Urinary Tract Infections and Indwelling Catheters

Introduction

The Evidence-based practice is important in nursing as it offers to help the nurses in making improved outcome for the patients as well as assist to deliver high care quality, eliminate obsolete practices and reduce care cost for the patients. The Nursing and Midwifery Code of Professional Conduct informs that all the nurses are required to practice in their best way by using the best available evidence (NMC, 2015). Thus, the evidence-based practice is important to be executed by the nurses to ensure better quality care and health outcome for the patients along with abiding by the professional code. In the Intensive Care Unit (ICU), use of indwelling catheter has led to rise of urinary tract infection among patients. This is evident from the study of Rezai et al.(2017) where the results collected from intensive care units shows that out of 1409 patients who were using indwelling catheter in the ICU, 256 patients reported incidence of urinary tract infection. The indwelling catheter is referred to a flexible plastic tube that is inserted in the urinary bladder for draining out urine. The indwelling catheter is often used for patients in the ICU because they face urinary incontinence due to medical reason, not being able to urinate for surgical reason and others (Mulder et al. 2018). The infection in the indwelling catheter arises as result of colonisation of the bacteria and other microbes within the tube. A properly strategized care of the indwelling catheters with effective nursing intervention is able to reduce urinary catheter infection in the ICU. This is evident from the study of Schelling et al (2016) where it is reported that development and implementation of nursing action plan reduced urinary tract infection among the ICU patients from 2.16 to 0.37%. In this respect, the key aim of the literature review being performed is to identify the care strategies that are effective to reduce urinary catheter infection in the ICU which is raised while using indwelling catheter. The research question regarding the literature review is to explore nursing care intervention and other care strategies for indwelling urinary catheter for reduction of urinary catheter infection among the patients in the ICU.

Rationale of the review

The ICU-acquired urinary infection is referred to the patients who show positive results of infection present in their urine culture within 48hours or later on insertion of indwelling catheter (Iwuaforet al. 2016). The NHS England reported that 43-56% of the urinary tract infections among the ICU patients are as a result of using indwelling catheters (www.england.nhs.uk, 2018). Moreover, in the study of Mladenović et al. (2015), it is seen that out of 1369 patients who were receiving care in the ICU, 226 patients were found to be suffering from catheter-associated urinary infection in the ICU due to use of indwelling catheters. The figure informs that there is concerned prevalence of urinary infection among patients who use indwelling catheters. The fact is also supported by the data of Public Health England where between 2012 and 2013 the monthly national "safety thermometer" found that urinary catheter infection rate has doubled than the national average and the patients in the ICU are the worst affected ones (www.safetythermometer.nhs.uk, 2014). The urinary catheter infection as a result of inserting indwelling catheter has become a problem for ICU patients because it has increased their hospital stay and medical cost. This is evident from the study of Rezia et al. (2017) where the researchers has informed that incidence of urinary tract infection among the ICVU patient increased theior length of stay at the hospital as well as hospital costs. It is reported by NHS that as a result of urinary catheter infection in the ICU and normal wards they are estimated to pay £1968 per patients which amount to £99 million annually (www.nice.org.uk, 2014). Moreover, it has presently become an issue because catheter-associated infections for longer time without care are seen to lead to bacteriuria which culminates into urosepsis syndrome among the patients in the ICU. This is often associated with increased mortality of patients such as in the study of Zilberberg et al. (2017) it was reported that lack of timely treatment of urinary tract infection among ICU patients led to 12% increased mortality and 5.2 days more stay at the hospital. Therefore, effective care strategies and interventions are required to be identified to resolve the issue so that reduction in infection can be ensured. This, in turn, is going to lower mortality rate, hospital stay and medical cost of the patients accessing care in the ICU.Thus, the literature review is performed to identify evidence-based care strategies and nursing intervention to care for indwelling care for reducing urinary catheter infection in ICU settings.

