A catheter is a flexible, hollow tube that is inserted into the bladder either via the urethra or via the abdomen (supra pubic) in order for urine to drain. It is kept in place with an attached balloon that is inflated using sterile water. It has been estimated that, in the UK, more than 90 000 people have a long-term catheter in situ (Gage et al, 2017). Catheters are rarely free of complications, and it is paramount that a thorough assessment be performed and all other options explored prior to their insertion. There are many problems that can occur as a result of catheterisation. Some of the more common ones are detailed below, and these rarely occur in isolation:
In 2014, the National Institute for Health and Care Excellence (NICE) produced guidelines for infection prevention and control, which recommended that an indwelling catheter should always be connected to a sterile closed urinary drainage system, and disconnection should be avoided unless it was clinically indicated (NICE, 2014). This is further supported by the epic3 guidelines (Loveday et al, 2014) for preventing CAUTIs and in the more recently updated guidelines published by NICE (2017).
Catheter maintenance solutions
In recent years, catheter maintenance solutions (Table 1) have been used primarily to minimise the effects of recurrent encrustation and blockage (Shepherd et al, 2017). A catheter maintenance solution is a prescription-only sterile solution that can be used to extend the lifetime of an indwelling urinary catheter by maintaining its patency. Older literature often refers to these solutions as ‘bladder washouts’. However, it is important to note that at no point should these solutions enter the bladder. Their primary purpose is to clear any build-up within the catheter. Citric acid solutions ‘G’ and ‘R’ have been found to potentially dissolve encrustation, but it has also been identified that they should be used with caution, as their benefits may be outweighed by inflammatory tissue reactions (Getliffe, 2003).
| Advantages | Disadvantages | |
|---|---|---|
| Solution G (3.32% citric acid) (e.g. Uro-Tainer Twin SUBY G, OPTIFLO G) |
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| Solution R (6% citric acid) (e.g. Uro-Tainer Twin SOLUTIO R, OPTIFLO R) |
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| Solution S (saline) (e.g. Uro-Tainer NaCl, OPTIFLO S) |
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There is very little else in the way of evidence that can be used to highlight any potential benefits or cautions of the use of these solutions. Recent guidelines provided by the Royal College of Nursing (RCN) on catheter care (2019) recommended that the use of these solutions should be based on individual assessment, where many factors need to be taken into consideration, for example, have other options of management been considered, such as different types of catheters, have earlier routine changes of catheter been attempted and has the cause of the blockage been determined? This is supported by NICE guidance (2014). Each time a maintenance solution is inserted into an indwelling catheter, the closed system of drainage is broken. Therefore, there is a potential to introduce infection each time a catheter maintenance solution is administered. Reducing the inappropriate usage of these solutions will probably help reduce the incidence of CAUTIs.
Evidence suggests that catheter maintenance solutions are relatively ineffective (Turner and Dickens, 2011). Very few studies investigate catheter patency solutions, and these studies are often biased and of poor quality; yet, these solutions are used within primary and community care on a daily basis. A recent Cochrane review (Shepherd et al, 2017) reported that there was no robust evidence either for or against the use of catheter maintenance solutions. The systemic review was performed in 2016 and included only seven papers. Other papers were excluded due to bias, poor methodological quality or poor reporting. Sheperd et al (2017) further mentioned a need for a large, rigorously designed randomised controlled trial, but no such research has been undertaken to date.
Centralised prescription service
In 2015, a centralised prescription service was set up within a South Wales health board to assess, review and prescribe containment aids. Prior to this service being set up, all containment aids were prescribed through GP surgeries and via both community nursing staff and GPs themselves. The aim of the service was to centralise prescriptions for these products and allow for routine assessments from trained specialist nurses who work within the community continence service. During these assessments, many aspects are reviewed, such as the appropriate usage of products, whether there is a need for a change in products, patient satisfaction and any ongoing management. The service also allows patients, relatives and carers easy access to sound advice, either via a telephone conversation or in person during a clinic appointment or home visit. At present, the service comprises a clinical lead nurse, one band 7 continence nurse specialist, two part-time band 6 continence assessors (the equivalent of 1.4 band 5 community nurses), two band 3 continence healthcare support workers (HCSWs) and three administrators.
During general conversations with some primary care nursing staff, it became apparent that very few staff were aware of the correct usage of catheter maintenance solutions. The ways in which they were using these solutions appeared to be based on historical practices and not governed by evidence-based practice. It was often a taught practice that had been passed on from nurse to nurse. The typical response that was received was that the nurses need them just in case the catheter became blocked. This highlights the need for more thorough training on catheter maintenance for community nurses, as they were often the individuals prescribing these products and are the ones requesting them from the prescription service at present.
Over the past 2 years, efforts within the prescription service have focused on assessing patients who are in receipt of catheter maintenance solutions. Through the role of a community continence nurse specialist, the author can access all data regarding the prescription of continence products, including catheter maintenance solutions. The system used is a live database, and the figures have been collected following authorisation from the clinical lead nurse of the community continence service. Since the community continence service started assessing patients prior to any new prescribing of maintenance solutions, and following review of patients who were already using them, the spend has decreased, as has the number of patients in receipt of these products (Table 2). These figures clearly indicate that a large amount of products were prescribed inappropriately. However, what they do not indicate is the potential prevention of repeated CAUTIs by only using these products when clinically indicated. During the same time, if catheter maintenance solutions were requested by patients or staff for the first time, advice was given to monitor the next three catheter blockages and to cut the catheter once it was removed, in order to determine the cause of the blockage. This was following the introduction of a blocked catheter pathway within the health board. At each blockage, community staff or the patients would inform the prescription service of any observed cause of blockage, and this would be documented in the patient notes. Following three blockages, an appropriate management plan would be established and commenced. Where possible, earlier planned changes in the catheter would be initiated to try to avoid a potential blockage and, therefore, prevent any anxiety or distress that an individual might have as a result of a blockage. If this was not possible, the trial of an alternative-style catheter would be suggested, and, if this, too, was unsuccessful, only then would a trial of a catheter maintenance solution be considered.
