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Improving nursing practice: The provision of equipment
Improving nursing practice: the provision of equipment ANNE MULHALL, B.Sc., Ph.D. KAREN LEE, M.Sc., R.G.N. Nursing Practice Research Unit, Department of Nursing and Midwifery, University of Surrqv. Guildford GlJ2 SXH. u. K.
SUSAN KING, B.Sc., R.G.N. Evuluation Cenrre. Sourhtnead Hospiral. Bristol BSIO SNB. U.K.
Abstract-The quality of nursing care depends not only on the knowledge and skill of practitioners, but also on the equipment provided for their use. The availability and storage of urinary catheters was recorded in two “point prevalence” surveys in one District Health Authority. The numbers of catheters available in different locations were not related to the prevalence or “predicted incidence” of catheterized patients. The second survey documented evidence of improvements in practice, in particular a reduction in excessive and/or outof-date stocks; a reduction in damaged stock; an increased availability of catheters with small balloons; and a greater awareness of those considerations important to a judicious choice of catheter for each individual patient. Equipment audits improve practice by raising awareness of clinical issues; by providing objective evidence of unnecessary expenditure; and by monitoring indirectly certain aspects of care such as the provision of standards and guidelines.
Introduction
The elements of good nursing practice are multifarious, but the effective and efficient provision, and use of equipment is a fundamental aspect. If appropriate equipment is unavailable within a hospital, or is not supplied in the correct locations, practitioners will be unable to provide good quality care. 205
Urinary catheters are one example of equipment which is regularly used for a wide variety of patients in many departments within District General Hospitals (Crow ef al., 1986). However, there is a large and confusing array of urinary catheters available. The selection of both a range of catheters for ward storage, and a catheter to suit an individual patient requires a knowledge of the types of catheter available and the recommendations for their use. The number and types of catheters stored will influence medical and nursing practice and have financial implications. Urethral catheterization may cause immediate damage to the urinary tract, and/or subsequent morbidity, consequent upon an injudicious choice of equipment (Ruutu et al., 1982, 1984; Smith and Neligan, 1982). Although catheterization is a procedure requiring both skill and knowledge, it is frequently delegated to the most junior and inexperienced medical staff (Carter ef a/., 1990). Nurses usually provide doctors with the equipment to be used, but may themselves insert as many as 42% of catheters (Mulhall et al., 1988). This study reports a two stage survey of the availability and storage of urinary catheters in one District Health Authority.
Design and methods
The study took the form of an initial exploratory survey, followed 24 months later by a second descriptive survey. Both surveys were cross-sectional. The following operational goals were defined at the outset. 1. To document the types and numbers of urethral catheters available for use. 2. To determine the conditions of storage. 3. To obtain details of the ward policies/procedures for selecting urethral catheters for individual patients. Purposive sampling was used since the studies were exploratory in nature. Survey I included all wards, accident and emergency departments, out patients departments and operating theatres in one District General Hospital. Survey 2 expanded to include all wards, accident and emergency departments, out patients departments and operating theatres in the seven hospitals in one District Health Authority. Information was collected and recorded directly onto preceded schedules. The development of schedules and choice of data to collect were defined through discussion, and with reference to the literature. All terms used were defined prior to data collection. The following information was collected from every ward/department in the hospital(s): 1. The number and types of catheters available for use. 2. The method and conditions of storage. 3. The ward policy for selecting a catheter for an individual patient. 4. The ward procedure for obtaining stocks of catheters. 5. The prevalence of catheterized patients on each ward at midnight of the day prior to data collection. Information was obtained by interview with the nurse-in-charge; examination of written ward policy and procedures; and visual examination of all urethral catheters.
Results The number and distribution of wards/departments studied are shown in Table 1, whilst Table 2 compares the availability of catheters across the District Health Authority.