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Background of the Literature Review

In this study of Conway et al. (2012), it is informed that catheter-associated urinary tract infection is regarded as a common healthcare issue among ICU patients. This is because patients who are present in the ICU experiences catheterisation for extended periods raising the risk of development of urinary tract infection (Chenoweth et al. 2014). In the study of Richards et al. (2017) it is reported that catheters which are placed in an inappropriate way by not following proper indication lead the ICU patients develop urinary tract infection. This is also supported by the study of Jain et al. (2015) where the researchers has informed lack of knowledge of nurses and doctors to properly manage and insert catheter has led patients in the ICU develop urinary tract infection. The CDC (2009) reports that increased incidence of urinary tract infection as a result of indwelling catheter are seen in the trauma ICU rather than the surgical or other medical wards. Moreover, they reports that there are three criteria that the ICU patients and others using indwelling catheter are to be met for being diagnosed with catheter associated urinary infection.The first criterion for the patients to be diagnosed for urinary catheter infection is presence of inserted indwelling catheter for more than 48 hours in their urinary tract. The second criteria include presence of at least one of the following which as fever more than 38ºC/ Dysuria/ low urinary frequency/ increased urinary urgency/ tenderness or pain in the costovertebral angle/ suprapubic tenderness. The third criterion to be fulfilled is showcase of positive urine culture with more than two or fewer pathogen growth with at least one of them being bacterium (www.cdc.gov, 2009). The study of Parida and Mishra (2013), informs that fever is the common symptom being considered for diagnosis of the ICU patient for urinary catheter infection. In order to develop strategies for resolving urinary catheter infection among ICU patients, the way in which the disease progress is required to be identified which is known as pathogenesis. The knowledge of progression of urinary catheter infection among the nurses would be helpful to make them alert about the strategioes to ve develop to avoid the infection from occurring (Trautner et al. 2015). The pathogenesis of urinary catheter infection informs that most of the microorganisms which cause infection in the urinary tract enter the bladder by ascending from the perineum to the urethra. The microorganismsare seen to be endogenous in nature which develops colony on the intestinal tract and perineum region of the patient. In some cases, it is seen that infections occur from the intraluminal contamination which is collected from exogenous sources such as resulting from cross-transmission of pathogens from the hands of the nurses and health professional while installing the indwelling catheters in the patients in the ICU. In most cases, catheter-associated urinary infection arises from the microorganisms deposited in their gastrointestinal tract (Vigil and Hickling, 2016). The knowledge regarding the pathogen responsible for urinary catheter infection is required so that the nurses and doctors can understand the antibiotics to be used for treatment of urinary infection among the ICU patients. The Enterobacteriaceae regarded as the most common form of bacteria which is responsible for causing urinary catheter infection among the patients in the ICU. This is evident from the research ofPeng et al. (2018) where it is mentioned that Escherichia coli. was the cause of 23.41%of cases of urinary catheter infection in the study. However, Candida spp. is seen to causes 27.4% cases of infection and is termed to be most frequent pathogen responsible for causing urinary catheter infection in the ICU. This is also evident from the study of Saint et al. (2016) where it is informed that 18% cases of Candida sp. was located compared to 10% cases of E.coli among ICU patients suffering from urinary catheter infection as s result of using indwelling catheter.Moreover, the study of Peng et al. (2018) reported that gram-negative bacteria for 47.46% cases, fungi for 27.81% cases and gram-positive bacteria for 19.06% cases were responsible for causing urinary catheter infection among ICU patients.

The ways in which catheter-associated urinary infection that are caused as a result of use of indwelling catheter can be resolved is needed to be known to implement the practices for lowering the infection rates among the patients. . The maintenance of a closed drainage system is seen to reduce total number of bacteria that can enter the catheter to cause infection. This can be accomplished by initially maintain proper hand hygiene process before as well as after the installation of the indwelling catheter in patients in the ICU and other wards. The nurses are required to wear personal protective equipment such as sterile gloves, wear an apron and others while caring for the patients in the ICU to reduce infection transmission to the catheter raising urinary catheter infection among the patients. The leg bag is to be changed as per manufacturer instruction by using non-touch method to reduce any cross-transmission of infection leading to urinary catheter infection in ICU patients.

Methodology

Introduction

The chapter provides information about the way literature searches are to be made for developing reviewed findings for the study. The proper selection of review methods to be used in the study is going to help the researchers effectively resolve the raised issue in the study.

Search Strategy

The systematic search strategy is the process in which systematic methods are used for collecting secondary data, critically appraising research studies and synthesising evidence to present the reviewed findings in the study. An appropriate systematic search strategy helps to formulate research questions which are narrow or broad in scope as well as helps to identifyand synthesise studies which have direct relation to the framed systematic question (Crocetti, 2016)The strategy helps to deliver a complete as well as exhaustive summary of the updated evidence which is relevant to the research question (Vaismoradiet al. 2015). Thus, the systematic search strategy is to be used as it provides deeper insight into the chosen topic.

