Here are the questions and answers from our experts. We will be updating this page as we receive new questions and answers. Q. I am working in neurosurgery intensive care unit. We have 22 beds and almost all patients are travelling from one test to another. Like CT scan to angiogram or MRI, some times patient stay in angiogram for almost 6-8 hours especially when intervention are done like coiling of aneurysm. Were averaging almost 300-400x travel per month. I know that we have to place the Foley catheter below the bladder but what happening is that foleys are placed on the bed or ct scan table . One of the staff suggested clamping the folly during transport…. It will be very hard not to forget to unclamped and cause more urinary retention. What can you advise for us to do to prevent CAUTI specific for the unit.A. The catheter bag should be emptied prior to transport, kept below the bladder during transport and during the test; the bag should be emptied again before transport back. This will require planning and coordination of personnel. Clamping that catheter is an option, but as you pointed out it could be forgotten (especially during shift changes). The bag should also have an anti-reflux feature. James Marx, RN, MS, CIC Q. What do you recommend using for prep solution for the patient that is allergic to betadine or iodine? A. The CDC UTI prevention guide found: Moderate-quality evidence suggested no benefit of antiseptic meatal cleaning regimens before or during catheterization to prevent CAUTI. This was based on no difference in the risk of bacteriuria in patients receiving periurethral care regimens compared to those not receiving them. One study found a higher risk of bacteriuria with cleaning of the urethral meatus-catheter junction (either twice daily application of povidine-iodine or once daily cleaning with a non-antiseptic solution of green soap and water) in a subgroup of women with positive meatal cultures and in patients not receiving antimicrobials. Periurethral cleaning with chlorhexidine before catheter insertion did not have an effect in two studies. It goes on to say, Further research is needed on the use of antiseptic solutions vs. sterile water or saline for periurethral cleaning prior to catheter insertion. Based on this information, if the patient is allergic to betedine, you might consider antibacterial soap and water or chlorhexidine solutions that can be used on mucus membranes. James Marx, RN, MS, CIC Q. Are there any good training videos on catheter insertion in the A. I reviewed a number of websites with free videos detailing urinary catheter insertion in both males and females. None of the videos addressed urinary catheterization in the OR. A number of websites have written step-by-step procedures for urinary catheterization, while still others provide downloadable videos at no cost. Several options are listed below, but none of the procedures are performed in the OR. AORN does not include this topic in their list of videos available for purchase either. Here are three examples of better quality free videos available for viewing on-line via the internet – (2006) Thomsen, T.W & Setnik, G.S. Male urethral catheterization. The New England Journal of Medicine, Vol. 354:e22, No. 21 (2008) Ortega, R., Ng, L., Sekhar, P., & Song, M. Female urethral catheterization. The New England Journal of Medicine, Vol. 358:e15, No. 14. Urethral Catheterization – free video June Marshall, MS, RN, NEA-BC Q. I want to know when and how often should a Foley catheter be changed, if you can give me any evidence-based study data so I can convince the doctors here who wants them changed every two weeks. A. What we know is that 25% of patients requiring a urinary catheter for >7 days will develop hospital-acquired urinary tract infections and an individual’s risk of infection increases daily by >5%. The most potentially modifiable risk factor for CAUTI is prolonged catheterization, and by the 30th day of catheterization infection is almost universally present. The SHEA/IDSA Practice Recommendations do not support routine catheter changes. One small study of 54 patients suggests that replacing chronic indwelling urinary catheters in patients prior to initiating antimicrobial therapy improves patient outcomes by more quickly reducing febrile status and lowering the rate of symptomatic relapse of UTI following therapy. Interventions aimed at reducing CAUTI need to be focused on reducing the length of catheter dwell times whenever possible and defining clear indications for insertion and continuation of indwelling urinary catheters. When healthcare professionals anticipate that patients will require urinary catheters for greater than 7 days, the choice of catheter material such as silver alloy coated catheters may be considered as an option for reducing bacteriuria. References: June Marshall, MS, RN, NEA-BC Q. Several guidelines suggest changing it is prudent to change a catheter bag should the bag hold offensive urine. Does this apply to Flip Flow valves bearing in mind the offensive urine is like to be infected and therefore the bladder would be filling up with potentially infected urine, Would the be good practice or would it be better to change the catheter and the flip flow valve.I have been asked to convert a catheter bag to a flip flow valve, and had previously the day before changed the catheter bag, and sent off a catheter sample of urine, so what is the best practice in this scenario - can the panel advice. A. Changing the entire device (catheter, bag,, and value) is a prudent strategy when you suspect an infection or have an obstruction. Invasive devices like urine catheters develop a biofilm, which allow bacteria a place to grow. Routine changes do not seem to prevent infection, but when one is suspected, all components should be changed. Leg bags, such as the one you describe pose additional infection prevention challenges. While designed to be reusable, the disinfection of the bag is important, Teaching the patient/family proper disinfection practice is critical. Diluted bleach is probably the most effective product, if it can be safely handled. See