Table
I. Distribution
of wards/departments
in the seven hospitals Hospitals
Wards
A
I.3
C
D
E
F
C
j
_
_
_
-
-
-
3
-
-
-
-
-
-
_
-
_ -
-
-
-
, *
, 2 _ , -
_ _ -
I 1 , -
1 , 2 _ -
1 4 _ -
_ I
_ _ I
_ I
-
5 -
-
-
-
1
-
I
I4
bledicine Surgery Orthopaedics Isolation Paediatrics Oncology Urology Gynaecology Accident and emergency “Day cases” Operating theatres Intensive care unit Geriatric Psychogeriatric Young physically disabled Mental health Out patients Obstetrics
-
2
-
-
-
-
-
1 -
-
Total
17
12
5
7
I
3
I4
Table
2. Comparison
Hospital Survey
I 2
A A I3 C D E F G
2 , 1
1
2
of the availability
-
of catheters
Number of cathctcrs 1958 1413 557 I54 415 84 I82 92
across
Number of catheters/ patient 6.5 5.6 4.5 I.0
4.2 6.4 6.5 0.3
the seven hospitals Number of catheters/ catheterized patient 58 59 43 154 26 84 91 92
The number of catheters available per patient ranged from 0.3 in the hospital for mental illness (Hospital G) to 6.5 in Hospital F which was a small GP/Medical hospital. The ratio of catheters: catheterized patients also varied widely from 154 in the psychogeriatric unit to 26 in the hospital for geriatric and young physically disabled patients. Although all hospitals had catheters suitable for long or short term use, a small number of wards failed to stock both types. Comparison of Surveys 1 and 2 The numbers and types of catheter available for use. The urological, paediatric and “day”
208
A. MULH.4 LL er al.
wards, and the accident and emergency department, intensive care unit and operating theatres ordered catheters directly from central stores or the manufacturer. All the remaining wards obtained catheters directly from the urological ward. Three types of catheter were available from central stores: Warne-Franklin “Simplastic” (PVC), Simpla “all-silicone” (solid silicone) and Bard “all Silicone” (solid silicone). The total number of catheters available in the two surveys of the District General Hospital (Hospital A) is shown in Table 3. The distribution of patients across wards and the total proportion of patients catheterized were similar in each survey (x’ = 0.039; P > 0.05). The level of stocks was neither related to the number of patients, nor to the proportion of catheterized patients in a ward. Survey I indicated that large numbers of catheters were stored in wards responsible for their own ordering. Other wards which replaced catheters from a store on the urological ward held smaller, and on occasions, inadequate numbers. For example, 70% of these latter wards had no catheters in two or more of the “popular” sizes between 12-18 Charrieres. Specialist catheters, for example, paediatric or 3-way, were available in the appropriate areas. Warne-Franklin “Simplastic” and Simpla “all-silicone” catheters were available on all wards. Seven further brands of male length, 2-way catheters were recorded. Female length catheters were available only in the Intensive Care Unit. There was a general shortage of solid silicone catheters of large Charriere size with small (5-10 ml) balloon sizes. Table
3. The availability
of urinary
Number of catheters Survey I Survey 2 (a) Wards
obtaining
stock from urological
catheters
in a District
General
Number of patients Survey I Survey 2
Hospital Number and (% age) of patients catheterized Survey I Survey 2
ward
Medical Medical ~Medical Medical Surgical
7 6 9 24 20
16 10 10 9 2
30 29 26 28 28
25 24 28 30 23
0 (0) 4 (13.8) 5 (19.2) 4 (14.3) 2 (7.1)
0 (0) 2 (8.3) 3 (10.7)
Surgical. Surgical Orthopaedic Orthopaedic
5 6 8 25
13 4 5
29 28 28 23
29 30 23 I6
I (3.4) 3 (10.7) 4 (14.3) 4 (17.4)
0 (0) 6 (20.0) 4 (17.4) 3 (18.8)
0
0
5
2
0
0
Isolation (b) Wards obtaining catheters Accident and emergency Day Pacdiatric Urological Intensive care unit Operating theatres Total
from central I2
I
stores I9
(0)
I 2
(3.3) (8.7)
(0)
87
72
n/a n/a
n/a n/a
n/a n/a
n/a n/a
127 791 116 716
50 467 18 717
I4 28 7 n/a
I5 30 5 n/a
0 (0) 6 (21.4) I (14.2) n/a
0 (0) 9 (30.0) 3 (60.0) n/a
1958
1413
303
280
34 (11.2)
33 (11.7)