Database

The electronic literature search is executed by using various databases and search engine such as Google Scholar, EBSCOHost and others because the online search leads the researcher to find out updated evidence related to the raised research question by using specific words. It also makes the search performed to frame the literature review and the findings easier and simple in comparison to use of books and other resources from the library (McGowan et al. 2016). The search platform mainly used in the study to identify the sources for the literature review is EBSCOHost which is a platform that hosts multiple databases from which various clinical, as well as other journals, can be easily available. The databases used under the search platform are CINAHL, PsycINFO, MEDLINE, PubMed, etc. The selected databases are used in the search platform as they provide most relevant journals related to medicine and nursing that are compiling a vast range of information which is fundamental to the field of the research topic (www.ebsco.com, 2018).

Search Terms

The appropriate use of search term helps the researcher to retrieve more relevant articles and journals leading to perform a comprehensive search for the study. The search terms used for the study were: “indwelling catheters”, “reduction of urinary catheter infection”, “intensive care units”, “critical care”, “CAUTI”, “role of nurses for avoiding urinary catheter infection in ICU” and others. The customisation of the search strategies are done for suiting each database in the search engine and free keywords searches as well as Medical Subject Headings (MeSH) are done. Moreover, manual search was conducted for checking eligible journals and articles so that the relevant sources related to the research question is effectively identified. (Refer to Appendix 1)

Formulating the research question

The PICO process is the technique used for evidence-based practice for framing the answers related to a question regarding clinical health. As mentioned by Doody and Bailey (2016), a clinical question requires to be directly related to the clinical problem and need to be phrased in a way that it facilitates the search to get proper answer for resolving the problem. In this respect, PICO acts to effectively build the proper clinical question by identifying parts related to the resolve the identified clinical problem. Thus, in this study, the use of PICO (Patient/Problem, Intervention, Control and Outcome) framework tool is done for developing the reveiwquestion (Considineet al. 2017). The Problem refers to the raised clinical issue being faced in the nursingfield which in the study is urinary catheter infection in intensive care unit. The Intervention refers to the area of interest which in this study is strategies to care for indwelling catheters in ICU. The comparison refers to other treatment available for resolving the problem and at the present, no comparison between methods for reducing urinary catheter infection in ICU is done in the study. The outcome refers to the desired impact on the patient by resolving the clinical problem which in this research question is improved quality urinary system for patients in ICU who are using indwelling urinary catheters. The question formulated in this research: What are the care strategies to be used for indwelling urinary catheters to reduce urinary catheter infection in the Intensive Care Unit?

Boolean Operators

The Boolean operator is used for arranging the search terms as “AND” and “OR” operators assists to combine terms as well as allow precision to find data for improving sensitivity and specificity of the searches. (Refer to Appendix 1)

Inclusion and Exclusion criteria

The inclusion criteria are the factors or characteristics which the subjects required to have to be included in the study and exclusion criteria are the characteristics which disqualify the subjects that are irrelevant to the study. Thus, the criteria act to ensure better searches of literature for executing the study (Kirsten et al. 2016). In this research, the exclusion criteria include the journals and papers which are not written in English with publication date before 2013, without full text, patients not treated in the ICU or critical care and the papers which are non-academic in nature. The inclusion criteria include the journals that are fully accessible, written in English; have access to full text and abstracts, published after 2013 and academic papers. The papers within five years from present are chosen as they are going to include most current evidence being developed in the clinical worlds to care for indwelling catheters for reducing urinary catheter infection in patients being cared in ICU. Moreover, the search is limited to English journals as it is easier to be read and understood as it is the only language known by the researchers involved in writing the literature review paper.

Data Extraction

The data extraction from the journals and articles chosen are to be done through full and independent extraction method. This means that all the information mentioned in the journals being it qualitative or quantitative in nature is to be extracted. Further, the information was collected for each of the journals by identifying the name of the author, year of investigation, sample size, data analysis, discussion and key findings.

