Clean or sterile technique when inserting indwelling urinary catheter: An evaluation of nurses’ and assistant nurses’ interpretations of a guideline at an acute-care hospital in Sweden

Abstract

Insertion of indwelling urinary catheters should be performed in a way that minimizes the risk of introducing bacteria to the urinary bladder. Nurses and assistant nurses from three departments at an acute-care hospital in Sweden answered a questionnaire about their insertion of urinary catheterization. Of the 563 nurses, 92% answered the questionnaire. Among the 492 who performed catheterization, 58% (n = 287) said that they followed the hospital guideline. Two-thirds of those following the hospital guideline said that they used clean technique and one-third sterile technique. In all, 82% considered the catheter should be kept sterile while inserted but only 16% described all the prerequisites to achieve this. Over 90% of the respondents performed catheterization less than once a week. Our conclusion is that a guideline should describe every step of catheterization in detail and that an evidence-based process for implementation of the guideline is necessary to achieve uniformity in performance.

Keywords

clean technique healthcare-associated urinary tract infection indwelling urinary catheterization insertion technique sterile technique

Introduction

Indwelling urinary catheter (IUC) use is associated with symptomatic urinary tract infection, usually called catheter-associated urinary tract infection (CAUTI), as well as asymptomatic bacteriuria. CAUTI constitutes an important risk for blood stream infection.^1–3 The prevalence of indwelling urinary catheter use among inpatients in the US and Europe is in the range of 17–24%.^4,5 Among inpatients in Sweden the prevalence of IUC use in 2017 was 22.6% according to the yearly national survey covering just over 15,000 patients.⁶

As pointed out in previous studies, use of indwelling urinary catheters should be limited and when used catheter insertion and maintenance should be performed in a way that minimizes the risk of introducing bacteria to the urinary bladder.^1,2,7 Guidelines from The Centers for Disease Control and Prevention (CDC) and The European Association of Urology Nurses (EAUN) recommend ‘sterile technique’ when inserting an indwelling urinary catheter. Sterile technique includes a sterile catheter, sterile equipment and maintaining sterility during catheter insertion.^8,9

A method for urinary catheterization called ‘clean technique’ was introduced in the early 1970s by Lapides et al. as a safe way to perform intermittent self-catheterization in patients with neurogenic bladder dysfunctions.^10,11 Since around 1990 the Swedish national guidelines for urinary catheterization were altered from sterile technique to clean technique not only for intermittent self-catheterization performed by patients but also for indwelling urinary catheterization performed by professionals.¹² Sterile technique included a sterile catheter, a sterile set for catheterization, sterile gloves, sterile equipment, sterile draping and sterile fluids for peri-urethral cleaning before catheterization. With the introduction of clean technique in the Swedish national guidelines for urinary catheterization, a sterile set for catheterization was excluded and the need for sterile draping of the catheterization area was not included. Further, non-sterile equipment as well as non-sterile gloves and fluids were introduced. With these changes, sterile draping was no longer mandatory, and the sterile urinary catheter could be held and inserted with non-sterile gloves and/or non-sterile forceps. These changes from sterile to clean technique for insertion of an indwelling urinary catheter have influenced what has been taught at nursing schools for professional education in Sweden during recent decades.

The purpose of the present national guidelines, revised November 2017, is to emphasize the importance of maintaining the sterility of the indwelling urinary catheter during insertion. There is, however, no recommendation for sterile equipment and non-sterile examination gloves are recommended.¹³ The confusion about catheterization techniques in practice has been observed by the European Association of Urology Nurses (EAUN).¹⁴

In Sweden, urinary catheterization of patients at hospitals is mostly performed by nurses but also by assistant nurses after personal written delegation from a nurse. Local hospital guidelines are based on the national guidelines. The local guideline for urinary bladder catheterization via the urethra, at the hospital that participated in this study, was launched in 2006 and updated in 2011. The terms ‘sterile technique’ and ‘clean technique’ are not used and in contrast to the national guidelines it is clearly stated that the urinary catheter should only be touched by sterile gloves or sterile forceps. Draping is not mentioned in the guideline.

