Beyond Foley insertion: 5 practices to improve catheter care

Back in nursing school, Mary Pat Eble never learned about indwelling urinary catheters (IUCs) and the risk of infection. It wasn’t until she started working as a bedside nurse that she realized IUCs can produce airlocks that lead to urinary retention. Knowing how urine build-up can cause catheter-associated urinary tract infections (CAUTIs), Eble solved the issue by watching other clinicians drain the catheter bag and pull the walls apart to let air into the system.

Today, many nursing school students are learning about IUCs and evidence-based best practices for preventing CAUTIs, but they don’t always focus on a “catheter’s ongoing care,” says Eble, MSN, RN, Medline’s Clinical Product Specialist for the Urology Division. Often, clinicians will “learn these things as they start to practice” with mentors that help them understand “bedside care and how to turn learned theory into improved patient outcomes,” Eble explains.

But what happens when nurses don’t follow best practices for CAUTI prevention the same way? Many nurses are juggling multiple patient care needs, competing clinical priorities and busy shifts, making it even more challenging for clinicians to focus on prevention.

This could be why CAUTIs still account for more than 9.5% of all healthcare-associated infections (HAIs),¹ causing patient discomfort, extended hospitalizations and increased hospital costs. Bringing CAUTI rates down depends on helping clinicians use best practices on every patient, every time, in every care setting. Following are five best practices in IUC insertion and post-insertion practices to help you and your team make CAUTI prevention second nature.

Proper IUC maintenance begins with correct aseptic insertion technique. This can seem like basic practice that every nurse should know how to perform. But check to make sure your staff is correctly following evidence-based guidelines from the Centers for Disease Control and Prevention (CDC). Trays that organize everything clinicians need to follow aseptic technique can make it easier to follow best practices consistently.

Eble describes perineal care and catheter care as “missed arts” despite recommendations stressing their importance. Infection preventionists advise doing post-insertion perineal care and catheter care at least every 12 hours.

But “there’s a disconnect,” Eble says, “Hectic hospital shifts can make it hard for clinicians to clean the perineum and the catheter at the appropriate time, even when there’s a protocol in place.”

The more time passes between each cleansing, the higher the risk of biofilm buildup on the catheter and bioburden growth in the perineal area. Eble suggests encouraging clinicians to create more consistency by documenting when the patient last had these cleanings so they can be tracked and repeated at the correct time.

The CDC recommends that nurses use either soap and water or bath wipes to clean the perineal area and catheter. But Eble explains that water from the tap could be contaminated, as could the surface of the water basin. Clinicians may not know to use bath wipes as a safe and convenient alternative to soap and water for cleaning the perineum and catheter.

Dependent loops are a top contributor to CAUTIs. When the catheter tubing hangs down, it forms a U-shaped loop that forces the urine to drain uphill. This can cause the bladder to empty improperly, increasing the risk of infection. So, why don’t all staff position the IUC tubing correctly to avoid dependent loops? “That’s the $60,000 question,” Eble says.

One reason could be that clinicians have to treat hospitalized patients on different types of beds, so the way they place the catheter drain bag after insertion can change every time. This is especially true with urine meter tubing that’s 60 inches long. If nurses attempt to milk the drainage tubing, they can cause suction trauma to the bladder wall, opening the door to mucosal trauma, which can cause bacterial overgrowth that could lead to a CAUTI.

Consider trying urine meter drain bags that come with a notch that places the catheter tubing at a 90-degree angle. Bed sheet clamps can also secure the tubing to help the urine flow. But it’s still up to nurses to follow proper drain bag placement procedures. Clinicians need to work with the tubing and drain bag appropriately, “to enable the tubing and drain bag to do what you need them to do. Drain efficiently,” Eble says.

An open drainage system means that the catheter has been separated from the drain bag following insertion. This can be avoided by changing the entire catheter system every time there’s a break in the system, as recommended by CDC guidelines.

But this can get complicated when a patient is admitted to the ICU. After an emergency or operating room nurse inserts an IUC with a regular drain bag, an ICU nurse may switch to a urine meter drain bag without replacing the entire catheter. They do this to monitor the patient’s urine output on an hourly basis. But it means “breaking the system,” which can lead to an increase in infection rates.

Eble recommends thinking about the patient’s future needs and choosing a catheter system that’s least likely to be opened. Typically, patients undergoing simple procedures need only short-term IUC placement with a regular drain bag. Patients who go to the operating room for complex surgeries will usually need a urine meter. But patients admitted for a simple procedure who have comorbidities may end up in the ICU for monitoring. So, nurses need to use their critical thinking skills to decide which IUC system to insert.

“The nurse should be thinking about things like that and not automatically put on a drain bag without a urine meter,” Eble says. In fact, it’s a good idea to make urine meters easily available for acute care nurses to use instead of regular drain bags. That’s an advantage as long as clinicians also receive the right training on drain bag use.

After insertion, prompt removal is vital for CAUTI prevention. That’s not happening enough, and there’s a 3%–7% daily risk of infection the longer the IUC is in place.¹ Sometimes that’s because clinicians are stretched too thin and have to manage multiple patients. Or they rely on guidelines, which indicate the need for precise measurement of urinary output is a good reason for continued IUC use.²

But “nurses need to understand the difference between hourly need and 24-hour intake and output,” Eble explains. “Hourly urine measurement only applies to critically ill patients. For patients that require 24-hour intake and output totals, and are not in need of critical hourly measurement, external or intermittent catheters are a better choice.”

Eble recommends “assessing the need for an IUC continuously just like you would monitor a patient’s heart rate, blood pressure or temperature.” Bladder scanners can help clinicians decide the next steps in the care of a patient, including if an IUC is necessary based on CDC guidelines.