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Best practices for clean intermittent catheterization

Beauchemin, Lisa, BSN, RN, CURN; Newman, Diane K., DNP, FAAN, BCB-PMD; Le Danseur, Maureen, MSN, RN, CNS; Jackson, Angela, BSN, RN; Ritmiller, Mike, MPAS, PA-C

doi: 10.1097/01.NURSE.0000544216.23783.bc
Feature

Addressing the lack of educational standards for teaching intermittent catheterization, the authors present evidence-based research and methods designed to improve nursing practice and patient outcomes.

Lisa Beauchemin is a clinical nurse manager at Wellspect Healthcare in Waltham, N.H. Diane K. Newman is an adjunct professor of urology in surgery at the Perelman School of Medicine, University of Pennsylvania in Philadelphia, Pa. Maureen Le Danseur is a clinical nurse specialist at Sharp Memorial Hospital in San Diego, Calif. Angela Jackson is a nurse manager at the University of South Florida Department of Urology in Tampa, Fla. Michael Ritmiller is a neuro-urology physician assistant at Chesapeake Urology Associates, University of Maryland Rehabilitation and Orthopaedic Institute in Baltimore, Md.

The authors would like to acknowledge the CABIC Advisory Board members and Wellspect HealthCare, specifically Nikki McCormick and Grant Friedrich.

The authors have disclosed no financial relationships related to this article.

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INTERMITTENT CATHETERIZATION, also called clean (nonsterile) intermittent catheterization or CIC, is not taught in many undergraduate nursing programs; it is a skill that is typically learned as a peer-to-peer teaching session. This has created a problem for nurses who may not have access to nurses who are experienced in CIC.

In 2010, Wellspect HealthCare selected a group of clinicians practicing in urology, pediatrics, and/or rehabilitation with expertise in CIC to form the Clinical Advisory Board for Intermittent Catheterization (CABIC). The group was part of an educational initiative to outline best practices for teaching healthcare professionals how to educate patients about CIC and how to perform it. An objective was to assist in skill attainment for clinicians, primarily RNs, who teach CIC with methods based on evidence-based research, best practices, and clinical expertise.

CABIC's CIC: Guidelines for Healthcare Professionals is an educational resource utilized in many healthcare settings.1 This article will reference CABIC's teaching method and provide a synopsis of best practices for CIC. The intent is to educate nurses about performing CIC, establish a consistent CIC teaching method, increase CIC success, and promote patients' urologic health.

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About intermittent catheterization

The purpose of intermittent catheterization is to drain the bladder several times a day; it is the preferred bladder management method for patients with urinary retention.2,3 The procedure involves introducing a urinary catheter through the urethra into the bladder or a continent urinary diversion into the reservoir to drain urine. (Created from a segment of the patient's bowel, a continent urinary diversion is an internal pouch-like reservoir that stores urine until it can be drained.4) Once the bladder or reservoir is empty, the catheter is removed.

Intermittent catheterization allows the bladder to fill normally before being emptied again. Use of intermittent catheters is reported to reduce the risk of catheter-associated urinary tract infection (CAUTI) compared with indwelling urinary catheters in postoperative surgical patients while improving patient comfort and quality of life.5

The use of intermittent catheterization in bladder management has increased in acute care settings now that Medicare no longer reimburses hospitals for a CAUTI.6 Because minimizing the use of indwelling catheters reduces the risk of a CAUTI, different methods for bladder emptying and management need to be considered for patients who continue to have urinary retention or incomplete bladder emptying. A preferred alternative is intermittent catheterization.7,8

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Literature review

The CABIC method was developed in response to the lack of a standardized teaching model for clean intermittent self-catheterization. In 2010, CABIC carried out a literature search to identify available guidelines, best practices, and procedures or policies on teaching intermittent catheterization to healthcare professionals. At that time, no systematic processes were found. Information and patient education provided by catheter manufacturers were available in print and on the internet, but most was specific to the individual manufacturer's catheter. Online education by the National Institutes of Health and the Society of Urologic Nurses and Associates suggested techniques that were similar to those currently being followed by clinicians. At that time, guidelines included instructions on washing and reusing catheters. These sites were last updated in 2006-2007, before single-use catheters were available and/or covered by insurance. As discussed below, most catheters made today are for single-use only.9-11

Newman and Wilson addressed best practice standards for CIC, outlining indications, complications, CAUTI prevention, catheter design and materials, and frequency.12 When discussing the actual teaching standard, the authors noted that most nurses use practices based on experience, not evidence.

Le Breton et al. performed a Cochrane review regarding the education programs for CIC.13 Due to lack of randomized studies and education standardization, they developed a website to conference with experts. They concluded that the need for intermittent self-catheterization education is apparent, but the educational structure and availability of specialty-trained staff were not evident.

