Best Practice Urinary Catheterisation Catheter Care

Urinary Catheter Care Best Practice

Introduction
With the inherent risk of introducing infection to the urinary tract, catheterization must be performed as an aseptic procedure and only when clinically indicated. The catheter should be removed as soon as possible or when no longer required.

Materials

• Short Term (less than 10 days)
• Medium term (4 - 6 weeks)
• Long Term (6 weeks - 6 months)

• Latex
• Teflon, PVC & PVC coated
• Silicone & Silicone coated catheter

• Becomes very irritant if used for more than 10 days May cause inflammatory urethra stricture in males Because of soft consistency, may be difficult to insert in the presence of urinary outflow obstruction. Not suitable if the bladder contains debris, clot etc. Latex plastic catheters are not suitable for use as indwelling catheters.
• Less irritant than latex catheter Easily inserted and less likely to block Catheter can degrade by splitting or peeling of the coating if used for longer than 4-6 weeks
• Least irritant of materials Because of soft consistency, can be difficult to insert.

Drainage Bag
Only a sterile bag, which facilitates a closed system of drainage, should be used which should be fixed on a hanger. The bag and tubing should at all times be below the level of bladder so that the flow can be continuously maintained by gravity.

Procedure
In order to minimize the risk of infection it is extremely important that the aseptic technique be maintained throughout the procedure and the area through which the catheter is to be introduced into the bladder be thoroughly disinfected.

• All equipment must be washed sterile
• Hands must be washed thoroughly with antiseptic solution before and after the procedure.
• Sterile gloves must be worn. Clean peri urethral area with 1% povidone iodine or 3.3% aqueoue savlon.
• Prior to insertion use a disinfectant containing lubricant e.g. 0.05% chlorhexidine gluconate in glycerin.

Emptying the Drainage Bag
Extreme care must be taken when emptying the drainage bag to prevent cross infection. The hands are washed and non sterile disposable gloves must be worn when emptying each bag. The bag should be emptied via the drainage tap at the bottom of the bag. When the bag is empty, the tap should be closed securely and wiped with alcohol.

A separate jug must be used for each patient and each bag should be emptied separately as required. The jug should be disinfected in a disinfector and stored dry. After emptying urine the gloves must be discarded and hands washed.

Specimen Collection
If sample of urine is required for bacteriological examination, it should be obtained from sampling port. Wiping the sampling port with 70% alcohol in impregnated swab must disinfect this. The sample may then be aspirated using a sterile needle and syringe and transferred into a sterile container.

Do not use disconnected drainage bag to obtain a sample as these cause interruption to the closed drainage system and may pose a risk of infection to the patient.

Do not obtain sample for bacteriological culture from the drainage bad as this will not give an accurate result. Such specimens reflect the bacterial count within the bag, not the patient's urinary tract.

Bladder Irrigation
Irrigation should be avoided unless obstruction is suspected. In such cases, closed continuous irrigation may be used to prevent obstruction.

Bladder washouts with antiseptics i.e. chlorhexidine are not recommended. They rarely eradicate organisms, may introduce infection, can cause inflammation of the bladder wall and therefore increase the likelihood of systemic invasion. They may also cause damage to the catheter.

How to Clean and Disinfect a room — ICU — O.T. — Isolation room

1. Mop the room thoroughly.
2. Wash floors, walls, ceilings with clean warm water. Leave it for 10 minutes. Let it dry.
3. Make proper concentration solution of water with cleaning agent (E.g. Bacilloflor) Read manufacturer's instructions on how to make the solution.
4. Use hard brush (not a mop) to scrub floors, walls, ceilings etc thoroughly, mechanically, effectively.
5. Clean beds, furniture, fans with soft cloth soaked in Bacilloflor solution.
6. Careful while cleaning equipments. e.g. Ventilators, monitors etc.
7. Leave room and its contents to dry for 15 to 30 minutes.
8. Spray "Bacillocid" or other similar chemical. Wait for 2 hours before using the facility.
9. Fumigation is outdated. Thorough I to 8 steps mentioned above means proper disinfection.
10. Discard the mop, chemical solution and use a new one before moving to clean other room.
11. Teach cleaners how to do the cleaning.