At the time of the second survey the total ward stock of catheters was reduced by 27.8%. Three of four wards/departments which had previously held excessive numbers of catheters had reduced these considerably. However, stocks in the Day Ward and in the Accident
IMPROVING
NURSING
PRACTICE
209
and Emergency Department (which had a written policy not to perform catheterizations) were still high. As before, some wards held inadequate stocks (4/17 having five or fewer catheters in total). The majority of catheters were of the same two brand types as before, but one further brand, Bard “all Silicone” was quite widely available. A further 15 different types of catheter were recorded, the widest range being held in the operating theatres, urological ward and day ward. Specialist catheters were available in appropriate locations, but only 22 female length catheters were stocked (all in the Urological Ward). Three wards including the Intensive Care Unit only held Simplastic catheters (Warne-Franklin). There was widespread availability of catheters with small balloons (i.e. 5-10 ml). Methods and conditions of srorage. All catheters were stored on shelves or in pigeon holes, either in a clean utility room or a dedicated store room, with the exception of the day ward where a window sill was used (in both surveys). The manufacturer’s box was utilized for storage in five locations. In the first survey 1l/l7 (64.7%) wards possessed some stock which had either passed the expiry date or was greater than 5 years old. In the second survey this had reduced to 5/17 (29.4%) locations. Damage to the catheter or packaging, or the potential for damage by direct heat or sunlight was recorded in seven locations in the first survey, but only one location in the second. Ward policy for selecting a catheter for an individual parient. No ward had a written policy for selection of the material, Charritre size, length or balloon volume of a catheter. However, 5/17 wards in the first survey and 12/17 in the second, stated that the material chosen depended on the expected duration of catheterization. “Simplastic” catheters being for “short term” and solid silicone for “long term” use. In addition 5/ 12 wards in Survey 2 had unwritten recommendations concerning the Charrihre and/or balloon size of catheters.
Discussion
The complexities of urethral catheterization have been highlighted previously (Mulhall, 1990). Effective nursing management of catheterized patients relies on a knowledge of both the complications which may arise, and the preventative strategies which will minimize adverse events. Choice of equipment is one of the first stages involved in the care of patients undergoing catheterization. Urinary catheters need to be carefully selected on the basis of individual needs (Belfield, 1988). The material, gauge size, balloon volume and design of catheters will influence the occurrence of adverse sequelae such as tissue trauma, encrustation, formation of biofilms and patient comfort. Urethral trauma and “by-passing” of urine are associated with catheters of large Charriere size (Kennedy et al., 1983). Catheters with 30 ml balloons are probably only required following urological surgery (Slade and Gillespie, 1985) and should therefore be stored only in the operating theatres or urological ward. The choice of which catheter to use will be dependent on the stock available and the knowledge of the personnel performing the insertion. That both medical and nursing staff lack the relevant knowledge to ensure good “catheter/drainage bag practice” has been demonstrated recently (Carter et al., 1990; Crummey, 1989). It is essential therefore that experienced personnel should decide which catheter should be ordered, and good stock control procedures should be invoked to ensure adequate availability whilst avoiding waste. The storage of excess numbers of catheters is an unnecessary expense. The volume and range of stocks held on wards should be dictated by the incidence of catheterizations. However, a minimum range should be stored to provide sufficient choice for practitioners.
210
.-I. .\IL’L H.-l L L er al.