In 2013, the European Association of Urology Nurses released evidence-based guidelines for urethral catheterization in adults.14 These provide information on patient education, catheter selection, frequency of catheterization, and methods that can be used for catheterization. However, only general guidelines were given and no detailed procedural steps were made for clean technique, a nonevidence-based method (as discussed below).

Bardsley reported on factors that may reduce the risk of CAUTIs in women who perform self-catheterization.15 These factors included adequate patient education, patient concordance, catheter selection, and a consistent technique.

Bickhaus et al. explored the feasibility of teaching CIC to a specific group of female patients preoperatively in an outpatient clinic setting.16 The teaching sessions were timed from start to successful catheter insertion. The median time was less than 4 minutes. Of the 51 participants taught, 41 completed their post-op trial. Of those 41 participants, 33 successfully performed the procedure without assistance. No step-by-step teaching process was described; participants performed repeated catheterizations until they were successful.

Lamin and Newman revisited current CIC practice, types of catheters available, and the controversy over single versus reuse catheters, including a detailed discussion of CAUTI incidence associated with type of catheter lubrication.8 Their article includes a section on best practices for preventing UTIs associated with intermittent catheterization, which has some helpful tips. However, they made no recommendations regarding best-practice CIC technique.

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Clean or sterile?

The use of the term “clean” in association with intermittent catheterization was introduced in 1972 by urologist Jack Lapides, who described a method of performing the procedure using a clean technique and postulated that reuse of nonsterile but clean catheters would not increase the risk of UTIs.7 Consequently, use of the same catheter for multiple catheterizations, called multiple-use catheters, became common practice. However, as the literature review suggests, catheter cleaning between catheterizations has no basis in evidence-based research and no standardized cleaning methods have been developed.8,17

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Park et al. reported on changes in quality of life in patients (n = 38; 21 male:17 female; mean age: 21.7 ± 5.3) with neurogenic bladder who changed from a multiple-use catheter to a single-use catheter for self-catheterization.18 Using the Modified Intermittent Self-Catheterization Questionnaire (mISC-Q),19,20 they found that single-use catheters were significantly easier to use than multiple-use catheters (P = .002). Patients who performed catheterization via the urethra favored single-use catheters for ease of use (P < .001) and convenience (P = .011).

Today, catheterization in acute care or rehab settings is generally performed aseptically by an RN using a closed sterile catheter system or a sterile catheter kit.2,21 However, using a clean technique to insert single-use catheters is recommended for patients performing the procedure in the home.

If a hospitalized patient will be performing intermittent catheterization at home, education and training with return demonstration is necessary before discharge. If urinary retention is diagnosed on an outpatient basis, the patient may be referred to a urology practitioner to learn to perform the procedure.

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Indications for CIC and barriers to success

Conditions that may necessitate intermittent catheterization include underactive bladder, prostatic hyperplasia causing urethral obstruction, trauma, post-op complications, and neurogenic lower urinary tract dysfunction such as may occur with brain or spinal cord injury, multiple sclerosis, stroke, and certain birth defects such as spina bifida.2,21 Patient assessment should include the cause of the urinary retention and the patient's urologic health history.

When obtaining a health history, the nurse needs to explore psychological, emotional, and social issues that could be barriers to a successful treatment plan, because the patient's ability and willingness to follow the treatment plan are essential to success. Psychological factors include motivation, acceptance, and maturity. Social and environmental issues include employment status, financial means, and availability of family or other caregiver support.

A patient's success with a new self-catheterization program also depends on such factors as readiness to learn, ability to perform the task, and clinical support.12 Other circumstances that can affect the patient's ability to perform self-catheterization include positioning, sensory and visual capabilities, dexterity, body habitus (such as a large girth that can obstruct the patient's view or prevent the patient from reaching the meatus), cleanliness, and cognitive ability.22 If the patient cannot perform intermittent self-catheterization, the nurse should try to identify a family member or other caregiver who is available and willing to learn.

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Catheter considerations

Catheters used for CIC are available in various sizes and lengths. See All about catheters for points to consider when choosing a catheter for a patient.

In addition, catheters can be coated, uncoated, or contained in a closed system (see Catheters used for intermittent catheterization). Each type has advantages and disadvantages. In making the best choice for a patient, the nurse considers these factors:

  • hand strength—can the patient open the package and pass the catheter?
  • sensory capabilities—is the patient's vision or hearing impaired?
  • dexterity—can the patient easily grip and insert the catheter?
  • mobility issues—where will the patient perform the procedure, on the bed, toilet, or wheelchair?
  • allergies—is the patient sensitive to latex?
  • expectations—does the patient understand the need for intermittent catheterization?
  • urethral problems—are strictures or scarring present? Intermittent catheterization is the preferred treatment option for stricture dilation.
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Catheter material varies and ranges from nonlubricating plastic catheters to hydrophilic-coated catheters. Choosing the appropriate catheter material depends on such considerations as the presence of urethral strictures or injury, patient reports of continuing discomfort during catheterization, repeated episodes of bleeding during or after catheterizations, and recurrent UTIs. (See Troubleshooting tips.)

