Do Catheter Washouts Extend Patency Time in Long-term Indwelling Urethral Catheters - Essay Example

?Do Catheter Washouts Extend Patency Time in Long-term Indwelling Urethral Catheters? Introduction Catheter washout is a process applied in order to flush out the bladder through the catheter by introducing clean water (Queensland Spinal Cord Injuries Service, 2005). This process is used in order to keep the bladder and the catheter clean and free from any prospects of infection. Bladder washouts do not have to be carried out all the time, however they may be essential when there is a significant amount of sedimentation in the urine; and in treating urinary tract infections (Queensland Spinal Cord Injuries Service, 2005). In this process, about 60 mls of water is usually introduced into the catheter gently via a syringe; the syringe is then removed and the catheter end is drained into a container. The procedure is repeated until 500 mls of water is used (Queensland Spinal Cord Injuries Service, 2005). This topic was chosen because of the growing interest of the impact of catheterization on long-term care patients and on practices which can be used to minimize the negative impact of catheterization (NHS Quality Improvement Scotland, 2004). It is relevant to my future practice as a nurse because it would provide me with evidence on the importance of carrying out catheter washouts on patients under long-term care. This aspect of practice personally interests me because I have often encountered long-term care patients under catheterization and I have always been interested in finding ways to improve the quality of their lives. Evidence based practice Evidence-based practice is defined by Sackett, et.al., (1996) as the explicit and effective use of current and most appropriate evidence in health care decisions on individual patients. It also means incorporating individual clinical skills with the most appropriate clinical proof from research. Evidence-based practice is basically about getting the patient the best care possible, as proven by evidence, and according to his needs and preferences (Manzoukas, 2006). It also helps ensure that the knowledge of the nurses are up to date, that it supports clinical judgments, and can reduce time in considering appropriate care (Drisko, 2010). There are various forms of evidence which can be utilized including systematic reviews, randomized controlled trials, cohort studies, case-control studies, case series/case reports, and editorials/expert opinion (University of Illinois, 2006). Not all evidence in this case is research base, most especially in cases of editorials and expert opinion where the weight of the evidence is based on the skill and the authority of the practitioner. The Nursing and Midwifery Council (NMC) Code of Professional Conduct describes the specific duties of nurses. It also specifies that nurses have the responsibility of providing a high standard of care for patients at all times, and this includes providing “care based on the best available evidence or best practice” (NMC, 2009, p. 16). These provisions form the legal and practice-based support for the evidence-based care required of nurses. Evidence can therefore be used in this case in order to establish whether or not carrying out catheter washouts would extend the patency of catheters among long-term care patients. Moreover, evidence can be used to determine if these washouts would improve the care of catheterized long-term care patients. Literature review Various studies have been carried out on the current topic under study. Hagen, Sinclair, and Cross (2010) carried out their study in order to establish if some specific washout regimens are better than others in relation to effectiveness, acceptability, and quality of life. About five trials were able to meet the inclusion criteria covering 242 patients in two cross-over and three parallel-group randomised control trials. After witling down the studies based on the inclusion criteria, authors reported that there is no difference between the different washout solutions, however these results were not sufficient to support the conclusions. One of the trials nevertheless claimed definitively that there was no difference in the use of saline and acidic solutions in catheter washouts (Hagen, et.al., 2010). In a related study, Moore, et.al., (2009a) set out to evaluate whether catheter washouts reduce and prevent catheter blockage. A review of 73 respondents did not reveal sufficient usable data due to respondents dropping off and with some respondents terminating early. In general however, there was no statistical difference seen after the use of catheter washouts (Moore, et.al., 2009a). These studies have been carried out through an electronic search for scholarly articles using the keywords: catheter washouts + long-term care. Data included were those studies published from 2001 to 2011, those assessing the effects of bladder washouts to the patency of catheter use, and those including patients under prolonged use of the catheter. Keywords were utilized because they are based on the topic and they provide a general representation of the issue being discussed. Primary research evidence critique The Critical Appraisal Skills Programme (CASP) for Randomised Controlled Trials (NHS, 2006a) was used to critique the article “Do Catheter Washouts Extend Patency Time in Long-term Indwelling Urethral Catheters? A Randomized Controlled Trial of Acidic Washout Solution, Normal Saline Washout, or Standard Care.” First and foremost however, this type of evidence sits at Level II in the hierarchy of evidence, or second from the very top (Tidy, 2010). They are the second most rigorous means of establishing whether a cause-effect relationship is apparent between the treatment and outcome in assessing the cost effectiveness of a treatment (Cecil Sheps Center, 2009). Based on the CASP tool, the authors considered a clearly-focused question, one