations or dispensing costs (Rawlinson

and Clark, 2004). FREQUENCY OF DRAINAGE BAG EMPTYING It is widely accepted that the main benefit of sterile, continuously closed urinary drainage is to delay if not to prevent the onset of

infection. Breaks in the system, such as unwarranted emptying or changing of the drainage bag, increase the risk of infection and should be avoided (Pellowe, 2004). However, there is little

guidance about when a urine drainage bag should be emptied. Stilwell (1992) advises that frequency of emptying will depend on the individual patient’s needs. Getliffe (1995) recommends

frequent emptying in order to prevent the drainage bag becoming too heavy and to minimise problems of urethral tissue trauma and inflammation. Although this advice is more specific, it is

still open to interpretation so it is therefore difficult to make clear recommendations based on this advice. Bissett (2005) suggests emptying the bag when it is no more than half full to

prevent backflow into the bladder. Penfold (1999) advises that the bag should be kept closed, except for emptying twice daily, or more often only if the bag is full. Others recommend every

4–6 hours (Toughill, 2005; Newman, 2002), or when it is three-quarters full (Coloplast, 2005). The NICE (2003) guidelines advise that ‘the urine drainage bag should be emptied frequently

enough to maintain urine flow and prevent reflux’, which is reiterated in the latest Epic guidelines (Pratt et al, 2007). This does not guide the caregiver to the optimum time for emptying

the bag. HOW SHOULD THE DRAINAGE BAG BE EMPTIED? The majority of articles emphasise the need for handwashing before and after contact with catheters and drainage bags, and the use of clean

non-sterile gloves (Pratt et al, 2007; CPHVA, 2005; Pellowe and Pratt, 2004; Wilson, 1997). Both Wilson (1997) and NICE (2003) specify the use of disposable plastic aprons to protect

clothing from exposure to body fluids, secretions or excretions. There was a greater consensus over the type of receptacle used to empty the drainage bag. Wilson (1997) recommends emptying

the bag into the toilet or into a clean receptacle, Stilwel (1992) suggests a container which is discarded or thoroughly washed (although does not specify how) and Penfold (1999) states that

the receptacle used should be sterile, or have been washed in a bedpan washer and dried. The Epic guidelines (Pratt et al, 2007) recommend a separate and clean container for each patient

and that contact between the drainage tap and container should be avoided. Only one other article emphasised avoiding this type of contact as well as ensuring that the tap does not touch the

floor (Stilwell, 1992). There is conflicting advice regarding contact with the tap before and after emptying. Stilwell (1992) recommends that the tap should be cleaned before opening, and

again afterwards, but does not specify how this should be done. Sienty (1999) states that ‘caregivers must be taught to keep the drainage bag spout from becoming contaminated’ but does not

say how this can be achieved. Wilson (1997), Penfold (1999) and Dougherty and Lister (2004) recommend that the outlet tap should be cleaned with a 70% isopropyl alcohol swab before opening

and after closing. Epic2 (Pratt et al, 2007) does not mention handling of the tap. CARE OF THE REUSABLE DRAINAGE BAG WHEN NOT IN USE When a reusable night drainage bag is not in use within

the patient’s own home, rinsing out the bag with a diluted bleach solution was frequently recommended (Madigan and Neff, 2003; Nash 2003; Newman, 2002). There were also recommendations to

clean and deodorise with distilled vinegar (Toughill, 2005; Washington, 2001), and to wash or rinse out with soap and/or water and allow it to dry thoroughly (Coloplast, 2005; Roe, 2001).

Coloplast (2005) reminds the user to replace the dust cap after rinsing. Tew et al (2005) make no recommendations but guide the caregiver to follow the manufacturers’ guidelines.

Interestingly, Toughill (2005) comments that cleaning of the bags remains controversial and Pomfret and Mackenzie (2005) question the practice and highlight the need for further research.

HOW LONG CAN THE DRAINAGE BAG BE USED FOR? Most of the articles reviewed recommend that reusable urine drainage bags are changed every five to seven days (Pomfret, 2006; Pellowe and Pratt,

2004). The Association for Continence Advice (2007) suggests that reusable drainage bags are changed every 5–7 days in accordance with manufacturers’ recommendations and Department of Health

guidelines. However, Madigan and Neff (2003) suggest that a bag can last up to four weeks if decontaminated daily with a 1:10 diluted bleach solution. Tew et al (2005) is less helpful,

suggesting that a drainage bag should be changed when clinically indicated, and Roe (2001) recommends reusing as per local policy or guidelines. The Epic2 guidelines (Pratt et al, 2007)

advocate that ‘the connection between the catheter and the urinary drainage system is not broken except for good clinical reasons, for example changing the bag in line with the

manufacturers’ recommendations’. MEATAL CLEANSING Meatal cleansing has always been considered an important area of catheter hygiene; however, there is little conclusive evidence as to best

practice. Various techniques have been tried in the past including antibacterial creams, antiseptic solutions and four-hourly meatal care. The latest Epic guidelines (Pratt et al, 2007)

suggest that ‘vigorous meatal cleansing is not necessary and may increase the risk of infection, and that daily routine bathing or showering is all that is need to maintain meatal hygiene’.

