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The evaluation and focus on the infection control among the hospitals has been under the monitoring of many Health Organizations and government. The issue on the infection prevention and control usually arise in the nursing practices and centers in the way on how they handle the patients. Eventually, aside from the needles or injections and hand contacts, the diseases and other infections can be transmitted or found to be associated with the urinary catheter. As identified by the Hong Kong Department of Health (2010), there should be preventive measures for the four major concerns - "surgical site infection, intravascular catheter associated with the bloodstream infection, ventilator-associated pneumonia and catheter-associated urinary tract infection". To be familiar with the method, the urinary catheter is used to drain the bladder via the patient's urethra. Due to the incapability of the patient to go to the bathroom that is most likely appeared after the operation, the method allows the patient to urine freely without messing the bed. However, this procedure is usually done by the clinicians or nurses to ensure that the catheter is held at place and will not fall or hurt the patient. Within this process, the infection is possible. As it believed, the infection can be prevented and controlled if there are standards that can be set in the nursing care of Hong Kong.
The purpose of the paper is to investigate the infection control based on urinary catheter and the associated nursing practices. In order to gather all the information, there are objectives that need to consider. First is to discuss the background of the case based on the clinical practice implemented in the settings. Second is to critically evaluate the nursing care dealing with the infection prevention and control particularly in Hong Kong through comparing the practices from those of the neighboring or developed countries like US. And third is to formulate the appropriate recommendation based on the investigation.
Background of the Case
The area of practice has been based on nursing care dealing to the principles of infection prevention and control. As working in acute female Urology ward, this will be realized through a critical evaluation of infection control on urinary catheterization found within Urology ward. In my work area, both clinical and emergency urology cases are found. Emergency cases include acute retention of urine, renal stone, acute pyelonephritis and heamaturia etc. Also there are cases that include renal stone, tumour of bladder, carcinoma of kidney, neurogenic bladder for operation etc. Therefore, insertion of urinary catheter is extremely common in my work area. Actually it is not a pure Urology ward. General surgical emergency and clinical cases, like abdominal pain, intestinal obstruction, gall stone, hernia, would be admitted to my ward. The ratio of nurse to patient is about 1:6 on week day and even 1:7 on weekend. This manpower distribution is very common in public hospital in Hong Kong. Hence, the workload in my work place is heavy. There is a need to comprehensively discuss infection control practices based on urinary catheter cases determining of best practices and recommendations from within Urology ward experience. Infection control effectiveness is essential in this evaluation to understand promptly the care for patients with urinary catheters.Â
According to McConnell (2001), urinary tract infections (UTIs) account for 35% to 40% of nosocomial infections in the USA each year. In Hong Kong, as recorded in 2010, the situation with the central line-related bloodstream infection associated with the catheter and haemodialysis results in the 44.61% and is in fifth rank in the global health situation (Lam, 2010). Among the most common nosocomial infections in the elderly are UTIs caused by urinary catheterization. Saint and Lipsky (1999 cited in Madeo and Roodhouse 2009) estimates that 8.5-10.0% of all patients who have indwelling catheters develop catheter-associated urinary tract infection (CAUTI) and contributes to enhance morbidity and mortality. Glynn et al (1997 cited in Madeo and Roodhouse 2009) indicated that the overall rate of catheterization in acute care was 26.3%, with a range of 12-40% dependent on specialty. According to The Hospital Infection Society 2007 (cited in Madeo and Roodhouse 2009), there was recorded up to 31% of inpatients had a urinary catheter. Based on the study of Chow and his associates (2010), there are 65% among the 75 participants they studied in Hong Kong that had bacteraemia episodes due to catheter-related infection. This situation is considered as the major cause for the catheter loss, and has been associated with the morbidity and mortality among the haemodialysis patients (Chow, et al., 2010).
There is a suggestion that, since the use of urinary catheterization is very common; staff may develop "catheter apathy" by viewing the complications as a consequence of the procedure that is harmless, acceptable and easy to treat (Tew et al (2005 cited in Madeo and Roodhouse 2009). The management of urinary catheterization among the patients is monitored by the nurses (Chenoweth, 2010; Chow et. al., 2010). Therefore, I assume that the implementation of best practice encompassing infection prevention evidence will decrease associated risks and help to prevent serious complications such as blood stream infection.