which seeks to review whether or not using washouts would extend the patency of long-term indwelling catheters. This study was a quantitative study, specifically a randomised controlled trial, and appropriate for this research (Liebman, 2004). It sought to gather, tabulate, and analyse numerical data in order to answer the research question raised (Piquero and Weisburd, 2010). The sample population included patients who resided in a long-term care setting or received homecare and who had a long-term indwelling catheter which was often blocked. This sample population was very much appropriate for this study as it was very specific in terms of coverage and qualities of the participants in relation to the research goals and purposes (Moore, 2009b). It covered three groups to be studied – control, saline washout group and the acidic washout group. The sample size was very much limited because after 112 potential participants were screened, 73 ended up being enrolled and randomised. However only 53 completed the data collection; of these 53, 16 terminated early due to catheter changes or self-reported UTI (Moore, et.al., 2009a). In the end, the sample size could not sufficiently provide an answer to the issue raised. The data was gathered through chart reviews and weekly recordings of data by the researchers. Data recorded included the age, gender, mini-mental state assessment score, mean urinary pH, and incidents of blockage (Moore, et.al., 2009a). This was a single blind study. The administration of the trials was carried out by the nurse and no blinding was possible because of the nature of the solutions; nevertheless, the participants were blinded to the type of trial being carried out on them. Understandably, a double-blind study could not be possible for this research because it was not possible to blind the nurse to the type of washout she was going to use for the study (Moore, et.al., 2009a). The next best remedy – blinding the respondent -- for the research was nevertheless applied by the researchers. A research RN was assigned to gather the data needed for this study. The data collection process was reasonable as it allowed for the appropriate information to be gathered for this study and it established a basis for the evidence to be used for the question raised (Sapsford and Jupp, 2006). All the respondents were accounted for, and the accounting revealed that there was a substantial drop in the number of respondents enrolled to the number of respondents completing the research process. All the participants were evaluated within the groups they were assigned to, and an appropriate follow-up was carried out by the researcher RNs for each group of respondents (Moore, et.al., 2009a). The data gathering and follow-up for each group was consistent and was carried out in the same way. The data analysis was carried out by entering the data gathered via the SPSS software with variables and outcome measures previously determined by the researchers (Muijs, 2004). There was some potential for bias in terms of the variables being measured for each of the participant, but this was reduced by the researchers when they allowed another nurse (not one of the researchers) to do the follow-up assessment for the participants. This prevented any unconscious or conscious manipulation of data gathered. The study did not however have enough participants to minimise the play of chance. As was apparent during the research process, the number of participants was whittled down considerably from the original enrolled participants. During the follow-up process, some participants dropped out and others were also excluded due to personal reasons. The Kaplan-Meier survival curve analysis established no significant difference between the groups in time to first catheter change (Moore, et.al., 2009a). The data was insufficient to establish whether catheter washouts with saline or Contisol was more effective than the usual care with no washouts in promoting catheter patency (Moore, et.al., 2009a). The researchers were ethical in gathering data for this study. The informed consent was sought by the respondents and no coercion was used by the researchers (Clarke and Oakley, 2007). No name identification was seen in the data sheets for each respondent, only numbers were assigned and the numbers with corresponding names were only available to the researchers (Waltz, 2005). Secondary evidence In relation to the primary research, this secondary research evidence also compares the application of various washouts for long-term indwelling catheterised patients. The secondary research was more general in terms of the washouts it was reviewing, while the primary resource was very specific in the washouts it was going to consider for its study. The secondary research is a systematic review while the primary research was a randomised controlled trial. The Critical Appraisal Skills Programme (CASP) for Systematic Reviews was the Critique applied for this research (NHS, 2006b); on the other hand, the CASP for Randomised Controlled Trials was applied for the primary evidence. The validity of this review is also based on primary evidence in this case, peer-reviewed randomised and quasi-randomised control trials (Jadad and Enkin, 2008). These randomised control trials are considered level II evidence in the hierarch of evidence (Tidy, 2010). This systematic review is situated at the very top of the hierarchy of evidence, in other words, it is considered to be level I evidence which is the most reliable and most relevant information which can be used to support evidence-based practice (Tidy, 2010). The evidence was created by credible authors, all nurses with graduate degrees in nursing management and clinical practice. They are also involved in the academe as professors in nursing. They have had clinical experience as clinical nurses. Their development of evidence was thorough enough as it considered various databases for