http://www.public.asu.edu/~cbaldwi1/swborderlands/Cleaning_the_Urinary_Drainage_Bag.pdf James Marx, RN, MS, CIC Q. I am trying to find the latest recommendation on the use of sterile drapes while inserting a foley. Our local nursing faculty is not teaching students to use the underpad drape or the fenestrated drape on either male or female for foley insertion. I am reluctant to give up these barriers. Which is correct, and if the drapes are not needed, what is the rationale? A. The draft CDC CAUTI Prevention Guideline, 2008, does address training and technique for insertion of indwelling urinary catheters. For the latter there is a general term that this be done aseptically and with Russell Olmstead, MPH, CIC Q. What are acceptable indications to keep a catheter in?? Many are obvious but is the need for close monitoring of I & O's acceptable? Indications for urinary catheterization are listed below - these are from the draft CDC CAUTI Prevention Guideline, 2008 - the final version Accurate monitoring of input and output does meet one of these. Generally this is directed to patients in ICUs and not necessarily for
Russell Olmstead, MPH, CIC Q. I relieved on a case for lunch as a circulating nurse and the case was a placement of a sling for stress incontinence. The surgeon puts a foley catheter in at the beginning of the case where it stays in until the end of the procedure. The surgeon removes it and keeps it in his sterile field and does a cystoscopy to check his sling placement. This procedure is done vaginally. After he finished the cystoscopy he reinserted the same foley. I could not believe this had just happened and when I questioned it the surgeon said the catheter remained sterile on his field . It was a closed system. The nurse anesthestist in the room who does an abundance of these cases states this is normal procedure for this surgeon. My circulating nurse says it was her first experience with this case and did not know he was going to do this. My scrub tech stated he always does this. A. This is an interesting question. To the best of my knowledge there is no published investigation on the safety of this practice vs. use of a new sterile indwelling urinary catheter for each entry. The mucous membrane through which the catheter is introduced is not sterile and applying the Spaulding classification the device that enters need only be high level disinfected. I suspect the time between the sling creation and then reentry with the catheter is short. Also, the fact that this device is used on the same patient does not violate FDA labeling directions - i.e. single patient use. I don't know if the risk of infection from this current practice is any greater than using a sterile straight intermittent catheter but I'd recommend first raising the possibility of using a sterile straight catheter with the surgeon. Next, review the label of the indwelling urinary catheter. It may have specific instructions for use, e.g. only insert once and then discard after clinical need is fulfilled. Overall, while this sounds questionable, I think one would be hard pressed to show outcomes of catheterization are compromising patient Russell Olmstead, MPH, CIC Q. In a client in long term care with an indwelling uretheral catheter that develops a UTI, how soon after initiation of antibiotics should the catheter be changed? A. There is no science that addresses this question, but it would be prudent to change the catheter BEFORE starting antibiotics if the catheter may be the source of infection. Antibiotic treatment may not be effective in killing the bacteria living in the biofilm of the catheter. You should evaluate the need to continue the use of an indwelling catheter and remove it if possible. There are several alternatives to an indwelling catheter, such as a proper management of the incontinent patient, the use of a condom catheter (males only), intermittent catheterization, or a suprapubic catheter. James Marx, RN, MS, CIC Q. How do we reduce UTI rates in long term ventilated sedated patients where removing them is not an option? A. Long term ventilation with sedation is not an indication for a indwelling urine catheter. Incontinence can be managed in unconcious patients without adverse outcomes, such as pressure ulcers. It requires vigilant nursing care, including the use of barrier cream, pads, and adult briefs. Do not use an indwelling catheter to manage incontinence-- it puts the patient at risk of a urinary tract infection. If the patient has a medical indication,such as a neurgenic bladder, then a suprapubic(SP) urine catheter should be consider. SP catheters carry a lower risk of infection than an indwelling catheter. With male patients, a condom catheter can be considered. Another alternate is intermittent straight catheterization,which also carries a lower risk of UTI than an indwelling catheter. This program works best with the use of an ultrasound bladder scanner with perimeters for catheterization. James Marx, RN, MS, CIC Q. What is your opinion on the relationship between catheter securement devices and acquisition of a UTI? A. While the evidence states that there is no significant reduction in infections due to securing, there is an increase in comfort and less bladder neck irritation and inadvertent catheter removal. Catheter straps are now more comfortable, as they are wider and made of more comfortable materials. Catheters should be secured to the thigh in women. There is some disagreement as to whether the strap should be secured to the abdomen or thigh in men. Stabilizing the indwelling urinary catheter can prevent or reduce the risk for multiple adverse events, such as accidental dislodgement, as well as tissue trauma and inflammation induced by excessive traction of the tubing or drainage bag. Although stabilization cannot prevent all complications associated with urinary catheter, the value of this practice is exemplified by its inclusion as a category 1 (strongly recommended for adoption) recommendation in the 1981 CDC Guidelines for Prevention of Catheter-Associated Urinary Tract Infections. B.J. Reid Czarapata, RN, CRNP, CUNP
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