The prevalence of catheterized patients cannot be used to predict accurately the levels of stock necessary. However, in conjunction with the total number, and types of patient within a hospital, it may be used as a guide to estimating demand. Previous research has demonstrated that the highest incidence of catheterizations occurs in surgical, gynaecological, genito-urinary and intensive care units (18.6-70.7/1000 patients), whereas medical, orthopaedic and geriatric wards have a lower incidence (3.1-7.3/1000 patients) (Crow er al., 1986). The numbers of catheters stocked by wards in Hospitals D, E and F were therefore probably excessive with regard to the types and numbers of patient treated. The survey as an audit tool The aim of a clinical audit is to improve patient care and the use of resources. The surveys reported here provided objective evidence by which the quality of practice concerning the availability and storage of catheters could be examined and subsequently monitored. Ideally practice should be evaluated against written and agreed standards of care (Lewis, 1990). In this study a comparison was made with recommendations within the research literature. Thus the availability of catheters suitable for long and short term use, catheters with small balloon sizes, and specialist categories of catheter, provided examples of “good quality” practice. The first survey highlighted a number of areas for concern: ?? The high level of stock on wards which obtained catheters directly from central stores. ?? The possession of out-of-date stock. ?? The potential or actual damage to stored catheters. ?? The low levels of popular size catheters on some vvards. ?? The lack of written guidelines for the selection of catheters. ?? The lack of female length catheters. By repeating the first survey, a valuable extra dimension was added-that of monitoring. The first three items of concern had broadly received attention, although one particular ward where improvements were still required was identified. Written policies or guidelines fulfil a dual purpose, firstly in providing guidance to practitioners and secondly by stating a given standard of care. Written policies/guidelines for selection were not recorded during either survey. However, the proportion of wards recognizing, in unwritten policies, such fundamental aspects of good practice as using small balloon sizes increased. The lack of female length catheters has been recorded in several surveys (Crow et a/., 1986) and practitioners remain to be convinced of their advantages for non-ambulant females. Although equipment audits may be labour intensive in the short term, in our experience they have proved successful by: raising awareness of clinical issues, for example; the need for correct storage conditions; highlighting economic and space issues, eg. the maintenance of excessive stock; and monitoring basic practice and procedures as in the provision of written standards. Acknowle~gemenrs-The Nursing Practice Research Unit is funded by the Department to all participating hospitals for allowing us access.
of Health.
We are grateful
References Belficld. P. \V. (1988). Everyday Carter, R.. Aitchison. &I.. bluffi. Merl. J. 301. 905.
aids and appliances. Urinary catheters. Dr. Med. J. 296, 836-837. G. R. and Scott, R. (1990). Catheterisation: your urethra in their hands. Br.
211
I.WPROk’ING NVRSI<~G PR.-lCTICE
R. G., Roe, B. and Wilson, J. (1986). tl srud.v of parienrs with an indwelling urethral from the Nursing Practice Research Unit, University of Surrey. Crummey, V. (1989). “Ignorance can hurt”. Nurs. Times 85 (21), 66-70. Kennedy, A., Brocklehurst, J. C. and Lye, M. D. W. (1983). Factors related to the problems of long term catheterisation. J. Adv. Nurs. 8. 207-212. Lewis. M. (1990). .4n overview of components necessary for the systematic evaluation of nursing practice. Standards and Nursing Audit. Int. J. Healfh Care Qual. Assur. 3. 21-32. \lulhall, A. B., Chapman, R. G. and Crow, R. A. (1988). Bacteriuria during indwelling urethral catheterisation. J. Hosp. Inject. II. 253-262. Ruutu, M., Alfthan, O., Heikkinen, L., Jarvinen, A.. Lehtonen, T.. Merikallio, E. and StandertskjoldNordemstam, G. G. (1982). Epidemic of acute urethral stricture after open-heart surgery. Lancer 23, 218. Ruutu, M.. Alfthan, 0.. Heikkinen, L., Jarvinen, A. M., Lehtonen, T.. Merikallio, E. and StandertskjoldNordemstam. C. G. (198J). Unexpected urethral strictures after short-term catheterisation during open-heart surgery. Stand. J. Vrol. Nephrol. 8. 9-12. Slade, N. and Gillespie, W. A. (1985). The Urinary Tract and the Carheter. Infection and Orher Problems. John Wiley, Chichester. Smith, J. M. and Neligan. bl. (1982). Urethral strictures after open-heart surgery (letter): Lancer I. 392. Crow.
