Draping and associated equipment for indwelling catheter manipulation by hospital staff: an assessment of attitudes and adequacy

Authors


Nathan Lawrentschuk, Department of Surgery, University of Melbourne, Austin Hospital, Studley Road, Heidelberg Victoria 3084, Australia.
e-mail: lawrentschuk@gmail.com

Abstract

OBJECTIVE

To address the usability and safety aspects of current equipment for indwelling urinary catheter (IDC) manipulation, by assessing the attitudes of doctors and nurses to infection control, occupational health and environmental waste, and the perceived adequacy of available catheter packs, particularly drapes, when performing such manipulations.

SUBJECTS AND METHODS

A self-administered survey instrument was created using an online database and completed by doctors and nurses. The survey covered basic demographics and experience with IDC, attitudes to infection control, occupational health and safety, and the environment, as well as adequacy of current equipment in containing spillage of urine and/or blood.

RESULTS

In all, 87 doctors and 228 nurses completed 315 of 350 (90%) surveys. Doctors and nurses were concerned about infection control, occupational health and safety issues, and environmental waste. Incidents involving spillage of urine and/or blood often go unreported. There were no differences between nurses and doctors having specialist training in urology or experience (P > 0.05). The second major finding is that available catheter packs, particularly drapes, when manipulating IDCs, are inadequate and spillage is likely. These findings were more pronounced in doctors and those with urology training (P < 0.05).

CONCLUSION

The attitudes of health professionals involved with IDC manipulations are consistent with other fields, as is the under-reporting of episodes of contamination by bodily fluids. The current equipment, particularly drapes, are inadequate for containing urine and blood, leading to infection control, occupational health, environmental and cost implications.

Abbreviation
IDC

indwelling catheter.

INTRODUCTION

It is well understood that an indwelling urinary catheter (IDC) should be introduced under antiseptic conditions, as catheters remain a risk factor for developing infection [1]. However, scant attention has been paid to the equipment used to manipulate catheters and perhaps more importantly, the adequacy of such equipment, particularly in relation to protecting health workers from blood and urine contamination. Commonly used equipment is a disposable catheter pack and drape, or linen drapes and kidney dishes, with minimal innovation for decades [2].

Stringent guidelines for draping materials are leading to linen being phased out in health environments [3,4]. Consequently, as with other medical equipment, disposable drapes will need to be of higher quality, be easy to use, but also beneficial to patients and staff. They also require favourable occupational health and safety, infection control and environmental credentials [5–7].

To date, current equipment for IDC manipulations, i.e. those for insertion, removal or washout, has never been scrutinized, with scarce evidence-based medicine related to draping materials [5]. The end users, i.e. doctors and nurses, are rarely consulted on how equipment might be improved and they often improvise to overcome design shortfalls (Figs 1,2) [8].

Figure 1.

The result of a typical vigorous manual washout with subsequent contamination of the patient’s bed linen and surrounds, exposing staff to urine and blood.

Figure 2.

Both the disposable drape and linen failed at containing urine with this catheter manipulation.

Against this background, the aims of the present study were to assess the attitudes of doctors and nurses to infection control, occupational health and safety issues, and environmental waste, as it relates to IDC manipulations. Further, we assessed the perceived adequacy of available catheter packs, particularly drapes, when performing IDC manipulations.

SUBJECTS AND METHODS

A self-administered survey instrument was created using an online database (http://www.surveymonkey.com, Survey Monkey, Portland, USA) and distributed to urology trainees and associates, whilst paper copies were completed by nurses and doctors at three metropolitan hospitals and a regional centre in February–March 2008.

In all, 350 surveys were administered, consisting of 10 questions in three domains: (i) basic demographics and experience; (ii) attitudes to infection control, occupational health and environment; (ii) adequacy of current drapes and equipment when performing IDC manipulation. Question response categories were ‘strongly agree’, ‘agree’, ‘disagree’ or ‘strongly disagree’.

Data were collected on the basis that subgroup results could be compared between doctors and nurses, those with urology specialist training and those without, and experienced (>6 years) with less experienced, to determine if these were factors in attitude and perception of equipment. Positive responses (strongly agree/agree) were combined against negative responses (disagree/strongly disagree), and were only considered relevant for comparison where one subgroup had a majority of either positive or negative responses (i.e. more than half in either group). The data were analysed using Fisher’s exact test to compare subgroups, with a significant difference indicated at P < 0.05.