Pomfret (2000) have asserted that urinary catheterization is a common procedure for both community and hospital patients, nurses make many of the decisions with regards to the catheter selection and the subsequent catheter care. The nurses can use the necessary information to help the patients to form their own decisions such as determining what type of catheterization that can be appropriate to their situation. Actually, there are two main types of catheter that can be used namely intermittent catheter and indwelling catheter. Intermittent catheter is where the catheter is temporarily inserted into the bladder and removed once the bladder is empty, while indwelling catheter, where the catheter remains in place for many weeks (Urinary Catheterization). In relation to all aspects of catheter care, it is recommended that nurses have a formal update for at least five years, and more often if appropriate or required to aid them in the type and size of catheters can be used among the patients. This is a recommended practice in order to gain competency in catheterization (RCN, 2008). This may lead in choosing the optimum catheter material and size that emphasizes towards the precise catheter care. In addition, Pomfret (2000) argued that without proper attention coming from the nurses and management there might be serious problems that are associated in catheterization.
Based on Doherty's (2006) findings, the issues on the urinary catheter in connection with the nursing care should be kept in the priority of the clinical settings and have an infection control guideline. Although Doherty's study is focused on the male catheterization, I admire the same principle that he promoted in the nursing environment. The same thing goes for the female ward that I'm working into and because of the concentration of the nursing practice in terms of the infection prevention and control; the nursing task will be more focus in providing the quality of health care.
The importance of nursing care responsibility is to provide the best and possible practices in order to follow infection control standards for catheterization. The safety precautions that nurses should need to know can be introduced to help them apply it in their performances. In general, the nursing idea promotes that the knowledge of catheterization and most embody the fundamentals of nursing practice primarily in prevention of the infection and through the control management. In addition, the professional nursing practice should be flexible at all times in order to provide the nursing care during the call of emergency. Based on my experience, the infection control practice should be firstly sought and introduced in the nursing practitioner and be part of the entire team to achieve the desirable outcome in the quality of health care.
As stated by the Hong Kong Department of Health (2010), there are four major infections that present in every health care setting. Therefore, the proper hand hygiene is one important infection prevention and control practice. Supervised hand hygiene can prevent the spread of infection as well as the use of personal protective equipment like gloves prior to the insertion and removal of catheter (RCN, 2008). This practice is essential to prevent transmission of infection due to urinary catheterization. In the nursing care area, the preventive actions should be administered to prevent the transmission of an infectious agent and include salient elements through transmission (Saint et al 2002). In the ward setting, catheter practices varies on the level of care given to the patient and with that fact, the risk in infection is high because of the lack of standard practices.
Creating the guidelines concern with the infection prevention and control is possible through the aid of the nursing professional's catheter knowledge and the evidence-based practices (Pearson, et al., 2007). As the first step, the hand washing practice will provide opportunities for nursing care to be effective in the Urological practice in the ward particularly in placing an emphasis on the safety of the patients' subject for the use of catheter. Through the simple hand washing technique, the infection prevention can be introduced while at the same time and the maximizing effects of nursing care in the female ward. If the practice applied, there would be a better control with the infection that is related in the catheter insertion or removal (Brown et al 2005).
There can be ample need to ensure that there is safe, effective and ethical infection prevention and control measurements and served it as an important component of nursing care. The hand washing and other prevention practice standards has been evidence-based and outline practice expectations for every nurses involved of specific roles and practice care setting. Infection control guide and standards provide a path to information, skill, decision and attitude that has been needed to the practice of safe urine catheterization (WHO, 2009). There describe what each nurse is accountable and responsible for in infection control practice. Public protection can be achieved when nurses practice according to the formulated standards that will work appropriately in their clinical environment. Knowledge of clinical infection control practices is continually growing and changing. While the principles of infection control do not change, specific clinical practices may evolve as a result of new evidence. For this reason, hand washing practice standard provide broad statements and does not include specific clinical practice information (Saint and Chenoweth 2003). Because of the benefits that can be gained in the hand hygiene, we can apply this to nursing practice and focusing on the catheterization nursing practice.
