How many "sacred cows" are still in your pasture?
Catheters to prevent leaks are not best practices
[Editor's note: This is the second article of a two-part series on how to reduce the risk of infection for patients with indwelling bladder catheters. Last month we discussed the factors that increase the risk of infection, patient and staff education, and identification of best practices. This month, the "sacred cows," or practices that are not based on scientific evidence, will be identified along with the proper practices for catheter care.]
Participants in the Infection Surveillance Project of the Missouri Alliance for Home Care (MAHC) see their bladder catheter infection rates drop when they participate in the project for several reasons that include a staff focus on the issue, comprehensive education, and the exchange of best practices and ideas among the project participants.
One of the other frequent topics of conversation are the "sacred cows," or the myths about catheter care that physicians, nurses and patients believe because "this is how we've always done it."
"Early on in the project we discovered through group conference calls that many nurses were increasing the size of the catheters if there was leakage," says Mary Schantz, executive director of MAHC. Scientific evidence shows that you should not use a larger catheter, she adds.
"Smaller is better," agrees Lisa Gorski, MS, APRN, BC, CRNI, FAAN, clinical nurse specialist at Wheaton Franciscan Home Health & Hospice in Milwaukee. "There is less irritation, less pressure, and less stress on the urethra," she explains. In fact, a larger catheter can damage the urethra, she adds.
Because patients who experience leakage might reduce their fluid intake to control it, be sure to teach them that it is important to maintain urinary output, points out Gorski. " Fluid intake is important to keep urine flowing through the catheter; if the patient is experiencing leakage, it is important to assess for causes. For example, constipation or drinking caffeinated fluids may contribute to bladder spasms," she suggests.
Another long-time practice is the catheter change at regular intervals, says Gorski. Changing the catheter every four weeks, even if the patient is not experiencing any problems, is not necessary, she says. "The catheter should be changed based upon patient need. If the patient is not experiencing problems, reducing catheter changes to every 4 to 6 weeks is fine; if the patient has sediment problems, catheters should be changed more often, before blockage occurs," she adds.
Patient education is toughest
Perhaps the most difficult challenge to changing the practice of replacing the catheter at regular intervals is the patient, points out Rita Sansoucie, RN, BSN, staff development director of Phelps Regional Homecare in Rolla, MO. Even though her nurses no longer change catheters if it is not necessary, there are some patients who are resistant to the change. "We have one patient who has had a catheter for a long time, and we change her catheter every 30 days," she explains. Even though her nurse talked about the evidence that shows it is not necessary, she insisted that it be changed. "You have to take the patient's preferences into account," she adds.
Educating patients about a change related to catheter change intervals must be taken slowly when the patient has had a catheter for a long time, says Gorski. Many patients believe that one month is the "magic" time when the catheter must be changed, she says. Who educates the patient also has an impact on the patient's acceptance of the change, she points out. "It takes a nurse who understands the reasons for the change and believes that the change is better for the patient," she says.
Even when you educate your nurses and patients and demonstrate that there is no reason to change the catheter, you need to share that information with the physician as well, suggests Schantz. "Sometimes, the requirement for regular catheter changes comes from the physician," she explains.
Some physicians are also writing orders to irrigate the system on a regular basis, says Sansoucie. "We can't eliminate flushing completely, but we do share information with the physician to show that we can address some problems with dietary changes, such as adding cranberry juice to the patient's diet," she says.
Some physicians tend to order cultures on a routine basis but that is not necessary, points out Gorski. "When I first started working at this agency, there was an overreaction to changes in the urine appearance, and cultures were frequently ordered," she says. It is more important to look at the pattern of symptoms that the patient typically has when an infection is present rather than the single symptom of unusual appearance to the urine, she says. Fever or increased confusion along with cloudy urine indicate a possible infection, while cloudy urine alone does not in all cases, she adds.
Good hygiene practices are an important part of education for patients with catheters, but even in this area there are some myths, says Gayle Lovato, RN, MS, infection control practitioner at Inova Loudoun Hospital in Leesburg, VA, and a member of the Association of Infection Control Professional's communications committee. "Some patients still use an antimicrobial cream at the insertion site," she says. There is no evidence that it does any good and it is unnecessary, she says. "The best way to keep the insertion site clean is to use soap and water, and pat the area dry," she adds.
Sacred cows are hard to eliminate in any healthcare setting because people accept long- time practices without asking the reason, admits Lovato. Education and asking questions about the purpose of certain activities is important, she says. "I've been a nurse for 34 years, and I remember that early in my career in a hospital the nurses were told to face the open end of the pillowcase away from the door," she says. After some time of doing this one of the nurses asked the floor nurse who insisted on this practice the reason for keeping the opening away from the door. The nurse answered, "Because my mom did it that way."
Sources
- Mary Schantz, Executive Director, Missouri Alliance for Home Care, 2420 Hyde Park, Suite A, Jefferson City, MO 65109-4731. Telephone: (573) 634-7772. Fax: (573) 634-4374. E-mail: [email protected].
- Rita Sansoucie, RN, BSN, Staff Development Director, Phelps Regional Homecare 1202 Homelife Drive, Rolla, Mo. 65401. Telephone: (573) 364-2425. Fax Number: (573) 364-3993. E-mail: [email protected].
- Gayle Lovato, MS, RN, Infection Control Practitioner, Inova Loudoun Hospital, 44045 Riverside Parkway, Leesburg, VA 20176-5101. Telephone: (703) 858-6630. Fax: (703) 858-8933. E-mail: [email protected].
- Lisa Gorski, MS, APRN, BC, CRNI, FAAN, Clinical Nurse Specialist at Wheaton Franciscan Home Health & Hospice, 9688 W. Appleton Avenue, Milwaukee, WI 53225. Telephone: (414) 535-6922. E-mail: [email protected].
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