Best Practices for Management - Intermittent Catheters

Intermittent catheterization can have a significant physical and/or emotional impact on patients’ lives.

nurse male patientPatients may be concerned about the discomfort associated with intermittent catheterization, the need to maintain privacy, the fear of performing the catheterization, and the inability to find a clean and appropriate toilet when traveling outside their home. Clinicians need to consider these patient concerns in their teaching and recommend possible strategies.

Teaching Catheterization

Intermittent self-catheterization requires education and support, particularly during initial teaching and follow up. A knowledgeable and experienced clinician, in most cases a nurse, is an important component for successful self-catheterization teaching. The nurse should assess the patient and/or the person performing the catheterization about the urinary tract. Providing an overview of anatomy with pictures or the use of an anatomic model of the perineum can be very helpful. Many catheter manufacturers have visual guides or videos that can be used when teaching patients and/or caregivers.

Most adults learn best under low to moderate stress, so it is important to teach self-catheterization in a low stress setting. The nurse should also assess the patient’s ability to learn intermittent self-catheterization, motivation to continue long-term catheterization, awareness of problems associated with catheterization, and the understanding of how to avoid possible complications.

Disabilities, such as blindness, poor hand dexterity, lack of perineal sensation, tremor, mental disability, and paraplegia, do not necessarily preclude the ability to perform catheterization. These obstacles are difficult to overcome in some patients and caregivers. Teaching a patient with a spinal cord injury may be even more of a challenge because the motor and sensory impairment may require changes to catheterization technique. There is a lack of uniformity and standardization in nursing practice in terms of performing self-catheterization because most nurses use experience-based practice. Initially, many patients may be extremely reluctant to perform any procedure that involves the genitalia, but this is basically a “fear of the unknown.” Determining acceptance of intermittent catheterization is vital because non-compliance is seen in many patients, particularly adolescents.

Teaching components include how to handle the catheter, identify the urinary meatus, and care of the catheter.
It is important that patients and/or the person performing the catheterization demonstrate understanding and/or ability or perform catheterization under supportive supervision of the nurse.
In patients performing long-term intermittent self-catheterization, monitoring patients for adverse events is advised.
An assessment of the patient’s personal hygiene (hand washing and cleansing of the genitalia) is important to avoid UTIs.

Schedule

The catheterization schedule or frequency should be based on frequency-volume records, functional bladder capacity based on urodynamics findings, ultrasound bladder scans for PVR, and the impact of catheterization on a patient’s quality of life.
As a general rule, bladder volume should not exceed 500 mLs, and some advocate not exceeding 400 mLs.
Based on an individual’s average output, catheterization is usually performed four to six times during the day.
Many patients, especially older patients, may need to catheterize at bedtime and during the night. 
The bladder should be emptied completely with each catheterization.
When starting intermittent catheterization, the patient and/or caregiver should record the amount of urine drained from the bladder.
If the patient voids, catheterization should always be performed after voiding.

Catheter Use and Care

US Medicare Changed Reimbursement Policy to End Re-use of Intermittent Catheters

On April 1st, 2008, Medicare changed its reimbursement policy on intermittent catheterization. The previous policy only allowed reimbursement for one intermittent catheter per week (4 per month), unless the individual user had lab results or medical documentation stating the existence of at least 2 urinary tract infections (UTIs) in the course of one calendar year.  

This change allows for up to 6 catheter changes a day in hopes to stop re-use of FDA labeled "single-use" catheters. The old policy made individuals sterilize and clean their catheters any way they knew how which lets a very high-risk opportunity to have the individual get infected with catheter-associated bacteria to arise. No longer will catheter users suffer from severely painful UTIs.

 

malenurse femalepatient wheelchairAs there are no clear guidelines about the length of time for catheter use if the patient is re-using an uncoated catheter, re-using the same catheter for multiple catheterizations is not recommended..
The cleaning of the catheter between uses has no basis in research because there are no published randomized controlled clinical trials of cleaning methods.
The comparative effectiveness of cleaning methods, therefore, is unknown

Currently, catheter manufacturers do not provide instructions for catheter re-use or cleaning.
Best practices do not support the re-use of single-use catheters at this time.

There are no set guidelines for monitoring patients performing intermittent self-catheterization, although many urologists advocate regular urine cytology and cystoscopy with random or targeted bladder biopsies.
In reality, many patients performing intermittent catheterization are lost to urologic follow up.

 

 

References:
1. Beauchemin L, Newman DK, Le Danseur M, Jackson A, Ritmiller M. Best practices for clean intermittent catheterization. Nursing. 48, 9 (Sept 2018):49-54.
2. Goetz LL, Droste L, Klausner AP, Newman DK. Catheters Used for Intermittent Catheterization. Clinical Application of Urologic Catheters, Devices and Products. Cham: Springer International Publishing; (2018):47-77.
3. Martins, G., Soler, Z.A., Batigalia, F., & Moore, K.N. Clean intermittent catheterization: Educational booklet directed to caregivers of children with neurogenic bladder dysfunction. Journal Wound Ostomy Conti. N, 2009; 36(5), 545-549. 
4. Moore, K.N., Fader, M., & Getliffe, K.. Long-term bladder management by intermittent catheterisation in adults and children. Cochrane Database System Review, 2007; 4, CD006008.
5 Newman DK. (2017). Devices, products, catheters, and catheter-associated urinary tract infections. In: Newman DK, Wyman JF, Welch VW, editors. Core Curriculum for Urologic Nursing. 1st ed. Pitman (NJ): Society of Urologic
6. Nurses and Associates, Inc; 439-66.
7. Newman DK, Willson MM. Review of intermittent catheterization and current best practices. Urol Nurs. 2011 Jan-Feb;31(1):12-28, 48; quiz 29. PubMed PMID: 21542441
8, Vahr S, Cobussen-Boekhorst H, Eikenboom J, et al. Evidence-based guideline for best practice in urological health care. Catheterisation. Urethral intermittent in adults. Dilatation, urethral intermittent in adults. . EAUN guideline. 2013.
9. Woodbury M.G., Hayes K.C., & Askes H.K. Intermittent catheterization practices following spinal cord injury: A national survey. Canadian Journal Urology, 2008;15(3), 4065-4071.

Written by: Diane K. Newman, DNP, ANP-BC, FAAN