Critical Appraisal Tool

The critical appraisal is a systematic process which is used for identification of the strength and weakness of the research article for assessing the validity, trustworthiness and relevance of findings in the research. It is effective to be used in clinical research as it is central to making informed decision for healthcare purposes (Zeng et al. 2015). The CASP (Critical Appraisal Skill Programme) tool has the key focus to assist individuals adopt effective skills to identify and make sense of the evidence in research for implementing the gathered evidence in practice (Bourne et al. 2018). Therefore, in this study CASP tool is to be used for critical appraisal of the articles so that evidence-based approach can be undertaken to care for indwelling urinary catheter to reduce urinary catheter infection in ICU. (Refer to Appendix 2)

Summary

The databases in the search platform are systematically searched by using Boolean operators and the articles selected are critically appraised by using the CASP tool. The journals are selected through inclusion and exclusion criteria so that the best articles are chosen for executing the study. The research question is framed by using the PICO framework.

Results and Findings

Theme 1: Risk factors of Urinary Catheter Infections in the Intensive Care Units as result of using Indwelling Urinary Catheter

In this review, a total of 12 studies are included out of which only two studies identified the key risk factors associated with indwelling catheter use that results to cause urinary catheter infection to the patients in ICU. The risk factors are required to be known so that while caring for the patients the determinants are kept in mind by the nurses and physicians to ensure effective supervision of the patients for reducing the incidences of urinary catheter infection in the ICU. The study of Vyawahareet al. (2015) reported that increased age, gender of the patient and debilitation is responsible for increasing the risk of development of urinary catheter infection in the ICU. However, in the study of AlKhawajaet al. (2017), it is informed that the key risk factors which lead to increased incidence of urinary catheter infection in the ICU patients are gender, increased age and reason of admission to the ICU (surgical vs medical category) along with longer hospital stay. The difference between the information by the studies is likely due to sample size and length of study phase. This is because Vyawahareet al. used only 345 participants for 1 year whereas of AlKhawajaet al. used 1490 participants that are studies for two consecutive years to identify the key reasons of urinary catheter infection in ICU. In the study Vyawahareet al. (2015), it is mentioned that 41.4% patients who are within the age of 40-60 and 30% of individuals above 60 years developed urinary catheter infection in their study. Moreover, 12% of patients who have a pre-existing chronic condition like Diabetes mellitus showed urinary catheter infection in the ICU. Further, they also identified that more men are affected by urinary catheter infection in the ICU compared to women in the study. These facts are similar to the study of AlKhawajaet al. (2017) where they also found that urinary catheter infection is more prominent among men compared to female (43:8 (85%)) and patients with increased age (mean age 55 years) are susceptible to the disease when receiving care in ICU. Moreover, the study informed that urinary catheter infection in the ICU patients was more who are admitted for medical condition compared to patients (85%) who are admitted for surgical reasons. This is because the patients admitted with medical conditions had comorbidities and are older in age thus supporting the risk factor of debilitation in the case identified by Vyawahareet al. in 2015. Apart from age, debilitation and gender, the study of AlKhawajaet al. (2017) also identified that longer hospital stay is a key risk factor among patients in ICU to develop urinary catheter infection. This is evident as they identified that individuals who stayed in the ICU between 14.6-7.9 days acquired urinary catheter infection compared to patients who stayed in the ICU for 7-9 days.

Theme 2: Care strategies to reduce Urinary Catheter Infections in the Intensive Care Units caused by Indwelling Urinary Catheters