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Reusing catheters: No longer recommended

For many years, catheter reuse was the norm, primarily because of reimbursement issues: Medicare and most insurers would cover the cost of only four catheters each month.23 Patients were instructed to wash and reuse the same catheter for multiple catheterizations. However, reuse of catheters manufactured for intermittent use is an off-label practice, as these devices are labeled for one-time use only. Also, no evidence-based guidelines on cleaning or disposing of a reused catheter are available.

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This practice has changed and up to 200 catheters per month are now provided by many insurers to decrease UTIs. However, some insurance plans and state Medicaid plans require prior authorization for more than 30 per month.

Based on the evidence, the CABIC teaching method does not endorse catheter reuse. Krassioukov et al. conducted a study that investigated the catheterization usage and UTI frequency at the London 2012 Paralympic games and the 2013 Para-cycling World Championships.24 Participants (n = 61) were divided into developing and developed countries based on economic status. The participants shared their current catheterization practices. Those from developing nations had a much higher catheter reuse rate and experienced twice as many UTIs per year compared with those who did not reuse catheters.

Catheterization frequency can range from two to six times per day based on provider recommendation and factors such as the severity of urinary retention or incomplete bladder emptying, volume of urine obtained via catheterization, and leakage between catheterizations. The American Urological Association recommends that patients attempt to keep bladder volumes less than 500 mL in order to preserve kidney function and prevent UTIs.25

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Clean vs. sterile technique

When a patient is catheterized in the hospital or an inpatient rehabilitation facility, sterile technique is used because these facilities are bacteria-rich environments and more precautions are necessary to prevent infection. Precautions include use of sterile gloves, antiseptic cleaning solutions, and a closed system (or touchless catheter) or sterile catheter insertion kit.

As previously discussed, when a patient self-catheterizes outside of a hospital or rehab setting, clean technique is recommended. Patients using clean technique do not need to wear gloves and catheters need not be packaged in a closed system. Soap and water or cleansing wipes can be used for cleaning the urethral meatus or stoma before catheterization. However, if a patient is having frequent UTIs or a family member/caregiver is performing the catheterization, sterile insertion supplies may be recommended.

Many positions can be utilized by patients when performing CIC. The most common is standing over or sitting on a toilet. This allows patients to use public restrooms, giving them freedom to leave their home, which improves their quality of life.

Positioning options and full instructions for educating patients can be found in CIC: Guidelines for Healthcare Professionals, available at www.wellspect.us/~/media/M3-Media/WELLSPECT/Urology/LoFric-Family/1224368-CABIC-Book.pdf. These guidelines also detail adaptive devices and clothing for patients with special needs, such as those with spinal cord injuries. These devices can be obtained through a medical supply company, local rehabilitation facility, or online.

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Standards for success

All clinicians need to utilize a standardized method of teaching CIC to enhance the patient's educational experience. Using the CABIC teaching model as a platform, nurses can improve patient self-care, advance nursing practice, and strengthen any future research efforts.

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REFERENCES

1. Clinical Advisory Board for Intermittent Catheterization. CIC: Guidelines for Healthcare Professionals. 2016. http://www.wellspect.us/~/media/M3-Media/WELLSPECT/Urology/LoFric-Family/1224368-CABIC-Book.pdf.

2. Cottenden A, Buckley B, Fader M, et al Management using continence products. In: Abrams P, Cardozo L, Khoury S, Wein A, eds. Incontinence: 5th International Consultation on Incontinence. The Netherlands: ICUD-EAU Publishers; 2013.

3. Newman DK. Devices, products, catheters, and catheter-associated urinary tract infections. In: Newman DK, Wyman JF, Welch VW, eds. Core Curriculum for Urologic Nursing. 1st ed. Pitman, NJ: Society of Urologic Nurses and Associates, Inc.; 2017.

4. National Institute of Diabetes and Digestive and Kidney Diseases. Urinary diversion. What is urinary diversion? http://www.niddk.nih.gov/health-information/urologic-diseases/urinary-diversion.

5. van den Brand IC, Castelein RM. Total joint arthroplasty and incidence of postoperative bacteriuria with an indwelling catheter or intermittent catheterization with one-dose antibiotic prophylaxis: a prospective randomized trial. J Arthroplasty. 2001;16(7):850–855.

6. Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections. JAMA. 2007;298(23):2782–2784.

7. Lapides J, Diokno AC, Silber SJ, Lowe BS. Clean, intermittent self-catheterization in the treatment of urinary tract disease. J Urol. 1972;107(3):458–461.

8. Lamin E, Newman DK. Clean intermittent catheterization revisited. Int Urol Nephrol. 2016;48(6):931–939.

9. National Institutes of Health. Clean intermittent self-catheterization (CISC): procedure for men. 2007. http://www.cc.nih.gov/ccc/patient_education/pepubs/bladder/ciscmen5_22.pdf.

10. National Institutes of Health. Clean intermittent self-catheterization (CISC): procedure for women. 2007. http://www.cc.nih.gov/ccc/patient_education/pepubs/bladder/ciscwomen5_22.pdf.

11. Society of Urologic Nurses and Associates. Clinical practice guidelines. Adult clean intermittent catheterization. 2006. http://www.suna.org/resources/adultCICGuide.pdf.

12. Newman DK, Willson MM. Review of intermittent catheterization and current best practices. Urol Nurs. 2011;31(1):12–28.

13. Le Breton F, Guinet A, Verollet D, Jousse M, Amarenco G. Therapeutic education and intermittent self-catheterization: recommendations for an educational program and a literature review. Ann Phys Rehabil Med. 2012;55(3):201–212.

14. Vahr S, Cobussen-Boekhorst H, Eikenboom J, et al. Evidence-Based Guidelines for Best Practice in Urological Health Care. Catheterisation, Urethral Intermittent in Adults. Dilation, Urethral Intermittent in Adults. Arnhem, Netherlands: European Association of Urology Nurses; 2013.

15. Bardsley A. Intermittent self-catheterisation in women: reducing the risk of UTIs. Br J Nurs. 2014;23(suppl 18):S20–S29.

16. Bickhaus JA, Drobnis EZ, Critchlow WA, Occhino JA, Foster RT Sr. The feasibility of clean intermittent self-catheterization teaching in an outpatient setting. Female Pelvic Med Reconstr Surg. 2015;21(4):220–224.

17. Christison K, Walter M, Wyndaele JJM, et al Intermittent catheterization: the devil is in the details. J Neurotrauma. [e-pub Feb. 1, 2018].

18. Park CH, Jang G, Seon DY, et al Effects on quality of life in patients with neurogenic bladder treated with clean intermittent catheterization: change from multiple use catheter to single use catheter. Child Kidney Dis. 2017;21(2):142–146.

19. Pinder B, Lloyd AJ, Elwick H, Denys P, Marley J, Bonniaud V. Development and psychometric validation of the intermittent self-catheterization questionnaire. Clin Ther. 2012;34(12):2302–2313.

20. Guinet-Lacoste A, Jousse M, Tan E, Caillebot M, Le Breton F, Amarenco G. Intermittent catheterization difficulty questionnaire (ICDQ): a new tool for the evaluation of patient difficulties with clean intermittent self-catheterization. Neurourol Urodyn. 2016;35(1):85–89.

21. Goetz LI, Droste L, Klausner AP, Newman DK. Catheters used for intermittent catheterization. In: Newman DK, Rovner ES, Wein AJ, eds. Clinical Application of Urologic Catheters and Products. Cham, Switzerland: Springer International Publishing; 2018:1–45.

22. National Institute for Health and Care Excellence. Lower urinary tract symptoms in men: management. Clinical Guideline 97. 2015. http://www.nice.org.uk/guidance/cg97.

23. Galinis J. Getting the intermittent catheter the patient needs: considerations in coding, coverage and documentation. Urol Nurs. 2013;33(5):257.

24. Krassioukov A, Cragg JJ, West C, Voss C, Krassioukov-Enns D. The good, the bad and the ugly of catheterization practices among elite athletes with spinal cord injury: a global perspective. Spinal Cord. 2015;53(1):78–82.

25. American Urologic Association. Non-neurogenic chronic urinary retention: consensus definition, management strategies, and future opportunities. 2016. http://www.auanet.org/guidelines/chronic-urinary-retention.

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RESOURCES

European Association of Urology Nurses. http://nurses.uroweb.org/wp.

Le Danseur M, Stutzman SE, Wilson J, Sislak I, Olson DWM. Is the CABIC clean intermittent catheterization patient education effective. Rehabil Nurs. 2018;43(1):40–45.

Prieto JA, Murphy C, Moore KN, Fader MJ. Intermittent catheterisation for long-term bladder management. Neurourol Urodyn. 2015;34(7):648–653.

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