| 2015–2016 | 2016–2017 | 2017–2018 | |
|---|---|---|---|
| Total cost of catheter patency solutions | £101 613.12 | £79 168.83 | £37 380.55 |
| Number of patients prescribed patency solutions | 771 | 618 | 220 |
This view is supported by Yates (2018), who further reported that open-ended catheters were widely available on prescription. The substantial reduction in the number of patients using these solutions following reviews by continence assessors highlights the extent of inappropriate usage there was prior to the centralised prescription service being set up (Table 2). Thus, it highlights a possible need for further education on the use of these products among community nursing staff.
Follow-up research
After the need for further training was initially identified, more information regarding catheter maintenance solutions and their usage was included in the catheterisation study days and update sessions that were already in place. However, not all community nursing staff attended these sessions, and the continence service relied on those who attended to share the information that they had learned with their colleagues. During this time, the author decided to conduct a small survey to determine community nursing staff 's knowledge regarding catheter maintenance solutions. This information could guide the identification of specific training needs and the development of a training programme suitable for community nursing staff. The ultimate aim is for all nursing staff within the health board to be practising safely in accordance with evidence-based knowledge. It is important to note that the author was unable to identify any previous studies that investigated community nursing staff 's knowledge with regard to the use of catheter maintenance solutions. This was the driving force underlying research on this topic.
Questionnaires
The questionnaire used for the study comprised 11 simple questions with multiple choice answers. These questions covered what each product should be used for and how they are being used. The only identifiable information on each questionnaire was job band and the choice of two localities, which was a late addition to the questionnaire. If any unsafe practice was highlighted, there needed to be a way of accessing this staff group to provide an urgent update. This information would also assist in developing future study sessions focused on a particular locality's needs. The questionnaires were sent via email from the continence clinical lead nurse to all clinical leads within primary and community care. This was accompanied by an invitation letter asking each clinical lead to print and distribute the questionnaire among their staff. All staff were giving the option of returning the questionnaires via internal mail or via a sealed box that was provided at each work base. These two methods were selected in order to maintain anonymity and to increase the response rate. Of the 50 questionnaires that were distributed, 16 were returned and analysed.
Data analysis
Data were analysed once all questionnaires were returned, approximately 4 weeks after distribution. The questionnaires were separately examined on the basis of locality and staff banding in order to determine any specific needs. Comparisons were made between localities and between staff bands. Any questionnaires that were submitted after the analysis began were not included and were destroyed.
Findings
The response rate from the distributed questionnaires was low, at 32%, despite reminders to complete and return them. The responses from the questionnaires revealed that the community nursing staff had variable degrees of knowledge of catheter maintenance solutions. All staff who completed the questionnaire felt that more education on the solutions would improve their practice. This was encouraging, as a better understanding would result in more appropriate usage and, therefore, a reduced CAUTI incidence.
Eight participants stated that they performed 0–5 home visits per week that involved the use of a catheter maintenance solution, one attended 5–10 such visits, 1 attended more than 10 and the remaining 6 did not attend any home visits where the use of a catheter maintenance solution was indicated. It was encouraging that the one participant who performed more than 10 home visits answered all questions correctly, which suggested that they had a sound knowledge on the use of catheter maintenance solutions and, therefore, use of these solutions would hopefully have been appropriate. Of the 16 participants, four believed that catheter maintenance solutions are used to unblock a catheter or washout the bladder, and three of these four responders were from locality A, which highlighted a need for further education on the appropriate uses of catheter maintence solutions in locality A in particular. Of the 16 participants, only four had previous training on the use of catheter maintenance solutions, but encouragingly, all 16 participants felt that an update would benefit their future practice.
The question that produced the most varying responses concerned whose responsibility it was to review the use of the solutions. This finding suggested that this responsibility was not clearly defined within the training that had already been provided.
Of the two localities that were studied, it appeared that locality A had a greater need for further education. However, it is important to note that there was a greater response rate from this area, and, therefore, a true comparison between the localities was not possible.
It is important to acknowledge that this is a very small study of two localities within a single health board, and the findings may not be a true reflection of community nurses' knowledge on catheter maintenance solutions within other localities. Future study updates should be developed, and nursing knowledge should be scored prior to the update and 12 months on. This will ensure that any educational sessions have assisted in improving practice.
Conclusion
Catheter maintenance solutions continue to be prescribed and used in the community, despite lack of an evidence base to support their use. This practice may underlie the high incidence of CAUTIs, as use of this solutions involves breaking the closed catheter system.
To the best of the author's knowledge, there have been no other studies that focus specifically on community nurses' knowledge on catheter maintenance solutions. The results of the small-scale study described in this article showed that there is a need for change within primary and community care regarding catheter maintenance solutions, as they indicated a lack of knowledge on catheter maintenance solutions among staff nurses working in the community. Despite NICE (2014) guidelines highlighting the paucity of robust evidence for or against the use of catheter maintenance solutions, these products continue to be requested from the prescription service, and health board pathways are not followed. Thus, it is vital that community nursing staff be made aware of and educated about the indications for use of catheter maintenance solutions.
In their Cochrane review, Shepherd et al (2017) mentioned the need for more thorough, robust trials, but disappointingly, none have yet been performed. It is vital that these trials are performed, to yield data that could influence future practice and education of nurses.