I’ll take the tube.. out!

file6971249324663A few papers on the use of urinary catheters have caught my eye recently. It’s a subject close to my heart and was the subject of my eponymous lecture at the Infection Prevention 2013 meeting in London, available online for insomniacs via the excellent Webber Training Teleclass recording The slides are here. Despite these devices being second to peripheral cannulation in the ‘most’ used devices’ awards annually (and a clear winner in the ‘most overused’ section), the evidence base is somewhat thin. Are they inserted well? Possibly (and indeed probably) not. Do they only get inserted appropriately and are they speedily removed? Um… maybe not.

So I’d like to highlight a couple of papers. The first, from Manojlovich and colleagues (naturally including Sanjay Saint) is an observational study examining practices in the emergency department. They were interested in breaks in asepsis, barriers to the implementation of aseptic techniques and bacteriuria following catheterisation. The main finding of the study was there were major breaches of asepsis in 59% of 81 attempted insertions, mostly relating to the environments in which the procedures were performed. Lack of, or poor placement of hand hygiene products, no space to set up for the procedure, and a tendency for nurses to put sterile gloves over unsterile ones with no hand hygiene. Of the seven patients that developed bacteriuria post-catheterisation, five were performed with a major aseptic breach. It would be easy to assume that the pace and urgency of procedures in emergency centres would be at the root of failures to follow best practices, however it seems that the old chestnuts of not enough or poorly placed equipment and a lack of space are more of an issue.

The second paper from Paras and colleagues used questionnaires and looked at the knowledge of house staff relating to catheters and CAUTI, noting that it is this staff group that are responsible for issuing orders to catheterise. Although the knowledge base of the staff with regard to risk relating to duration was high, only a minority or respondents identified reasons for appropriate and inappropriate catheterisation and only a half were doing a daily review of the need for continuation. Particularly low was the knowledge base on when to remove catheters post-surgery. I do have to say that there have been a few papers on this recently that have identified that early removal of catheter after bowel surgery, epidural anaesthesia and robotic surgery. Perhaps, just perhaps a basic principle is beginning to emerge here. It is safe to take catheters out soon after surgery in the majority of procedures (even if you didn’t need it in the first place..).

I finished my Cotterall lecture with a little ditty ‘The Catheter’s Lament’ that I wrote on the train. Still valid I think..

I am a urinary catheter

Dark places I must go

My job is clear

I have no fear

I need to ease the flow

You are the one I am inside

It enters not your head

That if I’m left in

(a mortal sin)

You could just end up dead

At times, I am a useful aide

But my use you should not flout

On every day

Someone should say

It’s time to take me out!

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