In the light of these changes of the routines for indwelling urinary catheterization in Sweden over the years our aim was to investigate how nurses and assistant nurses described their performance of catheterization in daily work, their opinion on sterility of the catheter, how they denominated the routine they practice, and whether they followed the local hospital guideline for urinary catheterization.

Method

Design

The study design was comparative and descriptive, and the study was based on a structured questionnaire.

Measurement

The questionnaire included seven questions concerning occupation, time of professional education and time of employment and 12 questions concerning performance of indwelling urinary catheterization (i.e. frequency of catheter insertion, type of equipment used when inserting an indwelling urinary catheter, sterility requirements for the catheter and equipment used and designation of insertion technique).

Setting and participants

The participants were nurses and assistant nurses employed at the acute-care hospital with 600 beds. All participants worked on wards caring for inpatients at the departments of cardiology and internal medicine and surgery. At the end of 2015 the medical director at the hospital and the managers of the three departments were contacted by email to inform them about the study and to gain their permission to perform it. At the beginning of 2016, head nurses of the included departments were contacted to inform them about the study. Head nurses from 15 wards answered that insertion of indwelling urinary catheters was practiced in their ward and 14 of them accepted participation in the study. A list containing names and professions of all the nurses and assistant nurses working in each ward was received from the head nurses. Employees on long-term sick leave and parental leave were excluded. All other nurses and assistant nurses were included. Each included person received a serial number and the questionnaire received the same serial number. During spring 2016 the questionnaires were distributed to all included persons together with written information about the study. Verbal information was given in groups and, in some cases, individually. The participants were asked to not discuss the questions in the questionnaire during the period of participation. Each participant received a preaddressed envelope and was informed that participation was by choice. They were asked to return the completed or unanswered questionnaire in the preaddressed envelope to the study conductor within two weeks. No information was given to the head nurses concerning who answered the questionnaire and who did not.

Construct validity

Prior to the study being conducted a nurse and an assistant nurse at another hospital in Stockholm County Council individually answered the questionnaire to evaluate the comprehensiveness of the questions.

Data analysis

Microsoft Office Excel was used for entering the data from the questionnaires. Statistical analysis for significance was performed with the chi-squared test by using the software Epi-info 7™ (https://www.cdc.gov/epiinfo/index.html). Odds Ratios (OR) > 1.0 and p-values < 0.05 were regarded as significant.

Ethical considerations

Participation in the study was by choice. During the process of entering and analysing data in the computer only the serial numbers were used. The study was not subject to judgement by an ethics committee as it was regarded as a quality evaluation project.

Results

A total of 563 nurses and assistant nurses were included. Of the 518 participants who returned completed questionnaires, 323 were nurses and 195 were assistant nurses. According to their answers 12 nurses and 14 assistant nurses never inserted urinary catheters. The results presented are thus based on the answers from 492 persons who said that they performed urinary catheterization. Among those were 311 nurses (127 cardiology, 134 internal medicine, 50 surgery) and 181 assistant nurses (59 cardiology, 89 internal medicine, 33 surgery). All questions were not completely answered by all responders (see Table 1).

Table 1.

Distribution of nurses and assistant nurses from the departments of cardiology and internal medicine and surgery.

	Total		Nurses		Assistant nurses
	Included, n	Answers, n (%)	Answers, n	Never insert urinary catheter, n	Answers, n	Never insert urinary catheter, n
Cardiology	204	192 (94.1)	131	4	61	2
Internal medicine	270	241 (89.3)	140	6	101	12
Surgery	89	85 (95.5)	52	2	33	0
Total	563	518 (92.0)	323	12	195	14

Below we present results from 7 of the 12 questions concerning performance of catheter insertion. Answers concerning peri-urethral cleaning, single-use equipment, hand disinfection and bladder irrigation will be presented separately.

