Catheter Types and Care for Residents with Catheters National Content Series for All LTC Staff June 2015 Welcome to today’s session on how to care for residents with urinary catheters. This training is part of the Agency for Healthcare Research and Quality’s (or AHRQ’s) Safety Program for Long-term Care that addresses healthcare-associated infections (or HAIs) and catheter associated urinary tract infections (or CAUTI).

Learning Objectives Upon completion of this webinar, clinicians and staff care for residents with catheters will be able to: explain the similarities and differences between the four different types of catheters; explain ways to prevent CAUTI; and identify some common errors when caring for catheters. Here are the goals for today’s session. At the end of this program, you should be able to: explain the similarities and differences between the four different types of catheters; explain how to prevent CAUTIs; and identify some common errors when caring for catheters. This session will help you understand how you, regardless of your role, can make a difference in the safety and quality of care for the residents we serve. So let’s get started.

Indwelling Urinary Catheter Entry Pathways for Microbes Bladder Urine Collection Bag Urethra (Urinary tract entrance) Entry during insertion Bacteria movement up the catheter Breaks in the catheter tubing or collection bag Contamination of the catheter tubing or collection bag You are probably all familiar with catheters, and while they are sometimes necessary for residents, they can also act as a “way in” for bacteria, increasing the resident’s risk of a CAUTI. Probably the most common way microbes get in once an indwelling urinary catheter is in place, is by the outside surface of the catheter. Bacteria and other pathogens are able to use the outer surface of the catheter to work their way up the urethra, the urinary tract entrance, and into the bladder. Over time, and through poor catheter care and maintenance, the inside of the catheter and the drainage bag can also be a source for microbe entry. So it’s very important that proper care and maintenance is used to help prevent bacteria from entering the closed system. Additional Facilitator Notes Why might a resident have a catheter? The criteria for a resident to have a catheter are from the CDC and the LTC regulation based on scientific studies. It is important to know the criteria so we do not have residents with catheters who don’t need them, which can unnecessarily expose them to CAUTI. Urinary retention, bladder outlet obstruction, assist in healing perineal /sacral wounds, prolonged immobilization, end of life comfort, accurate output measurement in critically ill, and perioperative for selected surgical procedures of the genitourinary tract or long procedures are accepted criteria for residents to have an indwelling catheter. Figure Source: Dennis G. Maki and Paul A. Tambyah. Engineering Out the Risk of Infection with Urinary Catheters. Emerg Infect Dis, Vol. 7, No. 2, March-April 2001. http://www.cdc.gov/ncidod/eid/vol7no2/makiG1.htm; CMS, State Operations Manual, 2014.

Alternatives to Indwelling Urinary Catheter Types Suprapubic catheters Straight catheters External “condom” catheters There are alternatives to indwelling urinary catheters as well. Suprapubic catheters are placed surgically through the skin and into the bladder. Similar to indwelling catheters, these are connected to a bag used to collect and measure urine, and are kept in place for a period of time. A straight catheter is inserted into the urethra and bladder to drain urine from the bladder, and is then removed. Used intermittently it may be a scheduled procedure, or used as needed, when the resident cannot void or completely empty their bladder. External condom catheters attach over a man’s penis using a combination of adhesive and gentle compression. This type of catheter collects urine that the resident IS able to void, so it cannot be used to treat urinary retention.

Hygiene and Standard Precautions Assisting the Nurse with Catheter Insertion Wash your hands! Don gloves and gown Help the resident to get comfortable in a supine position and assist the nurse as needed Catheter insertion is done as a sterile technique. Do not touch the sterile field Assist to place and secure the catheter drainage bag below the level of the bladder and off the floor Remove gown and gloves and wash hands! Now we’ll talk about your role if you assist with the insertion of a sterile catheter. First, wash your hands and put on gloves and a gown. It’s recommended that you wear a gown if you’re assisting with any kind of intimate procedure or care. While you’re assisting with the insertion of a catheter, splashing can occur. Wearing a gown can minimize the risk of contaminating your clothing and it can also minimize the risk of transmitting multi-drug resistant organisms that can cause infection. Remember not to touch the sterile field as you assist. After the procedure, you can help to place and secure the drainage bag. And be sure to wash your hands after removing your personal protective equipment.

Drainage Bag Only trained staff should empty the urine collection bag and rinse/store containers Follow manufacturer instructions on use Empty drainage bags regularly (at least once per shift) Stabilize the catheter and drainage bag Keep drainage bag below level of bladder at all times OFF floor Consider where to place the drainage bag during resident’s daily activity Wheelchair Walker (clamp or hook) Bed Dining/activity area Lounge/reading chair (peg on side) It’s important that only trained staff empty the urine collection bag and rinse/store the containers. Follow the manufacturer’s instructions on use. Empty the drainage bags regularly (at least once per shift). And when you do, don’t contaminate the outlet valve by letting it touch the container you’re using. The container is for that resident only, so be sure to label it with his or her name. In addition to regular cleaning and disinfecting, it’s good practice to keep those collection containers as dry as possible between use because microbes tend to like moisture. The drier the better! Keep the catheter and bag stabilized and keep the drainage bag below the bladder at all times AND off of the floor And consider where to place the drainage bag during resident’s daily activities, like while they’re in their wheelchair, using a walker, laying in bed or when they’re down in the dining or activity rooms. Remember to always wash hands and use gloves before caring for the catheter and drainage bag and wash hands immediately following ____________ Additional Facilitator Notes The manufacturer may recommend their product is for single-use only and should not be reused due to a potential safety risk to the resident (e.g. infection, compromised structural integrity leading to device failure, etc.). An alternative approach to emptying the drainage bag is to perform a multi-disciplinary risk assessment that addresses the benefits and disadvantages of reusing the leg drainage bags. Advantages include cost savings and decreased environmental waste. The assessment should be documented and approved by the organization’s safety committee. If leg drainage bags will be reused, it is important to develop a policy and procedure that includes Performing hand hygiene and wearing personal protective equipment (PPE) Adhering to aseptic technique Wiping all connecting tips with an alcohol wipe Ensuring the connecting tips are kept covered and clean while being stored Washing the exterior of the bag and leg straps Rinsing the interior of the bag with diluted vinegar, full strength distilled white vinegar (5% acidity), diluted bleach (1:10 ratio) or antimicrobial liquid soap Storing the bag Replacing the leg and drainage bag on a schedule (e.g. weekly) and as needed

