Proper aseptic insertion of the sterile IUC, meaning maintaining the sterility of the IUC during procedure, is one of the corner stones in evidence-based international guidelines for prevention of healthcare-associated urinary tract infections among patients in need of an IUC. The sterility of the catheter is kept by using sterile equipment, lubricants and solutions, by proper hand hygiene and by skills in ensuring not to contaminate the IUC during the whole procedure [5–9]. Our study revealed that a majority of the study participants at both hospitals called their insertion technique “non-sterile technique” (hospital A 71.5%, hospital B 76.9%) although the term “sterile technique” for indwelling urethral catheterization was more common at hospital A (p = 0.011).
Irrespective of what the insertion-technique was called, mainly soap and tap water were used for periurethral cleaning prior to catheter insertion (hospital A 82.8%, hospital B 84.0%). It was mostly considered by the participants that the IUC should be kept sterile during insertion (hospital A 82.2%, hospital B 78.2%) which is in accordance with the EAUN-guidelines but not required by the local guidelines at hospital B. Despite of that only 62–69% of the participants used sterile gloves/forceps for catheter insertion or practiced a non-touch technique by keeping the catheter within its inner plastic cover during insertion. The latter method was uncommon to practice and was not mentioned in neither of the hospital guidelines. Only 16–20% of the participants at both study hospitals used sterile drapes on the insertion area to protect the sterile catheter from contamination during catheterization.
A Foley catheter is not as stiff as catheters used for intermittent catheterization and may be more difficult to manage and easier to contaminate. To our opinion, sterile gloves/forceps are not enough in keeping the sterility of the IUC during insertion. In efforts to protect the Foley catheter from unintended contact with the patient´s legs or bed linen, also sterile drapes on insertion area are required during procedure. We believe that a standardized sterile set for urethral catheterization, including all necessary equipment, such as gloves, forceps, and drapes can facilitate a uniform behaviour when performing indwelling urethral catheterization and secure sterility of the IUC throughout the whole procedure. This is also supported in our study as the participants performing in agreement with the sterility precautions described in the EAUN-guidelines (see Table 1) also used a sterile set for catheterization (OR 2.03, CI 1.40–2.94) and sterile drapes for dressing of the insertion area (OR 1.94, CI 1.25-3.00).
An association was found between the use of the term “sterile technique” for indwelling urethral catheterization and performing in agreement with the sterility precautions advocated in the EAUN-guidelines (OR 1.67, CI 1.13–2.47). The inconsistent use of different terms for insertion technique during urethral catheterization and uncertainties in understanding how proper aseptic insertion of the sterile catheter is accomplished has also been reported by others [10–13].
“Non-sterile technique” was mentioned in a study by Carapeti et al in 1994 . The authors compared “sterile technique” with “non-sterile technique” for indwelling urethral catheterization. Important to notice was however that the IUC was kept sterile during the whole procedure with both insertion techniques. Despite that, the changes in the Swedish national guidelines during the 1990s included “non-sterile technique” for IUC-insertion, defined as use of soap and tap water for periurethral cleaning, no dressing on insertion area, use of non-sterile equipment and non-sterile gloves. The previous emphasis on the importance of intact sterility of the catheter and the use of sterile dressing on insertion area during procedure was left out . “Non-sterile technique” was regarded as easier to practice and was also cheaper why sterile gloves and solutions were omitted. The use of the “non-sterile technique” among the participants from both hospitals and in the local guidelines at hospital B, may originate from what was advocated by the Swedish national guidelines during the 1990s, although the national guidelines were updated in 2006 and thus valid during the study period and based on same sterility precautions as advocated in present EAUN-guidelines (see Table 1). The heterogenic practice affecting the sterility precautions in IUC-insertion has been reported by others . In our study there was an association between less than two work years in profession and conformity with the sterility precautions describes in the EAUN-guidelines compared to nurses with longer work years (OR 1.54, CI 1.03–2.30).
The unfortunate adoption of “non-sterile technique” during the 1990s, minor but frequent changes of the national guidelines for indwelling urethral catheterization, different requirements on sterility and equipment in the local hospital guidelines, infrequency in IUC-insertion performance combined with the lack of a detailed description of the IUC-insertion process in local hospital guidelines are factors that counteract a uniform performance of indwelling urethral catheterization. This may jeopardize the patient safety.
Our study highlights the gap between the written national guidelines based on sterility precautions from EAUN and a uniform performance of sterility precautions during procedure among nurses. To fill this gap, emphasizing the sterility of the IUC during the procedure is not enough. For a uniform performance the updated national guidelines for urethral catheterization should include a stepwise description of what sterile equipment to use, how and where to prepare for procedure and how to maintain the sterility of the IUC during procedure .
Further, local implementation of the updated guidelines in health-care settings is important . This can be accomplished by training the nurses in aseptic urethral catheterization and validating the compliance to aseptic technique by evaluating the practiced skills on a yearly basis [13, 17–19]. Validated checklists for indwelling urethral catheterization can be used as a facilitator . Also “computer-assisted learning” and “simulation-based learning” can be beneficial in practicing aseptic technique in indwelling urethral catheterization and refining the skills [21, 22].
Why working in departments for surgery and cardiology was more associated with performing in agreement with the sterility precautions advocated in the EAUN-guidelines (OR 2.50, CI 1.78–3.49) compared to working in a medical department needs further investigation.
Knowledge may differ from behaviour why self-reported descriptions of sterility precautions during indwelling urethral catheterization rather than observing the actual performance of the nurses may be a limitation in our study. There is, however, no reason to believe that the answers to the questions in this study did not reflect the participants´ actual behaviour. As the aim of the study was to investigate the nurses´ self-reported sterility precautions in indwelling urethral catheterization in the light of different sterility requirements in present local hospital guidelines and the EAUN-guidelines, a questionnaire made it possible to cost-efficiently reach many more nurses from different departments at two hospitals than observation. A validation of the procedure described by the participants requires an observational study of the practiced skills such as conducted by Manojlovich et al . Another limitation is that the study did not include physicians. Urethral catheterization in Sweden is however performed mostly by nurses hence the focus on nurses in the study. The results of our study highlight the importance of a uniform approach to sterility precautions during urethral catheterization, both in national and local hospital guidelines. Implementation of guidelines are needed to achieve a uniform knowledge in and performance of aseptic indwelling urethral catheterization.