RESULTS

In all, 87 doctors and 228 nurses completed 315/350 (90%) surveys. Fourteen (16%) of the doctors were urologists whilst 17 (20%) were surgical/urological trainees; the remaining 56 (64%) were resident or nonsurgical doctors. Of the nurses, 59 (26%) were surgical/urological, 59 (26%) emergency, 50 (22%) intensive care, and the remaining 57 (25%) from general, operative or outpatient areas, with three unspecified.

Of the health workers, 40% had been in practice for >10 years, 19% for 6–10 years, 32% for 1–5 years and 8% for <1 year. In assessing experience with IDC, most inserted (71%), removed (76%) or washed out (68%) one to five catheters per month.

The results for all participants are summarized in Table 1. Considering attitudes about catheter manipulation, most respondents agreed that infection control, occupational health and environmental issues were important; most agreed that patient bed linen and clothing might be soiled with urine/blood after catheter manipulation; and most indicated that exposure of healthcare workers to bodily fluids/blood should be prevented or minimized when manipulating IDC, and systems should be in place to minimize exposure. About half the respondents indicated that they would always report exposure. On analysis there was no statistically significant difference (P > 0.05) in the assessment of attitudes between different subgroups for all responses (this data is therefore not included in Table 1).

Table 1.  A summary of responses on attitudes to infection control, occupational health and environment, and the adequacy of current equipment for catheter manipulations, with subgroups presented where any significant differences existed
Questionn (%) Total
Strongly agreeAgreeDisagreeStrongly disagree
Attitudes
Infection control is important (exposure to bodily fluids/blood, hand washing, etc.)296 (94) 17 (5)  0 2 (1)315
Occupational health and safety is important (safe workplace minimizing harm)278 (88) 34 (11)  1 (0) 2 (1)315
Environmental issues in hospitals are important (including waste generation)234 (74) 73 (23)  5 (2) 3 (1)315
Patient bed linen/clothing might be soiled with:     
 Urine/blood after catheter insertion/removal111 (35)155 (49) 40 (13) 9 (3)315
 Urine/blood after catheter washout115 (37)149 (47) 46 (15) 5 (2)315
Always report urine/blood on my skin and/or mucous membranes to infection   control authorities 81 (26) 71 (23)137 (43)26 (8)315
Current equipment     
Current disposable drapes for catheter insertion are adequate at containing bodily fluids/blood
 All 22 (7)124 (39)120 (38)49 (16)315
 Nurses 19 (8) 91 (40) 87 (38)32 (14)229
 Doctors  3 (3) 33 (38) 33 (38)17 (20) 86
 Urology doctors/nurses  1 (2) 12 (26) 16 (34)18 (38) 47
 Experience >6 years, doctors/nurses 11 (6) 67 (36) 69 (37)40 (21)187
Current linen drapes are adequate at containing bodily fluids/blood
 All 14 (4)110 (35)146 (46)45 (14)315
 Nurses 14 (6) 84 (37) 99 (43)32 (14)229
 Doctors  0 (0) 26 (30) 47 (55)13 (15) 86
 Urology doctors/nurses  0 (0) 12 (26) 21 (45)14 (30) 47
 Experience >6 years, doctors/nurses  6 (3) 63 (34) 79 (42)39 (21)187
When doing manual catheter washouts current drape systems are adequate at containing bodily fluids/blood
 All 16 (5)105 (33)136 (43)58 (18)315
 Nurses 15 (7) 83 (36) 91 (40)40 (17)229
 Doctors  1 (1) 22 (26) 45 (52)18 (21) 86
 Urology doctors/nurses  1 (2)  5 (11) 18 (38)23 (49) 47
 Experience >6 years, doctors/nurses  9 (5) 56 (30) 74 (40)48 (26)187
The current preparation trays/kidney dishes in catheter packs adequate for catheter manipulations
 All 26 (8)106 (34)125 (40)58 (18)315
 Nurses 23 (10) 87 (38) 80 (35)39 (17)229
 Doctors  3 (3) 19 (22) 45 (52)19 (22) 86
 Urology doctors/nurses  3 (6)  3 (6) 16 (34)25 (53) 47
 Experience >6 years, doctors/nurses 15 (8) 53 (28) 72 (39)47 (25)187
Excessive waste generation (e.g. unused tweezers, etc.) occurs in relation to catheter use
 All 68 (22)169 (54) 70 (22) 8 (3)315
 Nurses 43 (19)122 (53) 57 (25) 7 (3)229
 Doctors 25 (29) 47 (55) 13 (15) 1 (1) 86
 Urology doctors/nurses 16 (34) 22 (47)  6 (13) 3 (6) 47
 Experience >6 years, doctors/nurses 42 (22) 97 (52) 42 (22) 6 (3)187
I often use additional padding/towels in anticipation of a spillage when working with catheters
 All181 (57)112 (36) 19 (6) 3 (1)315
It is time consuming to clean up after catheter insertion/removal
 All 49 (16)114 (36)127 (40)25 (8)315

Regarding the adequacy of equipment when manipulating catheters, over half (54%) of respondents reported that current disposable drapes or linen drapes (60%) were inadequate for containing bodily fluids/blood. Most responded that additional padding or towels in anticipation of poor containment were required, and that the current trays were inadequate. Excessive generation of environmental waste was as an issue for most (e.g. unused tweezers), with over half also indicating it is time-consuming to clean the site after catheter manipulations.