Adherence to the hospital guideline

In all 287/492 (58.3%) persons said that they followed the hospital guideline. When comparing the perceived adherence to the hospital guideline for urinary catheterization among nurses and assistant nurses there was a significant difference (OR 2.1 [CI 95% 1.4–3.2], p < 0.05) in favour of the latter group. There was no significant difference in adherence to the guideline between staff working day, night or alternating shifts. Staff at the department for cardiology claimed to follow the guideline significantly less often (OR 0.6 [CI 95% 0.4–0.9], p < 0.05) when compared to staff at the two other departments. Self-reported adherence was highest in the department for surgery where about two-thirds of nurses and assistant nurses answered that they performed catheterization according to the guideline (see Table 2).

Table 2.

Number (n) and distribution of staff belonging to different categories among respondents who answered ‘Yes’ to the question ‘Do you perform insertion of indwelling urinary catheters according to the hospital guideline?’

	Do you perform insertion of indwelling urinary catheters according to the hospital guideline?
	Total answers	Yes
Nurses	304	164 (53.9)
Assistant nurses	172	123 (71.5)
Working day/evening shift	229	134 (58.5)
Working night shift	63	35 (55.6)
Working alternating shifts	176	111 (63.1)
Working at department of cardiology	177	93 (52.5)
Working at department of internal medicine	217	138 (63.6)
Working at department of surgery	82	56 (68.3)
Catheterization performed at least 2 times a week	26	20 (76.9)
Catheterization performed 1–5 times a month	207	125 (60.4)
Catheterization performed less often	240	141 (58.8)

Among the 287 persons who said that they followed the hospital guideline for catheterization, 280 answered the question about sterile or clean technique. Of those, 88 (31.4%) said that they used a sterile technique and 192 (68.6%) said that they used a clean technique.

Sterile and clean technique

Among all nurses and all assistant nurses, 20.6% (64/311) and 41.4% (75/181) respectively said that they used a sterile technique when inserting a urinary catheter irrespective of whether claiming that they kept to the hospital guideline or not. Clean technique was self-reported to be practiced by 75.6% (235/311) of the nurses and 52.5% (95/181) of the assistant nurses. The question was not answered by 12 nurses and 11 assistant nurses.

Among the 139 respondents who said that they used a sterile technique for urinary catheterization, 126 (90.6%) thought that the catheter should be sterile when inserted and 107 (77%) used sterile forceps or sterile gloves to insert the catheter. Nobody used the non-touch technique by holding the catheter by its plastic cover. A majority (n = 116, 83.5%) said that they used a sterile set for catheterization whereas 13 (9.4%) did not use a set at all. Only 57 (41%) used a sterile draping on the catheterization area (see Table 3).

Table 3.

Performance during insertion of an indwelling urinary catheter in relation to catheterization technique.

What kind of routine do you practice? How do you perform catheterization?	I practice a sterile technique when inserting an indwelling urinary catheter (n = 139)	I practice a clean technique when inserting an indwelling urinary catheter (n = 330)
The catheter should be sterile when inserted	126 (90.6%)	256 (77.6%)
I insert the catheter with sterile forceps, sterile gloves or by holding the catheter’s inner cover	107 (77.0%)	216 (65.5%)
I use a sterile set for catheterization	116 (83.5%)	147 (44.5%)
I use a sterile draping	57 (41.0%)	34 (10.3%)

Sterility of the urinary catheter

Of all the nurses, 81.4% (253/311) said that the urinary catheter should be sterile when inserted. The corresponding figure for assistant nurses was 82.9% (150/181). In the group of 403 persons who answered that the catheter should be sterile when inserted, 273 (67.7%) said that the catheter should be held with sterile forceps or sterile gloves. In addition, 22 persons (5.5%) said that the catheter could be inserted using a non-touch technique by holding the catheter’s plastic cover. More than half of the group (n = 249, 61.8%) said that they used a sterile set for catheterization but only one-fifth executed draping by using sterile drapes (n = 86, 21.3%) (see Table 4).

Table 4.

Performance during insertion of an indwelling urinary catheter in relation to desired sterility of the catheter.