In addition to the identification of risk factors, the key point of the review is to identify the care strategies to be implemented for reducing urinary catheter infection among patients in the ICU. In respect to identification of care strategies to reduce Urinary Catheter Infections, five studies are identified out of which Sampathkumaret al. (2016) informed a single detailed procedure named 6-C Bundle approach which is to be followed while inserting indwelling catheter to reduce infection among patients in the ICU. The other four Kanjet al. (2013), Mullin et al. (2017), Maxwell et al. (2018) and Arora et al. (2014) mentioned multiple care intervention strategies to be followed in brief to reduce indwelling catheter infection in their study settings. In all the studies impact of the strategies by measuring total catheter days use in ICU is being informed except Kumar et al. (2018) and this is likely to limit the validation of the results of the research. The study of Sampathkumaret al. (2016), Kanjet al. (2013) and Arora et al. (2014) were seen to be focused on developing best care strategies to reduce urinary catheter infection by investigating in single hospital. In comparison, the other two studies Mullin et al. (2017) and Maxwell et al. (2018) identified the care strategies based on investigation in different hospital around the areas. Further, out of all the studies, Kumar et al. (2018) only informed about use of antibiotic solution for bladder wash of patients using indwelling catheter for preventing or reducing urinary catheter infection among them in the ICU. In the study of Sampathkumaret al. (2016), they used rigorous quality improvement method to identify impact of 6C’s bundle approach for reducing incidence of urinary catheter infection in the ICU while using indwelling catheters. According to the 6 C’s approach, the nursing staffs initially require to Consider alternatives available for indwelling catheters each day (female urinals, condom catheters in men, etc). The Connection is to be done with a securement device to minimise the movement of the indwelling catheters. The nursing staffs require regularly check and Clean the catheters and keep it Closed. The Call for scan of the bladder before irrigation is to be done and the urine Culture is to be done when the indication is clear. The application of the care strategy was able to reduce urinary catheter infection by 70% in all wards including ICU as evident from the baseline of 2.0/1000 catheter days in 2013 to 0.6/1000 catheter days in 2015. The study by Kanjet al. (2013) uses before-after prospective study which informs that to prevent urinary catheter infection the infection prevention bundle which is based on the guidelines of SHEA and IDSA is to be used in the ICU. Moreover, the education of the nursing staffs in the ICU regarding urinary catheter infection is to be done and the surveillance of the urinary catheter is to be done. The hand hygiene is the key fact to be maintained while using catheters for patients and the feedback on the performance of the urinary catheters is to be taken regularly for patients in the ICU to avoid urinary catheter infection.The implement of the strategies was seen to cause 83% reduction in urinary catheter infection in the ICU between phase 1 (before implementation of care strategies) and 2(after implementation). This is evident as urinary catheter days were reduced from 13.07/1000 in phase 1 to 2.21/1000 in phase 2. The descriptive study design of Mullin et al. (2017) refers that multifaceted and collaborative intervention is required in reducing urinary catheter infection among the patients in the ICU. The study refers that assessment of the patient is to be done to identify their competency with the maintenance and insertion, closed system of the catheter is to be maintained, nursing-driven protocol is to be initiated for catheter removal, better fidelity of the electronic documentation of catheter, implementation of preservation tubes to collect specimen and periodic auditing of catheter is to be done to reduce urinary catheter infection among the ICU patients. Moreover, the researcher suggested that “stewardship of testing” is to be followed by abiding with the mentioned guidelines to evaluate a fever prior to providing order to execute a urine culture among the critically-ill patients in the ICU. The activities were seen to reduce urinary catheter days from 3.0/1000 days in 2013 to 1.9/1000 days in 2014. Maxwell et al. (2018) refer that to control the urinary catheter infection the catheter is to be changed no longer than 48 hours. The study informed that every four-hour perinetal care is to be provided and the indwelling catheter is to be cleaned with chlorhexidine for every 12 hours. Moreover, education was provided to the ICU team regarding the way to change catheter and encouragement was provided to use non-invasive catheter alternatives. The implementation of the processes led to show 87.5% decrease in urinary tract infection by the end of 2015 of the one year survey. Moreover, it was seen that 9% decrease in the use of indwelling urinary catheter was seen among the ICU patients. Further, the strategies led to face a zero rate of urinary catheter infection from May 2015 to May 2016 in the study settings. Arora et al. (2014) executed a retrospective study in which they used surveillance as the key care method to reduce and control urinary tract infection among the patients in the ICU. The care tool to control the infection developed in the study was able to facilitate daily communication among the interdisciplinary team and healthcare providers to provide timely care and abide by strict protocols of best practices. The implementation of the tool in the study was effective to reduce urinary catheter days from 4.71/1000 days to 1.98/1000 days ensuring better health outcome of the patients at the ICU.

The study of Kumar et al. (2018) executed a prospective randomised control study to identify the impact of polymyxin and neomycin solution to wash the bladder for reducing urinary catheter infection among patients admitted to the ICU. It was seen that there is significant reduction of urinary catheter infection among the patients on whom neomycin or polymyxin is used for washing their bladder in comparison to those who are washed with normal saline solution. This is evident as only 8 patients are found to have urinary catheter infection out of 50 in the test group whereas 26 patients are found to have infection in the control group out of 50 patients after the intervention. Thus, the antibiotics use was effective to reduce urinary catheter infection among the ICU patients.

