EVIDENCE-BASED PRACTICE PROTOCOL
Management of Long-Term Indwelling Urinary Catheters
Definitions / Long-term: 30 daysIndwelling: 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
- 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