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 8-12]. In this study 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 practised 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. The nurses at hospital A reported higher adherence to those techniques compared to hospital B (p = 0.04).
In effort to protect a catheter from unintended contact with the patient´s legs or bed linen, sterile drapes on insertion area are required during procedure. This is not required in the EAUN guidelines but is advocated in national guidelines from for example the United States of America and Ireland [8, 10]. 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.
Another measure aimed at securing an aseptic procedure is to use a disinfected trolley to prepare the equipment needed for catheterization. This arrangement was reported from 56-74% of the participants and significantly more often at hospital B (p < 0.001).
A standardized set for urethral catheterization, including all necessary sterile equipment, such as gloves, forceps, fenestrated drapes, gallipots and swabs can both 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) used a sterile set for catheterization (OR 2.08, CI 1.44-3.00).
Sterile or non-sterile technique
In contrast to the opinion among around 80 % of participants that the catheter should be kept sterile and to around 60 % practicing a behaviour to keep sterility a majority of the study participants at both hospitals called their insertion technique “non-sterile” (hospital A 71.5%, hospital B 76.9%). There was however a small difference in favour of hospital A where nurses used the designation “sterile” for the procedure slightly more often (p = 0.011). This might be associated with the requirement for keeping the catheter sterile and mentioning the term “sterile technique” in the local hospital guidelines contrary to the local guidelines at hospital B where non-sterile technique was advocated.
The discrepancy between the nurses´ reported behaviour and their use of the term “non-sterile technique” for the procedure might originate from the introduction of “non-sterile technique” in the Swedish national guidelines for indwelling urethral catheterization during the 1990s. This was influenced by a study from Carapeti et al in 1994 where the authors compared “sterile technique” with “non-sterile technique” . Important to notice was however that the IUC was kept sterile during the whole procedure with both insertion techniques. The Swedish national guidelines from the 1990s defined “non-sterile technique” 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 sterility requirements of the fluids for urinary bladder washouts were however kept. The previous emphasis on the importance of intact sterility of the catheter was left out . “Non-sterile technique” was regarded as easier to practice and was also cheaper as sterile gloves and solutions were omitted. An updated version of the national guidelines based on same sterility precautions as in the EAUN-guidelines was launched in 2015 and thus valid during the study period. This return to an earlier approach to the principles of keeping the sterility of the IUC during insertion in the national guidelines does not seem to have had an impact on what the participants in this study called their insertion technique. One reason could be that both designations “non-sterile” and “sterile” was kept for the procedure in this new version of the national guidelines. Another possible reason for the participants calling their technique “non-sterile” could be that the advocated use of soap and water for periurethral washing is associated with the concept “non-sterile”. 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 [16-20].
National and local hospital guidelines for indwelling urethral catheterization should use a harmonized description of the term “sterile technique” accompanied with an explanation of what necessary sterile equipment to use for successful aseptic procedure, with the emphasis on the use of a sterile set for catheterization and sterile drapes on the insertion area to create a protective field for the sterile urinary catheter so that it is not accidentally contaminated during procedure.
Conformity with the EAUN-guidelines
The different requirements for keeping the catheter sterile in the local hospital guidelines from Hospital A and Hospital B did not affect the adherence to the EAUN-guidelines (OR 0.99, CI 0.72-1.34).
Performing indwelling urethral catheterization according to the EAUN-guidelines was associated with working at departments for surgery and cardiology (OR 2.35, CI 1.69-3.26).
An explanation may be that skill training was more common at those departments compared with the department of internal medicine.
An association with performing according to the EAUN-guidelines was also found for the use of sterile set for catheterization (OR 2.08, CI 1.44-3.00) and sterile drapes for dressing on insertion area during procedure (OR 1.87, CI 1.21-2.89). There was also an association between adherence to the EAUN-guidelines and using the term “sterile technique” for indwelling urethral catheterization (OR 1.70, CI 1.15-2.51). A possible explanation for this may be that the term “sterile” is easier to relate to an aseptic performance than the term “non-sterile”.
Problems and potential interventions
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.
The effect of different kinds of interventions to improve urinary catheterization have been studied by others. Among those validating the compliance to aseptic technique by evaluating the practiced skills on a yearly basis, validated checklists used as a facilitator and “computer-assisted learning” and “simulation-based learning” have been successful [19, 21-26].
Further, the healthcare-settings need to have a strategy regarding repeated training of the staff in aseptic IUC-insertion procedure and also how to implement changes in updated guidelines for urethral catheterization.
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. 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 may be that the study did not include physicians. Although IUC-insertion can be performed by physicians, urethral catheterization in Sweden is performed mostly by nurses hence the focus on nurses in the study. The guidelines for catheterization are usually written by registered nurses.