Truly, infection control is a vital form of quality management for urinary catheter application from wherein health care skills are well suited to addressing catheterization quantity issues thereunto. The infection prevention and control on urinary catheterization can allow effective base of catheter quality process upon focusing adverse event and assess function of prevention of the infection (Simmons and Kritchevsky, 2002). Through the continuous practice and monitoring, the compliance with policies and procedures can be ensure and help the nurses to provide infection control in the future problems. There can be examples of appropriate quality indicators that include percentage of the registered nurses hand washing compliance (US Department of Health 2003).
Bad Practice in my work area
In my work place, shower bath is offered to bedridden patients, even patients with urinary catheter but twice a week only due to limited manpower. Poor personal hygiene may lead to urinary tract infection (Chenoweth, 2010), and as I have seen, many patients are suffering in the infection that caused by the catheter. Many bedridden patients are experiencing many health problems as well as sanitation which increase the chance of urinary tract infection, especially in female, and it is expected to increase if the proper perineal cleansing is not performed thoroughly.
It is a routine to empty drainage bag every 4 hours or whenever necessary. This procedure breaks the closed drainage system. Micro-organisms are present at the inlet and outlet tap, making the micro-organisms to enter the drainage system during opened. Apparently, in the current situation of the health care settings, this procedure is overlooked by the ward managers. However, if I suggested that the catheter should be changed more often, it will definitely cost the patient. Therefore, as a solution, the nurses should perform the task by wearing the gloves, doing the procedure within the fastest time, and if possible apply solutions to the inlet/outlet taps like hot water or concentrated alcohol to prevent the movement of the micro organisms. Maki and Tambyah (2001 cited in Madeo 2009) indicated that there are two recognized pathways through which bacteria can gain entry to the bladder of a catheterized patient: the periurethral pathway and the intra-luminal pathway. The periurethral pathway involves the migration of micro-organism into the bladder between the inner side of the urethral wall and the outside of the catheter. The intra-luminal route involves the upward movement of micro-organism inside the catheter drainage system as a result of contamination of the urinary drainage bag, either through the outflow tap or as a result of tubing disconnection. The intra-luminal pathway is thought to be the most common for bacterial entry (Madeo 2009).
In order to clean the perineal area during urinary catheterization and daily perineal swabbing is my ward practice; the 0.9% sodium chloride is recommended to clean the meatus during urinary catheterization, however there is no advantage in using any specific antiseptic solution as a cleansing agent (Madeo 2009). In addition to the study of Madeo (2009), Mucous membranes may be irritated by the use of antiseptic agents, making this painful for the patient. This espoused by the study of Wilson (2001) and concluded that antiseptic solutions present no additional benefit. In addition to the infection risks associated with urinary catheterization, patients can experience trauma and pain. Therefore, it is imperative that the procedure is done by competent and trained healthcare professionals (Madeo 2009). Although insertion of urinary catheter is done by professional registered / enrolled nurse in my work place, they might neglect the importance of aseptic technique. They might not follow protocol strictly or skip some key points such as the standard in cleaning the area in performing urinary catheter insertion when there is a heavy workload.
Minor staff (health care assistance) is lack of knowledge and experience to manage the urinary catheter, especially in cleaning the perineal area of the female patients. In my observation, health care assistances would not clamp the urinary catheter to prevent back flow of urine, when turning patients in bed because of the tendency that the position of the catheter might be affected. Pratt et al (2001) indicated that if downward flow of urine cannot be maintained, the tubing should be clamped for a short period till the correct drainage can be resumed. Occasionally, health care assistance would place the drainage bag above bladder level when the patient is sitting out of bed. But, the incorrect positioning of the drainage bag would assist the transfer of bacteria to the bladder. Therefore, bacteria could be transported distances of 0.9-1.2m in rising air bubbles, often generated when the tubing is kinked and column of urine is formed (Roberts et al 1965 cited in Wilson 2001).