Procedure for prevention of nosocomial infection in O.T.
Following steps must be ensured to prevent nosocomial infection in the O.T:

1. Restricted entry of personnel. Only the concerned people must be allowed top work area. Prior permission must be obtained from Sister in charge / DMS if visitors are to enter O.T.
2. Only personnel in O. T. dress cap and mask to be allowed inside sterile zone.
3. Slippers must be ear marked and used for the area. The slippers for bathroom must be marked. (Do not use same slippers for both areas)
4. No person must go out with O.T. dress and come back into O.T. in the same dress. Dress must be changed if person re-enters.
5. No septic cases must be posted in the main complex. Minor O.T. should be used. The sister in charge must be informed by doctor if any aseptic cases are being done prior to posting in minor O. T..
6. Due precautions must be adhered to if seropositive patients for HIV/HBsAg/HCV is posted for surgery. The doctor must be informed about the patient's status prior to posting must inform the theatre personnel.
7. Half an hour must be given between cases to clean up the room after each surgery.
8. Terminal cleaning must be done of each theatre at the end of the day.
9. Sister who is assisting must ensure proper disposal of sharps, blood stain, linen, gauge pieces and body parts are done at the end of each case.
10. During surgery, sister assisting must ensure that minimal spillage of blood, body fluids occur. The gauge pieces must be accounted for in the stand for gauge counting.
11. Weekend cleaning and mechanical scrubbing of the O. T. must be done. Only minor O. T. to be used for emergency cases on Sunday. No elective cases must be posted on Sunday.
12. One senior sister must supervise the weekly cleaning and scrubbing as per the "critical care room cleaning guidelines"

Work instructions for nurses in O. T.

1. All bins and sterile sets must be ensured that they are sterilized by colour change of the label.
2. After use, each instrument must be cleaned thoroughly in warm/hot water with a detergent and sent for sterilization.
3. All sharps must be disposed off in the cidex bin only. No sharps must be put into the buckets.
4. Nurse assisting must ensure that blood drops/spills are covered with 1% sodium hydrochloride and cleaned before leaving theatre after a case.
5. Nurse must supervise that proper disposal of gauge, human body parts, and the O.T. suction apparatus contents disposal.
6. The Nurse assisting the case must supervise all samples for investigations being sent to lab.
7. Nurse must use aseptic technique while using the bins. The chisel forceps must be decontaminated each day.
8. Nurse in charge must ensure frequent changing of the suction apparatus tubing.

Protocol for cleaning ICU's for house keeping

1. Supervisors to inspect that daily cleaning are done. Hands on training have to be given for reconstruction of disinfections. [Measuring cylinder to be used.] Keep a log-book for this.
2. Periodically supervisors have to be checked by housekeeping in charge that this is done. Log book to be checked.
3. Morning and Evening wet swabbing of the area has to be done with a disinfectant (correct concentration to be reconstituted as per the manufacturer) Daily vacuum to be done once a day in all ICU's.
4. Weekend carbonization to be done for all equipments and beds in the ward. (Date sticker to be attached to each)
5. Restriction of visitors to ICU's.

Protocol for house keeping to prevent spread of infection in case of an outbreak

1. Wearing gloves and masks by staff is essential. Hand washing with soap and water is mandatory.
2. Supervisors to inspect that daily cleaning are done. Hands on training have to be given for reconstitution of disinfectant. All used equipment to be cleaned with a disinfectant.
3. Morning and evening wet swabbing of the area has to be done with a disinfectant. (Correct concentration to be reconstituted as per the manufacturer.)
4. Weekend calibration to be done for all equipments and beds in the ward.(Date sticker to be attached to each)
5. All equipment used on a patient — the ventilation tubing; suction tubing must be disposed of till the outbreak lasts.
6. All excretion and secretion of the patient to be flushed off. The spittoon, kidney tray and bedpan to be disinfected, washed with soap and water and reused.
7. All spills to be covered with disinfectant. (5% sodium hypochlorite) for ten minutes with gloved hands.

Protocol for O.T. Cleaning, Carbolization and Fumigation

1. Every morning: O.T. is to be cleaned and carbolized before start of the first operation.
2. All equipments, O.T. tables, walls and floors have to be cleaned and carbolized.
3. Equipments and furnishings, not to be carbolized are marked" x II in red.