Subgroup results for the adequacy of equipment were also compared (Table 1). Doctors and nurses found current drapes inadequate, with doctors more likely to find drapes inadequate for washouts (P < 0.01) and equipment trays inadequate (P < 0.001). Nurses, although concerned, were less so about environmental waste and time taken to manipulate catheters than were doctors (P < 0.05).

In general, those with and without urology specialist training (nurses and doctors) agreed that current disposable and linen drapes were inadequate, but those with urology training were more negative in their appraisal of available drapes (P < 0.05). Those with urology training were also more concerned about the adequacy of trays and the time taken to clean (P < 0.005) than those without experience.

Finally, when comparing the adequacy of current equipment based on experience, there were trends apparent but the only significant difference was that the more experienced respondents found trays/dishes inadequate (P < 0.02).

DISCUSSION

This survey had two main findings, considering our aims: First, that doctors and nurses were aware and concerned about infection control, occupational health and safety issues, and environmental waste as it relates to IDC manipulations. Incidents regarding exposure to urine or blood often go unreported. There were no differences based on being a nurse or doctor, having specialist training in urology, or experience. The second major finding is that available catheter packs, particularly drapes, when manipulating IDCs are not adequate and spillage is likely occur. These findings were more pronounced in doctors and those with urology training.

Although concerned, health workers often under-report exposure to bodily fluids [6,7,9]. This is contributed to with IDCs by the lower risk of becoming infected with urine. However, this might not be true when considering that frank blood is often present (Fig. 1) [6,7,9]. Universal precautions (gloves, gowns, eye protection) reduce exposure but are not always followed [6]. Attitudes of health professionals are difficult to change, so risks can be further reduced by adopting intelligent equipment design [8,9]. In this context, poor design is supported by the findings of contamination of patient bed linen and clothing with IDC manipulations, despite using additional padding/towels. However, it is known that health workers often ignore poor equipment issues in the interests of patient care, and continue working [10]. Uptake of equipment appears to be more dictated by cost than measured benefits for patients or health workers [7,11]. A shift in focus to health worker-driven design and implementation, rather than ignoring concerns, will ensure progress, ironically advocated decades ago [8].

The key to reducing contamination with IDC manipulations is containment, usually assisted by drapes. Draping for surgery has traditionally been linen but disposable materials have challenged this [2]. Regarding the competing technologies, the debate moved to cost [11], infection control [12], environmental issues [13] and then occupational health [3]. Linen has largely been retained until recently [2]. Further pressure to replace linen has been fuelled by new stringent standards [4]. Interestingly, for many procedures requiring a drape outside of surgery, such as manipulating IDCs, disposable drapes have been introduced but with no supporting published evidence.

There are also additional subsequent effects of poor equipment design, i.e. unnecessary cleaning exposing additional staff, linen soiling with environmental consequences, and wasted time [7]. The use of additional padding/towels is also costly and appears not to offer additional protection against spillages, based on our findings, again having cost and environmental impact. The trays or dishes provided are considered too flimsy or cumbersome for controlling fluids. Healthcare providers and patients must be included in product testing, promoting innovations that are safer, effective and intuitive [7,8]. Devices using passive safety features are best, requiring no change in technique to engage the safety mechanism [14]. In this context better trays and drapes that do not differ greatly from those currently used (e.g. a drape that contains and maintains sterility) would be ideal.

In conclusion, the present study is the first to address usability and safety aspects of current equipment for IDC manipulation. The attitudes and under-reporting of episodes of contamination by health professionals are consistent with other fields. Current equipment, particularly drapes, are inadequate at containing urine and blood, leading to infection control, occupational health and environmental, and cost implications. Therefore, efficient equipment designs with innovative drapes that help to contain bodily fluids, that are cheap and easy to use as well as more environmentally friendly, will be a welcome addition to all settings where IDCs are manipulated. Until then, doctors and nurses need to remain aware of the deficiencies of current equipment and adhere to universal precautions.

CONFLICT OF INTEREST

None declared.

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