LOCAL PRIMARY CARE GUIDELINES The authors of this article also wanted to investigate if other continence caregivers were experiencing similar difficulties in establishing evidence-based

catheter care. Guidelines from 20 randomly selected PCTs in England were compared using set criteria. No consensus was evident about when a bag should be emptied. There was an even split

between recommendation for two-thirds full, three-quarters full, enough to maintain flow and prevent reflux ‘when it felt it was straining’ and ‘when almost full’. All 20 local primary care

guidelines recommended washing and drying of hands before and after emptying the bags, and the use of gloves and plastic aprons if the task is performed by a health worker. Again, all of the

trusts’ guidelines recommended taking care not to contaminate the tap by avoiding contact with jugs or emptying receptacles. However, they differed in their advice on if or how to dry the

tap mechanism afterwards. Three of the trusts recommended using an alcohol wipe, while four suggested wiping the tap, another four advised wiping the tap with tissue paper, and the remainder

suggested ensuring that the tap was closed. Most of the trusts advocated the use of reusable night bags for clients who cared for themselves in their own homes; however, care of the bags

when not in use varied. Some of the trusts suggested rinsing with water, and some with detergent and water. Some advocated draining and drying the bag with the lower tap open, while others

merely mentioned that the upper connection should be capped. Interestingly, none of the reviewed guidelines suggested using bleach or other disinfectants to clean the bag. The general

consensus from all of the guidelines studied was that leg bags should be worn for up to seven days, unless the bag becomes disconnected, when it should be replaced with a new sterile one.

Three of the trusts recommended disposable, single-use night bags, regardless of a client’s residential status. All of the guidelines recommended maintenance of good personal hygiene – 80%

suggested using soap and water to wash for meatal cleansing and most recommended daily washing. However, 50% of them recommended that talcum powder and creams or lotions should be avoided,

while only one trust specified the use of a disposable washcloth for personal hygiene. One trust recommended meatal cleansing after every bowel action. SUMMARY There is a lack of uniformity

in the evidence guiding the care of urinary catheters and their drainage. There is also a considerable variation in the recommendations for how often the drainage bag should be emptied,

allowing the caregiver freedom in their interpretation. The technique for emptying the drainage bag is described in most of the literature, allowing a more objective summary to be developed

and translated into an evidence-based guideline. There are conflicting opinions about the care of reusable drainage bags when they are not in use. Therefore translating this into care

remains a challenge. The life of the reusable night drainage bag is unclear and the latest Epic guidelines (Pratt et al, 2007) have recommended that the bag is changed according to the

patient’s need or the manufacturer’s recommendations. This advice is likely to continue to allow subjective interpretation, hindering the development of evidence-based guidelines. There does

appear to be a degree of uniformity about meatal cleansing practice, although conclusive evidence supporting the approach was limited. The small review of randomly chosen PCT guidelines

would appear to demonstrate the need for further research in order to consolidate standards and information into a thorough and comprehensive evidence-based guideline. CONCLUSION The authors

of this study had hoped to develop and/or update their guidelines for catheter care and drainage systems, ensuring that they were based on current evidence. Although the Epic2 guidelines

(Pratt et al, 2007) are based on the ‘best currently available evidence’, the Epic notice board recognises that ‘this is not always the best possible evidence’ and has included suggestions

for further research in each section. It is essential that the use of indwelling urinary catheters is restricted unless absolutely necessary and that measures known to be effective in

reducing the risk of infection be rigorously and consistently applied. As a result of their findings, the authors question whether it is safer to use clean, single-use non-drainable night

bags in all patient areas, despite the risk posed by the fact that these bags are not sterile and also have an environmental impact as seven bags are required per week instead of one. More

research is needed to ensure that guidelines and resultant care are based on current evidence rather than custom and practice. BOX 1: QUESTIONS ABOUT MANAGING URINARY CATHETER DRAINAGE * How

often and when should a catheter drainage bag be emptied? * How should the drainage bag be emptied, including handling of the tap? * How should a reusable bag be cared for when not in use?

* How long can the drainage bag be used for? * How should meatal cleansing be performed? * What do local primary care guidelines on catheters and drainage bags advise? REFERENCES Association

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