EVIDENCE-BASED PRACTICE PROTOCOL

Management of Long-Term Indwelling Urinary Catheters

Definitions / Long-term: 30 days
Indwelling: drainage tube inserted into the urinary bladder through the urethra, left in place, and connected to a drainage system
Catheter-related urinary tract infection (CAUTI):
Must meet one of the following criteria:
1) 2 of the following AND urinalysis or culture not done
-Fever (2-4 degrees F or 1 degree C above baseline) or chills with no other source
-Flank pain OR suprapubic pain OR tenderness OR frequency OR urgency
-Worsening mental or functional function
-Changes in character of urine (blood, foul odor, increase sediment, etc.)
2) One of the following AND urinalysis/culture done
-Fever* or chills
-Flank pain OR suprapubic pain OR tenderness
(re: urinalysis/culture: bacteriuria – positive culture or positive nitrite assay;
pyuria – 10 or more wbc/hpf on urinalysis or positive leukocyte esterase assay)
Indications / -Bladder outlet obstruction or retention
-Healing sacral wound (pressure ulcer on trunk) in incontinent pts.
-Palliative end-of-life
Types of catheters / -Antimicrobial catheters not supported for effectively preventing CAUTIs
-Use smallest size (caliber)
-Silicone may be preferred in long term catheterized patients to prevent obstruction
Maintenance /
  • Maintain closed system – minimize disconnections; if change to leg bag, disinfect tubing with 70% alcohol
  • Routine hygiene (daily bathing; no antiseptics; see patient/family education)
  • Keep drainage bag &connecting tubing below level of bladder and off the floor
  • Proper securing to prevent movement & urethral traction
  • Empty bag regularly when 1/3-1/2 full making sure not to touch the spigot to the container or toilet – clean spigot with alcohol
  • Empty bag before bedtime
  • No regular use of topical antiseptic or antibiotics, chronic antibiotic suppressive therapy, routine cultures, saline irrigation

Changing the catheter (or drainage bag) /
  • Antiseptic conditions
  • Adequate lubricant
  • Inflate balloon with sterile H20 and amt. determined by manufacturer’s recommendations
  • Routine changing of catheter monthly based on Medicare beneficiaries and/or physician order; note that changing the catheter at regular intervals is not fully supported – need to adapt to individual patient based on infection, obstruction or when closed system compromised
  • Change drainage bag when catheter changed or more frequently for clouding, odor, or discoloration

Cleaning the drainage bag /
  • Bleach solution method preferred (decrystalizes sediment and inhibits bacterial growth) (mix daily): MUST TEACH SAFE HANDLING OF BLEACH
Wash hands before & after; disconnect bag from catheter; rinse tubing with tap water using a soft, plastic squirt bottle or turkey baster; mix 4 oz. bleach with 1 gallon tap water; pour solution into tubing/bag; avoid wetting the air vent located at top of drainage bag; agitate for 30 seconds; drain; air dry; store in closed container
  • Vinegar solution method if cannot use bleach safely: Follow directions above; instead, use ½ c. vinegar to 1 ½ cups tap water

Infection Related /
  • Most S&S for CAUTI are nonspecific; only obtain specimens if patient exhibits S&S since treatment should target symptomatic patients
  • No prevention for biofilm (layer resistant to acidic irrigants & antibiotics
  • Change catheter, then get urine specimen – 1) disinfect port with 70% alcohol & pat dry prior to withdrawing specimen; 2) can obtain specimen from newly inserted catheter by letting urine drain directly into cup before connecting tubing; 3) if catheter already connected to tubing, and no port, disconnect and disinfect with 70% alcohol; Do not obtain urine culture from drainage bag
  • Transport urine culture according to recommendations (room temperature with chemical preservation and test within 24-72 hours)
  • Urine culture before antibiotics
  • Treatment is based on symptoms (criteria) and organism
  • Use SBAR-CUS when communicating assessment findings to healthcare provider

Patient/family Education /
  • Wash hands with soap & running water
  • Avoid tension on the catheter and kinks; anchor catheter appropriately
  • Drainage bag below level of bladder
  • Fluids – 6-8 glasses/liquid/day – keep urine yellow
  • Avoid irritants such as caffeine, ETHO, etc.
  • Avoid constipation
  • Daily perineal cleaning with soap and water; front to back in females; start at tip in men; wash away from body down catheter
  • Shower unless contraindicated
  • Teach self-management – emptying the drainage bag; changing the drainage bag; switching from drainage bag to leg bag; cleaning and storing drainage bag; complications

Other / -If urethral catheter for 10 years, screen for bladder cancer
-Discuss possible transition to subrapubic catheter
-May consider belly bag
Documentation /
  • Urinary NDP
  • Narrative: if appropriate, catheter changed without difficulty; next change (once individualized)
  • Plan for next visit: culture results, teaching

NOTE: With silicone catheters, check the balloon inflation every 2 weeks

References:

Association of Professionals in Infection Control and Epidemiology (APCI). (2008). Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs)Developing and Applying Facility-Based Prevention Interventions in Acute and Long-Term Care Settings. APIC: Washington, DC.

Healthcare Infection Control Practices Advisory Committee (HICPAC). (2009). Guidelines for the Prevention of Catheter-Associated Urinary Tract Infections. CDC: Atlanta, GA.

Hooton, T. M., Bradley, S. F., Cardenas, D. D., Golgan, R., Geerlings, S. E., Rice, J. C., Saint, S., Schaeffer, A. J., Tambayh, P. A., Tenke, P, & Nicolle, L. E. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the infectious diseases society of America. CID, 50, 625-663.

National Association for Continence. (2010). When The Drainage System Is Changed Frequently. Accessed from

National Guideline Clearinghouse. (2009). Catheter-associated urinary tract infections. In: Guidelines on urological infections.

Smith, J. M. (2003). Indwelling Catheter Management: From Habit-based to Evidence-based Practice. Wound Ostomy Management, 49(12). Access from

Urinary catheters. Accessed from

VNAA genitourinary policies (i.e., Decontamination of Vinyl Urinary Drainage Bag; Sterile Urine Specimen Collection from a Foley Catheter; Urinary Catheter Care).

Wound Ostomy and Continence Nurses Society. (2009). Indwelling urinary catheters: Best practices for clinicians. Mt. Laurel, NJ: WOCN.

Urinary catheters; Sue Fowler & Kim Druist, 4/15/10; input from Anne Lefferts & VNAA clinical-qi listserve; reviewed, revised and approved by NRC 4/15/10

Approved by NRC 4/15/10 with minor changes; shared with NCP 6/2/10; shared with NCC 6/10/10Page 1