Good practices in my work area
An observational study by Mulhall et al (1993 cited in Madeo 2009) revealed that disconnection of the urinary catheter and drainage bag happened in 11% of catheter care procedures, and that incorrect emptying of urinary bags was also a common problem. There was use of individual cleaned urinary collection container to avoid cross infection in my work area. Our staff uses 70% alcohol to swab the outlet of drainage bag before and after emptying urine bag. Pratt et al (2001 cited in Madeo 2009) stated that the drainage port should be cleaned with an alcohol swab and the urine drained into a single use receiver avoiding contact between the drainage outlet and the receiver. Then the tap should be cleaned with a new alcohol swab. Small bottles of alcohol based hand rub (pocket size) are distributed to every staff. Also, dispenser for alcohol-based hand rub is attached to the frame of each patient's bed. Staff wear clean individual gloves to empty urinary collection bag for each patient and use alcohol based hand rub to disinfect their hands (if hands are not visibly soiled) after removing the gloves. Compared to handwashing, alcohol-based hand rub has been shown to be more effective in decreasing the number of viable bacteria and viruses on hands, require less time to use, cause less hand dryness and hand irritation with repeated use and can be made more accessible at the point of care (Boyce et al cited in Soule and Memish 2007). Boyce et al (cited in Soule and Memish 2007) also recommended to use an alcohol-bases hand rub for routinely decontaminating hands (if hands are not visibly soiled) in the following situations: before inserting indwelling urinary catheters, after contact with body fluids, mucus membranes, non-intact skin, and wound dressings if hands are not visibly soiled, after removing gloves. When the urinary bag is emptied, care should be taken to ensure that bacteria are not introduced on to the tap by contact with a contaminated receiver or container. Urinary containers should be decontaminated in a bedpan washer or autoclaved after each use (Wilson 2001). Urinary containers are routinely decontaminated in a bedpan washer between uses in my work area.
Giving of leaflets about prevention urinary catheter associated infection is routinely given to patient with urinary catheter. Staff would explain the skill of managing urinary catheter, e.g. avoid kinking, stretching and disconnection of catheter, proper positioning of urine bag. Also, video of managing urinary catheter would be shown to patients, in order to reinforce the importance of infection control. Roe (1990 cited in Wilson 2001) revealed that encouraging patients to care for their own urinary catheters can reduce the risk of cross infection in hospital. The long-term catheterized patients in the hospital can benefit from education on how to manage the catheter and decrease the risk of introducing bacteria. In my work place, nurses would further explain the skill of managing urinary catheter, e.g. avoid kinking, stretching and disconnection of catheter, proper positioning of urine bag.
Upon reviewing the nursing practices in my workplace, I firstly recommend in maintaining the level of awareness of the nurses in the infections and how can it be transferred. In this way, we can start to change the bad nursing practices while at the same time, strengthening the good practices. For better personal hygiene, provide shower bath for bedridden patients daily. Advise ambulatory patients to have bathing or shower every day in order to prevent the bacteria that might produce infection. In addition, empty drainage bag daily, or whenever necessary to minimizes micro-organism from entering the close drainage system. Empty the bag as infrequently as possible (Wilson 2001). It is advised to use saline or soap and water, instead of salvon, to clean the perineal area during catheterization and daily swabbing. Wilson (2001) suggested that it is impossible to remove the perineal flora thoroughly prior to the procedure, but the number of bacteria may be reduced by cleansing with saline, or soap and water.
Ideally, regular talk or seminar should be held to reinforce the importance of infection control and hand washing. Wong (cited in Abrutyn 2001) described that hospital personnel and others who take care of urinary catheter should be given periodic in-service training focusing on the correct techniques and potential complication of urinary catheterization. Education is an important factor for improving compliance with guidelines and prevention measures. All health care workers need to know about the risk of infection and the route of transmission of pathogens. There has to be regular audits for nurses and health care assistance on hand hygiene and urinary catheter insertion, e.g. every half year, should be carried out to ensure proper standard (Abrutyn 2001). Thus, posters focusing hand washing can be posted in ward to reinforce important of infection control. Regular infection control seminars are important to the health care assistances and the new comers.
Based on the evaluation on the nursing practice in the female ward, an assessment of bad and good practices has been made and created a great impact to future of the nursing practice. It is not enough to be aware of the infection related to the patient's catheter, what we need is the application of the standards towards infection prevention and control. Through the recommendations presented, the nursing practice might gain its confidence again.
The patients have undergone immediate catheterization might acquire infection if not recognized and controlled properly. Therefore, the simple standards in managing and preventing the infection might be present in the overall catheterization process. Also, such risk factors as identified to be associated with infections and through the careful hand washing as a compliance of nurses in the care setting, there is an assurance that the role of nurses do not only denotes the quality of health care but also the function in promoting the safety and cleanliness.
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