After every operation

1. Collect linen and waste material in color-coded bags according to hospital waste disposal protocol.
2. Collect soiled linen in separate color coded plastic bags according to hospital waste disposal protocol.
3. Collect sharps and sponges separately in color-coded bags according to hospital waste disposal protocol.
4. After removing the blood from the floor and other, spillage areas (as per hospital protocol) disinfect and wash the areas thoroughly.
5. Carbolize the equipments giving special attention to the foot switches.
6. Bacillocid spray (as per manufacturer's instructions) after every infected case operated.

Note :Carbolization procedures shall be carried by using 1% hypochlorite solution.
Check the concentration of available hypochlorite, dilute accordingly.

Example : hypochlorite solution (available 4% solution of sodium hypochlorite: dilute 1 in 4, to 250 ml of 4% sodium hypochlorite add 750 ml of water)

At the end of the last operation

1. Clean the O.T. area, after removing all the used material & other items to be discarded.
2. Mop with 1% sodium hypochlorite solution, dilute as mentioned earlier.
3. After mopping the floor, carbolize the O.T. walls, floor, table tops and equipments except where contraindicated (marked" x II in red)
4. Bacillocid spray (as per manufacturer's instructions)

The sister in charge of O. T. shall ensure that there is proper time gap between the 2 operations for removing the used material, cleaning and Bacillocid spray (if necessary).

Fumigation

Fumigation of an area shall only be resorted to in the following circumstances :
A. Newly constructed area.
B. Construction activity undertaken recently in that area.
C. In any other circumstances where need of fumigation is felt, it shall be carried out with the permission of the N. D. (Nursing Director) and with immediate information to D.M.S., M.S., Infection Control Officer, AGM (Operations), Chief Engineer and Manager House Keeping.

In all other circumstances proper cleaning, carbolization & Bacillocid spray (as per instructions of the manufacturer) shall be carried out.

Note : For effective fumigation, humidity of the area to be fumigated shall be very high.

Before fumigation

1. Remove any containers with hypochlorite solutions and any other article that is likely to be damaged by fumigation, to an area away from fumigation area.
2. Clean O.T. properly.
3. Fumigate

Method of fumigation

1. Turn off AC.
2. Qilution of formalin (500 ml of 40% of formalin+1000 ml of water) for thousand cubic feet.
3. Put the solution in O. T. care machine (fumigators)
4. Put on the machine for half an hour
5. Seal the O. T. for 10 to 12 hours.
6. Then turn on A.C. and exhaust the fumes.
7. Remaining fumes, if any, shall be neutralized with ammonia.
8. Clean and carbolize before use.

All the house-keeping personnel working in the OT shall use heavy duty gloves while dealing with biomedical waste.

Construction activity

Construction activity is divided into following, depending upon the type and nature of the work being carried out:
Level-I: Electrical fittings/painting jobs/minor plumbing activity.
Level-II: False ceiling repairs, PCV floor repairs and major plumbing/electrical/air conditioning repair activity.
Level-III: Demolition/Construction of walls, fixing tiles, complete ceiling replacement and floor replacement.

All construction activity in patient care area should be undertaken with following proposed guidelines
Level-I
No particular Infection, Control measure except 'Universal Precautions' to be taken by staff

Level-II

• 'Universal Precautions' to be followed by staff.
• The area shall be isolated or cordoned off.
• Patients are to be moved away from the area.
• Wet cloth curtain should be provided for barricading.
• Behind this, plastic curtain or at least a dry cloth curtain to be put, to seal the area.
• If required, ear plugs may be provided to all likely to be affected in the nearby area.
• Frequent cleaning of the construction area and surroundings is carried out.
• At the end of the construction activity, air conditioning is switched on, to take out dust from ducts.
• Prefilter and micro filters are cleaned at the end of each such activity.
• Regular fumigation is carried out at least once and if needed twice, followed by plate counts by settle plate method.

Level-III
All the supply and return diffusers/grills to be covered and sealed before starting the construction work.

All other activities as for Level-II Construction
At least two fumigation cycles and if needed a third cycle is carried out, Plates counts are done.