	The catheter should be sterile when inserted (n = 403)
I insert the catheter with sterile forceps, sterile gloves or by holding the catheter’s inner cover	295 (73.2%)
I use a sterile set for catheterization	249 (61.8%)
I use a sterile draping	86 (21.3%)
I insert the catheter with sterile forceps, sterile gloves or by holding the catheter’s inner cover +	64 (15.9%)
I use a sterile set for catheterization +	Nurses 39
I use a sterile draping	Assistant nurses 25

Opinion on sterile and clean technique in relation to time of education

Irrespective of time of education (1980s or earlier, 1990s, 2000s) 27–30% of nurses and assistant nurses claimed that they used a sterile technique when inserting an indwelling urinary catheter whereas 63–70% said that they used a clean technique. The only group that differed from this pattern was assistant nurses educated during the 2000s, where almost half of the respondents said that they used a sterile technique. The difference between nurses and assistant nurses educated during the 2000s was significant (OR 3.6 [CI 95% 2.2–5.9], p < 0.05) (see Table 5).

Table 5.

Practice of sterile and clean technique when inserting an indwelling urinary catheter in relation to date of professional education.

	Educated during the 1980s or earlier (n = 65)		Educated during the 1990s (n = 80)		Educated during the 2000s (n = 342)
	Nurses (n = 30)	Assistant nurses (n = 35)	Nurses (n = 47)	Assistant nurses (n = 33)	Nurses (n = 231)	Assistant nurses (n = 111)
I practice a sterile technique when inserting an indwelling urinary catheter	8 (26.7%)	12 (34.3%)	12 (25.5%)	10 (30.3%)	44 (19.0%)	51 (45.9%)
Total	20 (30.8%)		22 (27.5%)		95 (27.8%)
I practice a clean technique when inserting an indwelling urinary catheter	20 (66.7%)	21 (60.0%)	34 (72.3%)	22 (66.7%)	178 (77.1%)	52 (46.8%)
Total	41 (63.1%)		56 (70.0%)		230 (67.3%)

Discussion

One of the strong recommendations in the CDC guidelines for prevention of catheter-associated urinary tract infections is to provide and implement a guideline for insertion of urinary catheters.⁸ South Hospital, Stockholm, where this study was performed has one single guideline for urinary catheterization. The guideline is easily reached on the hospital internal website and should be well known by all staff. Nevertheless, only 58% of the participating nurses and assistant nurses said that they followed the hospital guideline. Among those who said that they followed the hospital guideline around two-thirds related to an insertion technique which they called clean technique and one-third a technique which they called sterile although the hospital guideline does not use either of those terms.

The results from our study reflect that the participants called their insertion technique, ‘sterile’ or ‘clean’ in their description of performance when inserting an indwelling urinary catheter, and showed a wide variation within the two groups. There was no significant difference between the two groups, ‘sterile’ and ‘clean’, as shown in Table 3. There were no differences in performance of catheterization irrespective of when nurses and assistant nurses went through their professional education.

Even though there is a single guideline for urinary catheter insertion at the study hospital this seems to be insufficient to achieve uniform practice. Nicolle emphasizes that besides written policies for catheter indications, catheter selection, insertion and maintenance, it is crucial to have sufficient staffing, staff education and adequate supplies in an infrastructure to support an effective programme for implementation.¹ The necessity of education, performance evaluation and feedback to employees is pointed out by many others.^15–19 A single simulated skill checkoff is not enough according to the studies conducted by Gonzalez et al. and Manojlovich et al.^15,20

The results from our study show that there is a need for recurrent theoretical education and simulated skill training on a regular basis to achieve knowledge about the hospital guideline for urinary catheter insertion as well as a more uniform performance of catheterization. Lack of repeated education and training regularly given to all nurses and assistant nurses may have contributed to maintenance of an insertion technique adopted during their professional education.

As at least 20% of Swedish hospital inpatients receive an indwelling urinary catheter it could be anticipated that the catheterization procedure was performed frequently by all nurses and assistant nurses.⁶ In our study, however, 94% of the 473 participants answering the question about frequency of catheterization said that they performed indwelling urinary catheterization once a week or less often, which furthermore stresses the importance of a written, well known and implemented guideline.