its review and the inclusion criteria was clear, applicable, and appropriately used in the clinical practice (Fink, 2005). The review dates were specified by the author for each database: Cochrane was searched on the 30th of April 2009; MEDLINE (January 1966 to April 2009); MEDLINE In-Process (30 April 2009); EMBASE (January 1980 to April 2009); and CINAHL (December 1981 to April 2009). The review considered a highly focused question which was specific in terms of its population (long-term catheterised patients), the intervention being applied (saline washouts, acidic washouts, ordinary washouts), and the outcomes considered (bacterial infection, blockage, and fungal infection) (Hagen, et.al., 2010). The review included the right type of studies in this reviewed through the inclusion of randomised and quasi-randomised control trials, all of which posed the right questions for a peer-review. The reviewers also identified all the studies used, the bibliographic databases they utilised, and a follow-up of the reference lists were carried out by one of the researchers (Hagen, et.al., 2010). No personal contact with the researchers was carried out. Experts on catheter management were however contacted for other possibly relevant trials. Calls with the Association for catheter Advice and the ACA quarterly Journal were also made for information on other related trials (Hagen, et.al., 2010). Non-English studies were not considered by the reviewers. The reviewers assessed the quality of the studies included in the review by using a clear and pre-determined strategy and inclusion/exclusion criteria. Three reviewers were involved in the process of narrowing down the studies to be included. It was reasonable to combine the results of the studies, but the results for each study are clearly displayed and visible to the reader. Results and groupings of results were similar for each study. Reasons for any variations were not specifically discussed by the reviewers. The results were expressed through main themes and variables. They were also presented through percentages depending on the particular aspect or variable being reviewed (Nesbitt, 2004). There were five studies included in the review with respondents varying for each study, and totalling 242 respondents all in all. This is a sufficient total as it does not provide a substantial number by which the issue raised can be reviewed adequately (Nesbitt, 2004). In general, the results of the review revealed that there is insufficient evidence supporting the use of washouts for long-term indwelling catheters. In general, the results of this study are not precise. The confidence level was set forth on the lower limit, with the reviewers assessing the evidence base as poor due to inadequate data recording from the studies included (Sinclair, et.al., 2010). The personal assessment for this review would be on the inadequacy of the results. No p-values were used in this review. Since the results of this review are very much ambiguous and inadequate, it is difficult to judge if these results can be applied to the local population. With a larger population however, it may be possible to establish definite results for this current issue, the results may produce a more consistent answer to the issue. My local setting would not differ much from that of the review and it is possible to provide a similar intervention in my setting. Most important outcomes of the review were considered. The reviewers did not specify individual outcomes, but they specified possible suggestions and recommendations for professionals and policy makers. Outcomes for research were also specified in relation to recommendations for future research and improvements on these researches. No policy changes or changes in the practice must be implemented as a result of the evidence contained in this review. The results do not reveal any benefits which outweigh any harm and/or cost. The results do not provide a clear basis for policy changes, changes which are supported by firm and definitive evidence. Within the hierarchy of evidence, systematic reviews rank at the top, thereby giving firm support for the results revealed by this review (Tidy, 2010). This review can inform my future practice as a qualified nurse by providing me with the appropriate discerning skills in making the decision on the use of catheter washouts for long-term catheterized patients. Although this study does not provide a strong support for the use of catheter washouts, its practice would still assist in improving the quality of life of long-term care patients. The results of this study are very much similar to the results in the primary study. Both studies recommend that there is a need to establish more evidence on the use of catheter washouts. The influence of non-evidential factors on evidence utilisation Evidence utilisation is sometimes influenced by non-evidential factors including habits and traditions within the practice. These traditions include habits of nurses on maintaining patent lines and preventing blockage of catheters. Nursing practice has dictated that in order to maintain patent lines, the use of acidic catheter washouts have been common (Getliffe, 2003). Organizations, hospitals, and various health agencies have recommended the use of these washouts in order to maintain the patency of catheters among long-term patients (Australian and New Zealand Urological Nurses Society Inc, 2006). Based on these practices, the NICE, NHS, and other government agencies have made bladder washouts an important element of their health care delivery for long-term catheterised patients (NHS, 2008; NICE, 2003). The kind of washouts used has still been the subject of research evidence, however, it has not stopped the tradition of carrying out saline-based or water-based washouts on these patients. One of the most important aspects of nursing care is to make the quality of the patient’s life as high as possible. This