R. A.,
Chapman,
cafherer and related nursing procrice. Report
(Received I9 September
1991; accepred for publicarion
I4 November
1991)
SUSAN KING, B.Sc., R.G.N. Evuluation Cenrre. Sourhtnead Hospiral. Bristol BSIO SNB. U.K.
Abstract-The quality of nursing care depends not only on the knowledge and skill of practitioners, but also on the equipment provided for their use. The availability and storage of urinary catheters was recorded in two “point prevalence” surveys in one District Health Authority. The numbers of catheters available in different locations were not related to the prevalence or “predicted incidence” of catheterized patients. The second survey documented evidence of improvements in practice, in particular a reduction in excessive and/or outof-date stocks; a reduction in damaged stock; an increased availability of catheters with small balloons; and a greater awareness of those considerations important to a judicious choice of catheter for each individual patient. Equipment audits improve practice by raising awareness of clinical issues; by providing objective evidence of unnecessary expenditure; and by monitoring indirectly certain aspects of care such as the provision of standards and guidelines.
Introduction
The elements of good nursing practice are multifarious, but the effective and efficient provision, and use of equipment is a fundamental aspect. If appropriate equipment is unavailable within a hospital, or is not supplied in the correct locations, practitioners will be unable to provide good quality care. 205
Urinary catheters are one example of equipment which is regularly used for a wide variety of patients in many departments within District General Hospitals (Crow ef al., 1986). However, there is a large and confusing array of urinary catheters available. The selection of both a range of catheters for ward storage, and a catheter to suit an individual patient requires a knowledge of the types of catheter available and the recommendations for their use. The number and types of catheters stored will influence medical and nursing practice and have financial implications. Urethral catheterization may cause immediate damage to the urinary tract, and/or subsequent morbidity, consequent upon an injudicious choice of equipment (Ruutu et al., 1982, 1984; Smith and Neligan, 1982). Although catheterization is a procedure requiring both skill and knowledge, it is frequently delegated to the most junior and inexperienced medical staff (Carter ef a/., 1990). Nurses usually provide doctors with the equipment to be used, but may themselves insert as many as 42% of catheters (Mulhall et al., 1988). This study reports a two stage survey of the availability and storage of urinary catheters in one District Health Authority.
Design and methods
The study took the form of an initial exploratory survey, followed 24 months later by a second descriptive survey. Both surveys were cross-sectional. The following operational goals were defined at the outset. 1. To document the types and numbers of urethral catheters available for use. 2. To determine the conditions of storage. 3. To obtain details of the ward policies/procedures for selecting urethral catheters for individual patients. Purposive sampling was used since the studies were exploratory in nature. Survey I included all wards, accident and emergency departments, out patients departments and operating theatres in one District General Hospital. Survey 2 expanded to include all wards, accident and emergency departments, out patients departments and operating theatres in the seven hospitals in one District Health Authority. Information was collected and recorded directly onto preceded schedules. The development of schedules and choice of data to collect were defined through discussion, and with reference to the literature. All terms used were defined prior to data collection. The following information was collected from every ward/department in the hospital(s): 1. The number and types of catheters available for use. 2. The method and conditions of storage. 3. The ward policy for selecting a catheter for an individual patient. 4. The ward procedure for obtaining stocks of catheters. 5. The prevalence of catheterized patients on each ward at midnight of the day prior to data collection. Information was obtained by interview with the nurse-in-charge; examination of written ward policy and procedures; and visual examination of all urethral catheters.
Results The number and distribution of wards/departments studied are shown in Table 1, whilst Table 2 compares the availability of catheters across the District Health Authority.