Apart from influence from Lapides et al. who introduced ‘clean intermittent catheterization’ in the early 1970s the Swedish national guidelines for urinary catheterization were probably affected in the 1990s by a study by Carapeti et al. published in 1994 where 156 patients were randomized to sterile or non-sterile urethral catheterization when inserting an indwelling urinary catheter.^10,11,21 The conclusion from that study was that clean technique is good enough for indwelling urinary catheterization. However, the urinary catheter was kept sterile in both study groups. The misinterpretation of the studies by Lapides et al. and Carapeti et al. and the confusion concerning the different techniques supports a need for clarification of terms both in national and local guidelines as pointed out by the EAUN.¹⁴

Comparing the two groups in our study referring to practice of either ‘sterile technique’ or ‘clean technique’ there was a difference in opinion on sterility of the catheter as 91% in the ‘sterile technique group’ but only 77% in the ‘clean technique group’ claimed that the catheter should be kept sterile, although the hospital guideline stresses that the catheter should be kept sterile during catheterization. This difference in opinion did not significantly influence the performance of catheterization. Uncertainty concerning this important matter might lead to jeopardized patient safety.

Catheter insertion was mostly performed by using sterile forceps and/or sterile gloves in both the ‘sterile technique group’ and the ‘clean technique group’, which was in accordance with the hospital guideline. There were, however, about one-fifth of members of the ‘sterile technique group’ and about one-third of the ‘clean technique group’ who handled the urinary catheter with non-sterile forceps or non-sterile gloves, thus not keeping the catheter sterile. Among all participants declaring that they used clean technique in the questionnaire, 27 answered that they inserted the sterile catheter by holding it by its inner plastic cover, while there were no respondents performing this method among participants using sterile technique. Inserting a urinary catheter by its inner plastic cover is a difficult skill which not all have mastery of. Further, inner plastic covers on sterile indwelling catheters can have different constructions for opening, leading to difficulties to manage the catheter without touching it.

Using sterile forceps and sterile gloves is not enough to meet the requirements for aseptic technique in attempts to keep the sterility of the indwelling catheter while insertion. The sterile catheter must be protected from contact with the physical environment. This can be achieved by using sterile drapes to cover the insertion area.⁸ Draping is not mentioned in the hospital guideline although a sterile draping to our opinion is a prerequisite for keeping the indwelling catheter sterile.

Only 15.9% of all participants in our study described their catheterization performance in a way that secured sterility of the catheter regardless of what they called their insertion technique. To secure patient safety and to minimize the risk of introducing bacteria to the urinary bladder during catheterization the national and local guidelines for indwelling urinary catheterization need to clarify exactly how to maintain the sterility of the urinary indwelling catheter while insertion. Further, the terms ‘clean technique’ and ‘sterile technique’ should not be used in the guidelines as this might cause confusion about the correct performance.

Limitations and strengths

A limitation of our study can be the possibility of misinterpretation of the question asked about whether draping was maintained during the whole process of catheterization or just used prior to catheter insertion when washing the outer genitalia. Self-reporting of behaviour rather than observation could affect the results of the study. However, the intention of the questionnaire, and the included questions, was to identify differences rather than the ‘correct’ technique. Self-reporting made it possible to include participants from different professions and departments. The response rate of the questionnaires was very high at 92% (518/563). This can be attributed to the interest and acceptance of the study among the medical director and other approached managers in the hospital. The information about the study given personally to the head nurses and the participants before the questionnaire may also have contributed to this high response rate.

Conclusions

Our study highlights that nurses and assistant nurses have different interpretations of the terms ‘sterile technique’ and ‘clean technique’ when they describe their performance of indwelling urinary catheterization. These variations in interpretations and techniques seem not to support an effort to minimize the risk of CAUTI and may jeopardize patient safety. In efforts focused on preventing healthcare-associated urinary tract infections, the results from our study may add to increased knowledge and more uniform practice in the procedure concerning catheterization techniques.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors declare that there is no conflict of interest.

References

Nicolle

. Catheter associated urinary tract infections. Antimicrob Resist Infect Control 2014; 3: 23.

Hooton

Bradley

Cardenas

et al.

Diagnosis, prevention and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010; 50: 625–663.

Fortin

Rocher

Frenette

et al.