Theme 3: Nursing intervention and education of nurses for caring of indwelling urinary catheter to reduce urinary catheter infection in the ICU

In order to care for indwelling catheters to reduce the urinary catheter infection in the ICU, the education of the nurses and proper nursing intervention is essential regarding the way to manage the indwelling catheters. The studies of Richards et al. (2017) focused on the nursing intervention strategies and Bell (2018) focused on the way nurses are to be educated to make them effectively care for indwelling catheters for reducing the urinary catheter infection in the ICU. In both the studies, the validity of the intervention and education are shown with reduction of urinary catheter infection in the ICU settings. Richards et al. (2017) conducted a prospective interventional study where they informed that nurses are to execute effective auditing for prevention of inappropriate use of the indwelling catheters to reduce urinary catheter infection. Moreover, the nurses to accomplish reduction of urinary catheter infection are to label tubes of the indwelling catheter with date and time of insertion, make charts for patients who require the indwelling catheter to be removed and adhere to protocol and removal algorithms of catheters. They are also required to daily audit indwelling catheters which are to be removed, procure proper supply of units such as incontinence management material and silver-alloy catheters, minutely observe indwelling catheter insertion to avoid breaches in sterile techniques and maintain electronic records to get later about the automatic stop dates of indwelling catheter for each patient in the ICU. The study also mentioned that supplemental training to the nurses is to be given for properly inserting indwelling catheters among the ICU patients. The implementation of the nursing-driven strategies in the given settings of the study was effective to reduce urinary catheter infection instance in the ICU. This is evident as in the study urinary catheter infection in 2012 was 40 cases and in 2013 it was 38 cases but with the implementation of the strategies it was seen that the number was reduced to 15 infection in 2015. The study of Bell (2018) by using evaluation study design informs that the simulation-education on the nurses is effective to reduce urinary catheter infection among patients in the ICU. This is evident as in the study it is seen that reduction of urinary catheter infection occurred among 71.33% individual from 2013 to 2016. The simulation-based education of the nurses is the way of training nurses where clinical scenarios are replicated to help them practice and understand the strategies to be implemented for reduction of the infection or other issues.