Table
I. Distribution
of wards/departments
in the seven hospitals Hospitals
Wards
A
I.3
C
D
E
F
C
j
_
_
_
-
-
-
3
-
-
-
-
-
-
_
-
_ -
-
-
-
, *
, 2 _ , -
_ _ -
I 1 , -
1 , 2 _ -
1 4 _ -
_ I
_ _ I
_ I
-
5 -
-
-
-
1
-
I
I4
bledicine Surgery Orthopaedics Isolation Paediatrics Oncology Urology Gynaecology Accident and emergency “Day cases” Operating theatres Intensive care unit Geriatric Psychogeriatric Young physically disabled Mental health Out patients Obstetrics
-
2
-
-
-
-
-
1 -
-
Total
17
12
5
7
I
3
I4
Table
2. Comparison
Hospital Survey
I 2
A A I3 C D E F G
2 , 1
1
2
of the availability
-
of catheters
Number of cathctcrs 1958 1413 557 I54 415 84 I82 92
across
Number of catheters/ patient 6.5 5.6 4.5 I.0
4.2 6.4 6.5 0.3
the seven hospitals Number of catheters/ catheterized patient 58 59 43 154 26 84 91 92
The number of catheters available per patient ranged from 0.3 in the hospital for mental illness (Hospital G) to 6.5 in Hospital F which was a small GP/Medical hospital. The ratio of catheters: catheterized patients also varied widely from 154 in the psychogeriatric unit to 26 in the hospital for geriatric and young physically disabled patients. Although all hospitals had catheters suitable for long or short term use, a small number of wards failed to stock both types. Comparison of Surveys 1 and 2 The numbers and types of catheter available for use. The urological, paediatric and “day”
208
A. MULH.4 LL er al.
wards, and the accident and emergency department, intensive care unit and operating theatres ordered catheters directly from central stores or the manufacturer. All the remaining wards obtained catheters directly from the urological ward. Three types of catheter were available from central stores: Warne-Franklin “Simplastic” (PVC), Simpla “all-silicone” (solid silicone) and Bard “all Silicone” (solid silicone). The total number of catheters available in the two surveys of the District General Hospital (Hospital A) is shown in Table 3. The distribution of patients across wards and the total proportion of patients catheterized were similar in each survey (x’ = 0.039; P > 0.05). The level of stocks was neither related to the number of patients, nor to the proportion of catheterized patients in a ward. Survey I indicated that large numbers of catheters were stored in wards responsible for their own ordering. Other wards which replaced catheters from a store on the urological ward held smaller, and on occasions, inadequate numbers. For example, 70% of these latter wards had no catheters in two or more of the “popular” sizes between 12-18 Charrieres. Specialist catheters, for example, paediatric or 3-way, were available in the appropriate areas. Warne-Franklin “Simplastic” and Simpla “all-silicone” catheters were available on all wards. Seven further brands of male length, 2-way catheters were recorded. Female length catheters were available only in the Intensive Care Unit. There was a general shortage of solid silicone catheters of large Charriere size with small (5-10 ml) balloon sizes. Table
3. The availability
of urinary
Number of catheters Survey I Survey 2 (a) Wards
obtaining
stock from urological
catheters
in a District
General
Number of patients Survey I Survey 2
Hospital Number and (% age) of patients catheterized Survey I Survey 2
ward
Medical Medical ~Medical Medical Surgical
7 6 9 24 20
16 10 10 9 2
30 29 26 28 28
25 24 28 30 23
0 (0) 4 (13.8) 5 (19.2) 4 (14.3) 2 (7.1)
0 (0) 2 (8.3) 3 (10.7)
Surgical. Surgical Orthopaedic Orthopaedic
5 6 8 25
13 4 5
29 28 28 23
29 30 23 I6
I (3.4) 3 (10.7) 4 (14.3) 4 (17.4)
0 (0) 6 (20.0) 4 (17.4) 3 (18.8)
0
0
5
2
0
0
Isolation (b) Wards obtaining catheters Accident and emergency Day Pacdiatric Urological Intensive care unit Operating theatres Total
from central I2
I
stores I9
(0)
I 2
(3.3) (8.7)
(0)
87
72
n/a n/a
n/a n/a
n/a n/a
n/a n/a
127 791 116 716
50 467 18 717
I4 28 7 n/a
I5 30 5 n/a
0 (0) 6 (21.4) I (14.2) n/a
0 (0) 9 (30.0) 3 (60.0) n/a
1958
1413
303
280
34 (11.2)
33 (11.7)