would mean that all possible measures to make the patient as comfortable as possible must be carried out. For long-term care patients being catheterised, there can be major discomfort experienced from the catheterisation, and failure to maintain the patency of the line can make things more difficult for the patient. It can lead to urinary tract infection; it can cause distress, and can lead to repeated re-insertions of the catheter which can unfortunately lead to urethral damage (Evans and Painter, 2001). The nursing practice therefore has acknowledged the importance of applying preventive measures for the blockage of urinary catheters and one of these measures include the use of catheter washouts (Yates, 2007). This practice however has not been fully endorsed by practitioners because it is said to cause bladder mucosal damage through mechanical and chemical action (NHS, 2005). Considerations on the actual benefits of this practice have not been adequately established by research evidence; hence, its practice has not been significantly endorsed in the actual clinical practice. Nevertheless, it is being applied as a routine part of nurse’s duties and responsibilities. For whatever benefits it is set to bring, its application has been accepted in the practice. The lack of sufficient evidence supporting its application does not negate the fact that it can and has, brought about welcome benefits for affected patients. It is also important to note however, that not all nurses carry out routine washouts and that the patency of the catheters is often not checked regularly especially for long-term care patients (Yates, 2005). Habitual neglect in the use of washouts can therefore block evidence utilisation as it makes it difficult for practitioners to consider the application of evidence-based care. In some instances, the varying values and power relations between nurses and doctors can also affect the kinds and the forms of evidence which are utilized in practice (Coombs, 2004). In relation to the care of the catheterised patients, the nurse would most likely be the health professional with the most incidents of interaction with the patient. Her expertise in the care of these patients is therefore to be highly trusted and given much credit. She would know how long the catheter has been in a patient, how the patient feels about being catheterised, when possible risks of blockage in the line can be expected, and how often the washouts have been (or if at all) carried out. She can therefore make the proper assessment on the impact of the catheterisation on the patient and on possible recommendations on how to eliminate its negative impact and on the patient. The doctor on the other hand, has his own field of expertise on the matter of the patient’s catheterisation. He can make diagnosis on infections which may arise from the patient’s catheterisation and make the recommendations on medications which can be made for the management of infection. Both the doctor and the nurse can make their own recommendation regarding the use of washouts for the patient with each professional having his own concern on patient care. This can cause conflicts of opinion, and for the most part, the nurse can make her recommendations to the doctor about the patient’s condition (Coombs, 2004). The doctor can then consider these suggestions and make the appropriate decisions and orders after reviewing evidence, recommendations, and his own medical judgment on the matter (Coombs, 2004). The concerns of family and of the patient may also not coincide with professional interests and values (Morrison and Monagle, 2009). The patient may not feel that he needs washouts and this may not coincide well with the nurse and the doctor recommendations and with the evidence base. Family members may also believe the same. They may feel that the washouts would cause mechanical and chemical irritation as the patient may complain of pain during these washouts. They may therefore see the washouts as reducing the quality of the patient’s life. These are non-evidential factors which may influence the use of evidence to the use of catheter washouts. These non-evidential factors include habits of health practitioners as well as beliefs of patients and family members (Morrison and Monagle, 2009). In relation to the assertion that nursing should be evidence-based, non-evidential factors can blend well in to the practice for as long as they have firm evidence to support them. However, for practices which do not manifest apparent and immediate relief to the patients, the implementation can be difficult. It can make the practice more difficult in terms of educating the patients on the application of interventions and the accomplishment of the requirements under the NMC Code of Professional Conduct. Conclusion The patency of catheters among long-term care patients is often put at risk. This paper sought to evaluate the impact of catheter washouts on improving the patency of catheters among these long-term care patients. Primary evidence on this topic reveals that catheter washouts provide benefits for the patient, improving the patency of these catheters and reducing risks of infection and blockage. Secondary evidence reveals ambivalent results with some studies declaring benefits for the use of catheter washouts, but insufficient to provide a definitive and strong conclusion on the issue raised. The evidence established in this case has been employed as basis for practice and for future research on the same topic. Non-evidential factors impact on evidence utilisation in terms of providing basis for the usual practices applied by nurses in the management of catheterised patients. Evidence utilisation in this case would likely influence my future actions as a nurse in the sense that it would guide me in my action and would assist me in choosing the appropriate interventions for the patient. 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