Discussion

The evaluation of the articles conducted during the development of the literature review informs that the key risk related to urinary catheter infection among the patients using indwelling catheters in the ICU are age, gender, debilitation along with co-morbidities and longer hospital stay. The study of AlKhawajaet al. (2017) informs that elderly men are more prone to get urinary catheter infection in comparison to women in ICU as adult men commonly experience problem with enlarged prostate which limits their functional ability of the body to proper pass urine through the catheter. However, in the study of Vyawahareet al. (2015), it is highlighted that elderly women are prone to get urinary catheter infection in the ICU mainly due to their anatomic makeup which causes easy access to perineal flora of the bladder along with urinary catheter. AlKhawajaet al. (2017) explained longer hospital stay in the ICU to be a potential cause of urinary catheter infection because it creates greater changes of the urinary bladder of the patient to get colonised by multi-drug resistant bacteria, in turn, increases chances of infection. Moreover, both the studies reported co-morbidities, cause of hospitalisation and debilitation as other risk factor of urinary catheter infection as they increase the prevalence of bacterial colonisation of the perineal flora of the bladder supporting microbial growth in the urinary tract. In order to control the risk factors leading to urinary catheter infection, other articles in the literature review informed certain care strategies to be followed. This is because the care strategies are going to create better management of the indwelling catheters in turn controlling impact of risk factors leading to reduction of infection. The care strategies included implementation of 6C’s Bundle approach for urinary catheter installation and maintenance, maintaining hand hygiene, checking catheter competency with the patients, electronic documentation of catheter use, auditing of catheter-based in patient health and others. Sampathkumaret al. (2016) informed that abiding by the 6C’s Bundle approach for catheter installation is required because considering alternatives to indwelling urinary catheter in ICU patients reduce impact of risk factors of gender for urinary catheter infection. This is evident as alternative catheters are not placed inside the body and thus the anatomical structures related to gender do not pose hindrance for urinary catheter infection development as previously mentioned. Moreover, proper connection with the securement device is essential to reduce irritation and cleaning is essential to reduce microbial growth. The culture of the urine is required to keep a check on the urinary catheter among the ICU patients to avoid spreading of infection. Similar to Sampathkumaret al. (2016), Mullin et al. (2017) also reported close indwelling urinary catheter is to be maintained as open or damaged catheters led way to the microbes for colonisation which causes spread of infection to the urinary tract. In comparison to the studies, Kanjet al. (2013) focused that care strategies require to follow infection prevention bundle guidelines provided by Society for Healthcare Epidemiology of America (SHEA) and Infectious Disease Society of America (IDSA) for urinary catheter to reduce incidences of urinary catheter infection. The British Infection Society also suggests following guidelines of IDSA to reduce urinary catheter infection among patients in ICU and others (www.idsociety.org, 2019; www.britishinfection.org, 2019). Moreover, Kanjet al. (2013) inform hand hygiene of nurses a potential care strategy while installing, checking, and maintaining and removal of an indwelling urinary catheter to reduce urinary catheter infection among the ICU patients. This is because it reduces the scope of contamination of the urinary catheter while being used for supporting ICU patients. However, Mullin et al. (2017) with showing similarity by the study of Richards et al. (2017) refers that proper electronic documentation of urinary catheter regarding their stop dates for each ICU patients reduces the infection. This is because the indwelling urinary catheters are removed from each patient on time based on their health condition and is not overused in turn providing no time for colonisation of microbes or bacteria to spread infection. Further, in comparison, Arora et al. (2014) informed surveillance by multi-disciplinary team of the indwelling catheter referred by as it leads to presence of various experiences professional at a time to ensure no infection development from indwelling catheter use in the ICU patients during their short or long hospital stay. Mullin et al. (2017) also informed that periodic auditing of indwelling catheter reduces changes of urinary catheter infection in ICU as auditing leads to remove as well as install alternatives catheters for patients in time if it is seen that indwelling catheters are causing infection to them. Further, the nursing driven protocol is to be maintained for installation and removal of indwelling catheter so that proper ways are implemented in their management to have control for reducing spreading of infection due to microbial growth. Maxwell et al. (2018) informed indwelling catheters in all patients are to be changed within 48 hours to minimise the changes and atmosphere of microbial growth that leads to infection. They suggested use of chlorhexidine every 12 hours as antiseptic in cleaning and installing indwelling catheter so that no transmission of infection is faced which causes urinary catheter infection even during longer hospital stay. In comparison, Kumar et al. (2018) reported use of polymyxin and neomycin solution as antibiotics to be used in managing urinary catheter infection because they are potential drugs that are implemented to reduce and control urinary catheter infection among ICU patients. The information by Mullin et al. and Maxwell et al. since has been executed in different hospital can be generalised but findings by Kumar et al. cannot be generalised. This is likely to limit the generalisation of the findings to be put into evidence-based practice to reduce urinary catheter infection of the patients in the ICU.

The study by Richards et al. (2017) focused on the nursing intervention required to ensure effective care of indwelling catheters for reducing urinary catheter infection in ICU patients. The study reports that charts are to be maintained by nurses regarding when to remove catheters for each patient and when the tubes are to be changed so that reduced infection is faced by the patients at the ICU. This is because longer use of indwelling catheters may block the tube and develops environment for microbe formation which is responsible for causing infection. Moreover, the study informs nurses to minutely observe indwelling catheter insertion to avoid breaches in sterile techniques so that infection may not spread due to unhygienic issues. The nurses by labelling the installation dates and time on the indwelling catheters would be able to remember the date and time of removal of indwelling catheters. This, in turn, would avoid single use of indwelling urinary catheter for longer time where colonisation of microbes to spread infection would be easier. Further, the study suggested nurses use silver-alloy catheters as alternatives to indwelling catheters as they are regarded to reduce colonisation of microbes that spread the infection. Bell (2018) informed to use simulation-based education for nurses to learn regarding the way infection by the indwelling urinary catheter can be reduced. This is because in simulation-based education the nurses are educated to manage risk of infection regarding indwelling urinary catheter in ICU within replicated clinical scenario that is later applied to real-life situation. Thus, the nurses become effectively trained and educated to install, maintain and remove indwelling catheter as well as identify use of alternative catheter use in real life situation to ensure reduction of indwelling catheter infection among the patients in the ICU. Similar to Bell (2018), Richards et al. (2017) and Maxwell et al. (2018)also suggested training and education of nurses in management of indwelling catheters to reduce chances of infection among the patients in the ICU. In all the studies, the reductions in catheter days are related to success of reduction of urinary catheter infection because increased catheter days lead to increased chances of infection. Thus, reduction in indwelling catheter use in each article informs that lower number of catheter are used while staying at the ICU ensuring less spread and reduction of urinary catheter infection among patients.