Maintenance Avoiding Common Mistakes Wash hands BEFORE and AFTER any contact with urinary catheter, tubing or bag Keep bag below bladder at all times without kinking When emptying bag, do not let outlet port touch ANYTHING Drain into a container used only for ONE resident Sampling port must be DISINFECTED before any use Only STERILE needle/syringe can be used to aspirate urine We really want to stress the importance of proper and regular hand hygiene! Hand hygiene and gloves immediately before placing or removing an indwelling catheter, accessing the drainage system, emptying the drainage bag, collecting a urine sample, or handling a catheter at any time! When you enter a room and reach for gloves without cleaning your hands first you may contaminate the box and outside of the gloves. Then, your gloves can contaminate the catheter or the collection system. It is also critical to perform hand hygiene afterwards. Hand contamination may occur as a result of small, undetected holes in your gloves or during glove removal. Performing hand hygiene after using gloves to perform catheter care helps to protect your hands, the environment and other residents from being contaminated. So please remember to put on gloves and gown only after washing hands your hands. keep the collection bag below the bladder at all times without kinking, even during TRANSPORT. When emptying the bag, do not let outlet port touch ANYTHING, and only drain into a container used only for that ONE resident. As I already mentioned, it is also important to follow the manufacturer’s instruction to keep the urine measuring device clean and dry. It is also important to regularly check that the catheter has not become disconnected from the drainage system. Nurses, remember from training module 2 that the sampling port of the indwelling urinary catheter is another way that contamination can be introduced to the closed system. If a urine sample is needed for a laboratory test, disinfect the sampling port, then insert a sterile needle/syringe to aspirate the sample.

Maintenance Care of Indwelling Urinary Catheter Use standard precautions before contact with catheter, tubing or bag When performing peri-care use only soap and water Periurethral area should NOT be cleaned vigorously or with antiseptic solutions Keep the catheter and all tubing from kinking/obstruction Indwelling urinary catheter and suprapubic catheter systems must be kept CLOSED If any disconnection of tubing or bag leakage, must be replaced Make sure you don’t contaminate catheter outlet valve when emptying the collection bag CNAs are the daily hands on “front-line” between residents and families and potential infection causing microbes Only use soap and water to gently cleanse the urethral area around the catheter. Report any urine leakage from that area. If there is leakage or any disconnection, the catheter will need to be replaced. Keep the catheter from being kinked or obstructed. For example: when the resident is in bed don’t have the tubing going up over a pillow, or over a pillow and then under a leg. And ensure the catheter is secured to the medial thigh. CNAs: your job is so important! You give the daily care to residents with catheters and your proper technique in catheter maintenance is vital to helping prevent CAUTIs!

Teaching Family and Residents About Catheters Catheterout.org has a helpful FAQ page that can be distributed to family members and residents to help them understand the essentials of catheter care and CAUTI prevention. You can use this information to talk with your residents and their families about proper care and maintenance of catheters. Don’t be afraid to teach and demonstrate to them your techniques for avoiding potential CAUTIs. Your residents and families will thank you! These resources for educating residents and families can be found at: http://www.catheterout.org/?q=patient-family-ed

Stay Updated with Useful Resources AHRQ Safety Program for Long-term Care: HAIs/CAUTI Project Website Login information Username: ltcsafety Password: ltcsafety TeamSTEPPS® for Long-term Care AHRQ Safety Program for Long-term Care: HAIs/CAUTI Project Website Login information Username: ltcsafety Password: ltcsafety TeamSTEPPS® for Long-term Care www.catheterout.org As we wrap up today’s discussion, I’d like to thank you for your time and attention to this program and for working to make your long-term care facility a safer place for residents, family members and staff. The following resources are available to you as participants in this program. We hope that these resources will be useful as you help your facility improve its culture of safety. The first resource is a link to the AHRQ Safety Program for Long-term Care: HAIs/CAUTI project website. On the website you will find a variety of tools to help you prevent CAUTIs and improve your facility’s culture of safety. The second resource is a link to the TeamStepps for Long-term Care web page. TeamStepps is a communication and teamwork system that offers solutions to improving collaboration and communication within health care facilities. The resources on this page are specifically designed for the long-term care environment. The third resource is a link to the website CatheterOut.org. This website has a variety of resources about catheter care to help reduce UTIs and CAUTIs. Thank you again for participating in this training. Have a great rest of your day!