At the time of the second survey the total ward stock of catheters was reduced by 27.8%. Three of four wards/departments which had previously held excessive numbers of catheters had reduced these considerably. However, stocks in the Day Ward and in the Accident
IMPROVING
NURSING
PRACTICE
209
and Emergency Department (which had a written policy not to perform catheterizations) were still high. As before, some wards held inadequate stocks (4/17 having five or fewer catheters in total). The majority of catheters were of the same two brand types as before, but one further brand, Bard “all Silicone” was quite widely available. A further 15 different types of catheter were recorded, the widest range being held in the operating theatres, urological ward and day ward. Specialist catheters were available in appropriate locations, but only 22 female length catheters were stocked (all in the Urological Ward). Three wards including the Intensive Care Unit only held Simplastic catheters (Warne-Franklin). There was widespread availability of catheters with small balloons (i.e. 5-10 ml). Methods and conditions of srorage. All catheters were stored on shelves or in pigeon holes, either in a clean utility room or a dedicated store room, with the exception of the day ward where a window sill was used (in both surveys). The manufacturer’s box was utilized for storage in five locations. In the first survey 1l/l7 (64.7%) wards possessed some stock which had either passed the expiry date or was greater than 5 years old. In the second survey this had reduced to 5/17 (29.4%) locations. Damage to the catheter or packaging, or the potential for damage by direct heat or sunlight was recorded in seven locations in the first survey, but only one location in the second. Ward policy for selecting a catheter for an individual parient. No ward had a written policy for selection of the material, Charritre size, length or balloon volume of a catheter. However, 5/17 wards in the first survey and 12/17 in the second, stated that the material chosen depended on the expected duration of catheterization. “Simplastic” catheters being for “short term” and solid silicone for “long term” use. In addition 5/ 12 wards in Survey 2 had unwritten recommendations concerning the Charrihre and/or balloon size of catheters.
Discussion
The complexities of urethral catheterization have been highlighted previously (Mulhall, 1990). Effective nursing management of catheterized patients relies on a knowledge of both the complications which may arise, and the preventative strategies which will minimize adverse events. Choice of equipment is one of the first stages involved in the care of patients undergoing catheterization. Urinary catheters need to be carefully selected on the basis of individual needs (Belfield, 1988). The material, gauge size, balloon volume and design of catheters will influence the occurrence of adverse sequelae such as tissue trauma, encrustation, formation of biofilms and patient comfort. Urethral trauma and “by-passing” of urine are associated with catheters of large Charriere size (Kennedy et al., 1983). Catheters with 30 ml balloons are probably only required following urological surgery (Slade and Gillespie, 1985) and should therefore be stored only in the operating theatres or urological ward. The choice of which catheter to use will be dependent on the stock available and the knowledge of the personnel performing the insertion. That both medical and nursing staff lack the relevant knowledge to ensure good “catheter/drainage bag practice” has been demonstrated recently (Carter et al., 1990; Crummey, 1989). It is essential therefore that experienced personnel should decide which catheter should be ordered, and good stock control procedures should be invoked to ensure adequate availability whilst avoiding waste. The storage of excess numbers of catheters is an unnecessary expense. The volume and range of stocks held on wards should be dictated by the incidence of catheterizations. However, a minimum range should be stored to provide sufficient choice for practitioners.
210
.-I. .\IL’L H.-l L L er al.