Summary

The discussion informs that indwelling catheter is the drainage tube that is located inside the body used for draining out urine from the urinary bladder in the leg bag located outside the body. They are most commonly used for patients in the ICU because of urinary retention, urinary incontinence, medical and surgical condition and others. The prevalence of the development of urinary infection from the indwelling catheter is high as reported by the studies. The fever is the key symptom along with positive urine culture with presence of two or less microorganisms and indwelling catheter placed for more than two days in patients are the criteria to be fulfilled for getting diagnosed for urinary catheter infection. The Candidaspp is the key micro-organism responsible for causing urinary catheter infection as result of use of indwelling catheter in the ICU along with E.coli. The risk factors that give rise to the urinary catheter infection are age, gender, medical condition and longer hospital stay. The elderly often have complicated health state which makes them prone to require indwelling catheter while in the ICU leading them to be at risk to get infected. Moreover, female anatomy makes them more prone to get infected by indwelling catheter use but in the studies reviewed it is seen that mostly the men are affected. The care strategies to be implemented include 6C’s Bundle approach in which systematic way of installation, management and removal of indwelling catheter is mentioned that is to be followed to reduce incidence of infection among the patients in the ICU. The studies also mentioned that hand hygiene is to be maintained and the infection prevention bundle approach mentioned by the SHEA and IDSA are to be abided by to reduce urinary catheter infection in the ICU.Moreover, the competency of the catheter is to be identified and closed system is to be maintained for indwelling catheter use to reduce infection of the patients in the ICU. Further, it is reported that catheter is to be changed within 48 hours after installation in the patients in the ICU. This is because it is phase being consider under which infection may raise leading to urinary catheter infection in the ICU settings.The use of antiseptic named chlorhexidione and antibiotics polymyxinand neomycin are informed to be used to avoid urinary catheter infection. The other studies informed that simulation-education to the nurses is required to ensure effective care of indwelling catheter in reducing infection related to them in the ICU. It is also stated that nurses are to maintain electronic records of when the catheter is to be removed to avoid their overuse which leads to infection to the urinary tract in the ICU. Moreover, instead of plastic tubes, it is reported that silver alloy tubes are to be used for indwelling catheter to reduce changes of infection while in the ICU. The nurses are to follow proper removal and installation protocol to minimise reduction of urinary catheter infection in the ICU settings.

Limitation

The literature review encountered various limitations such as the adopted search criteria resulted to avoid various non-English studies and others which could have provided improved knowledge regarding the topic. Moreover, many of the articles used for the study were poorly presented as they lacked proper validity assurance of the statistical data. The lack of time was a potential issue that limited to execute proper comparison between various studies in an intricate manner. Further, the lack of finances led to avoid many updated journals from getting accessed which would have enriched the findings of the study. The papers did not focused impact of antibiotic prophylaxis in details that can be implemented to reduce the chances of urinary infection in ICU due to indwelling catheter use.

Recommendations

Intermittent catheterisation: The intermittent catheterisation is a potential way in which care of indwelling catheter may be taken to reduce urinary catheter infection among the patients in the ICU. In this process, the pathogens or micro-organisms responsible for colonising the urinary catheter are less likely to get collected as the catheter is to be inserted only after certain intervals and is to be removed after completion of void. This nature of catheter is used among patients who have spinal cord injury or neurogenic bladder. It is not only effective to lower urinary catheter infection but also is able to patient dignity and privacy in the ICU along with facilitates patient return of normal life with ease.

External catheterisation: The use of external catheter instead of indwelling catheters would be a potential way in which reduction of urinary catheter infection can be attained. However, it is to be used in patients in the ICU when they are facing urinary incontinence. In case of males, the condom catheters which are made of latex or rubber are to be used. They are to be attached to the penis with the help of an adhesive strip. The size of the condom catheter is to be considered at first as per the male patient in the ICU so that they do not face issues with urine leakage or trauma to the penis.

Avoid unnecessary catheterisation: The bladder scanner is to be used among the patients in the ICU to examine and confirm whether or not they are facing urinary retention and require installation of indwelling urinary catheter. The bladder scanner uses ultrasonic sounds in a non-invasive way to identify the volume of the urine present in the bladder after voiding to determine need of catheterisation in an evident way.

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