Healthcare-associated bloodstream infections secondary to a urinary focus: the Québec provincial surveillance results. Infect Control Hosp Epidemiol 2012; 33(5): 456–462. DOI: 10.1086/665323.

Magill

Edwards

Bamberg

et al.

Multistate Point-Prevalence Survey of Healthcare-Associated Infections. N Engl J Med 2014; 370: 1198–1208. DOI: 10.1056/NEJMoa1306801.

Zarb

Coignard

Griskeviciene

et al.

The European Centre for Disease Prevention and Control (ECDC) pilot point prevalence survey of healthcare-associated infections and antimicrobial use. Euro Surveill 2012; 17(46)): , http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20316 (2012, accessed 12 April 2018).

Swedish Association of Local Authorities and Regions, https://skl.se/halsasjukvard/patientsakerhet/matningavskadorivarden/matningvardrelateradeinfektioner.2333.html (2017, accessed 6 December 2017).

Yates

. Indwelling urinary catheterization: what is best practice? Br J Nurs (Urology supplement) 2016; 25(9): S4–9.

Gould CV, Umscheid CA, Agarwal RK, et al. The Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for prevention of catheter-associated urinary tract infections 2009, https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html (2009, accessed 3 March 2018).

Geng V, Cobussen-Boekhorst H, Farrell J, et al. Evidence-based guidelines for best practice in urological health care. Catheterisation: indwelling catheters in adults urethral and suprapubic. European Association of Urology Nurses 2012, http://nurses.uroweb.org/guideline/catheterisation-indwelling-catheters-in-adults-urethral-and-suprapubic/ (2012, accessed 3 March 2018).

10.

Lapides

Diokno

Silber

et al.

Clean, intermittent self-catheterization in the treatment of urinary tract disease. 1972. J Urol 2017; 197: S122–S124. DOI: 10.1016/j.juro.2016.10.097.

11.

Lapides

Diokno

Lowe

et al.

Follow-up on unsterile intermittent self-catheterization. J Urol 1974; 111: 184–187.

12.

van der Vliet A and Nyström B (eds). Metodbok för sjukvårdsarbete [Guidelines for professional work in the healthcare sector]. Stockholm, Sweden: Natur och Kultur, 1994.

13.

Lauritzen M. The handbook for healthcare, http://www.vardhandboken.se/Texter/Kateterisering-av-urinblasa/Oversikt/ (2018, accessed 15 August 2018).

14.

Vahr S, Cobussen-Boekhorst H, Eikenboom J, et al. Evidence-based guidelines for best practice in urological health care catheterisation. Urethral intermittent in adults. EAUN 2013, https://nurses.uroweb.org/guideline/catheterisation-urethral-intermittent-in-adults/ (2013, accessed 12 April 2018).

15.

Gonzalez

Sole

. Urinary catheterization skills: one simulated checkoff is not enough. Clin Simul Nurs 2014; 10(9): 455–460.

16.

Kanj

Zahreddine

Rosenthal

et al.

Impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in an adult intensive care unit in Lebanon: International Nosocomial Infection Control Consortium (INICC) findings. Int J Infect Control 2013; 17(9): e686–e690.

17.

Marigliano

Barbadoro

Pennacchietti

et al.

and the CAUTI Working Collaborative Group. Active training and surveillance: 2 good friends to reduce urinary catheterization rate. Am J Infect Control 2012; 40: 692–695.

18.

Goetz

Kedzuf

Wagener

et al.

Feedback to nursing staff as an intervention to reduce catheter-associated urinary tract infections. Am J Infect Control 1999; 27: 402–404.

19.

Altun

Karakoç

. The impact of an interactive workshop on the management of urinary catheterization on nurses. Int J Urol Nurs 2010; 4(3): 125–132.

20.

Manojlovich

Saint

Meddings

et al.

Indwelling urinary catheter insertion practices in the emergency department: an observational study. Infect Control Hosp Epidemiol 2016; 37(1): 117–119.

21.

Carapeti

Bentley

Andrews

. Randomized study of sterile versus non-sterile urethral catheterization. Ann R Coll Surg Engl 1994; 76: 59–60.