The prevalence of catheterized patients cannot be used to predict accurately the levels of stock necessary. However, in conjunction with the total number, and types of patient within a hospital, it may be used as a guide to estimating demand. Previous research has demonstrated that the highest incidence of catheterizations occurs in surgical, gynaecological, genito-urinary and intensive care units (18.6-70.7/1000 patients), whereas medical, orthopaedic and geriatric wards have a lower incidence (3.1-7.3/1000 patients) (Crow er al., 1986). The numbers of catheters stocked by wards in Hospitals D, E and F were therefore probably excessive with regard to the types and numbers of patient treated. The survey as an audit tool The aim of a clinical audit is to improve patient care and the use of resources. The surveys reported here provided objective evidence by which the quality of practice concerning the availability and storage of catheters could be examined and subsequently monitored. Ideally practice should be evaluated against written and agreed standards of care (Lewis, 1990). In this study a comparison was made with recommendations within the research literature. Thus the availability of catheters suitable for long and short term use, catheters with small balloon sizes, and specialist categories of catheter, provided examples of “good quality” practice. The first survey highlighted a number of areas for concern: ?? The high level of stock on wards which obtained catheters directly from central stores. ?? The possession of out-of-date stock. ?? The potential or actual damage to stored catheters. ?? The low levels of popular size catheters on some vvards. ?? The lack of written guidelines for the selection of catheters. ?? The lack of female length catheters. By repeating the first survey, a valuable extra dimension was added-that of monitoring. The first three items of concern had broadly received attention, although one particular ward where improvements were still required was identified. Written policies or guidelines fulfil a dual purpose, firstly in providing guidance to practitioners and secondly by stating a given standard of care. Written policies/guidelines for selection were not recorded during either survey. However, the proportion of wards recognizing, in unwritten policies, such fundamental aspects of good practice as using small balloon sizes increased. The lack of female length catheters has been recorded in several surveys (Crow et a/., 1986) and practitioners remain to be convinced of their advantages for non-ambulant females. Although equipment audits may be labour intensive in the short term, in our experience they have proved successful by: raising awareness of clinical issues, for example; the need for correct storage conditions; highlighting economic and space issues, eg. the maintenance of excessive stock; and monitoring basic practice and procedures as in the provision of written standards. Acknowle~gemenrs-The Nursing Practice Research Unit is funded by the Department to all participating hospitals for allowing us access.
of Health.
We are grateful
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R. G., Roe, B. and Wilson, J. (1986). tl srud.v of parienrs with an indwelling urethral from the Nursing Practice Research Unit, University of Surrey. Crummey, V. (1989). “Ignorance can hurt”. Nurs. Times 85 (21), 66-70. Kennedy, A., Brocklehurst, J. C. and Lye, M. D. W. (1983). Factors related to the problems of long term catheterisation. J. Adv. Nurs. 8. 207-212. Lewis. M. (1990). .4n overview of components necessary for the systematic evaluation of nursing practice. Standards and Nursing Audit. Int. J. Healfh Care Qual. Assur. 3. 21-32. \lulhall, A. B., Chapman, R. G. and Crow, R. A. (1988). Bacteriuria during indwelling urethral catheterisation. J. Hosp. Inject. II. 253-262. Ruutu, M., Alfthan, O., Heikkinen, L., Jarvinen, A.. Lehtonen, T.. Merikallio, E. and StandertskjoldNordemstam, G. G. (1982). Epidemic of acute urethral stricture after open-heart surgery. Lancer 23, 218. Ruutu, M.. Alfthan, 0.. Heikkinen, L., Jarvinen, A. M., Lehtonen, T.. Merikallio, E. and StandertskjoldNordemstam. C. G. (198J). Unexpected urethral strictures after short-term catheterisation during open-heart surgery. Stand. J. Vrol. Nephrol. 8. 9-12. Slade, N. and Gillespie, W. A. (1985). The Urinary Tract and the Carheter. Infection and Orher Problems. John Wiley, Chichester. Smith, J. M. and Neligan. bl. (1982). Urethral strictures after open-heart surgery (letter): Lancer I. 392. Crow.
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cafherer and related nursing procrice. Report
(Received I9 September
1991; accepred for publicarion
I4 November
1991)