Indwelling urinary catheters remain one of the most commonly used invasive devices across the NHS and social care (Loveday et al, 2014). There are significant risks associated with urinary catheters that have been widely researched and evidenced. Catheter-associated urinary tract infections (CAUTIs) account for a high proportion of healthcare-associated infections across the NHS, with the cost of treatment estimated at almost £2000 per episode (Loveday et al, 2014).
The use of indwelling urinary catheters should be a last resort and must adhere to the best-practice guidance available designed to reduce risk of harm to the patient (National Institute for Health and Care Excellence (NICE), 2012; Davey, 2015; Yates, 2016; Simpson, 2017, Royal College of Nursing (RCN), 2019).
Catheter fixation is not given the attention it deserves in practice. This is despite the concept of, and evidence supporting, the use of fixation devices having been discussed since the 1960s (Billington et al, 2008).
Problems with non-stabilised catheters
Non-stabilised catheters can increase the movement of the catheter inside the bladder, leading to unstable detrusor contractions and muscle spasms. This will increase the incidence of bypassing, pain and self-expulsion of the catheter (Geng et al, 2012; Wound, Ostomy and Continence Nurses Society (WOCN), 2012; RCN, 2019). Bypassing of urine increases the risk of skin integrity issues, incontinence-associated dermatitis and contamination of any existing wounds.
A non-stabilised catheter also increases the risk of trauma on the bladder neck, urethra and abdominal opening (in suprapubic catheters), each of which significantly increases the risk of the patient developing a CAUTI (Spinks, 2013; Feneley et al, 2015).
Fixation devices
A fixation device is designed to minimise the movement of the catheter itself rather than the drainage device (Geng et al, 2012; WOCN, 2012; Yarde, 2015; Health Protection Scotland, 2017). It should secure the catheter to the thigh or abdomen, minimising any tugging or stretching of the catheter and thereby reducing the traction on the urethra or abdominal site (WOCN, 2012).
Best practice guidelines over the past few years all advocate the use of fixation devices on any patient using an indwelling catheter (Geng et al, 2012; WOCN, 2012; RCN, 2019). A careful assessment of each individual is needed to ensure correct choice and effective use of fixation devices.
Types of fixation devices
There are several bespoke devices available commercially although, in the short term, a simple tape can be as effective if applied correctly. The choice of which fixation device to use should be based on the individual patient's lifestyle, activity level, dexterity and ability to self-care; it should be comfortable and easy to use (Yarde, 2015).
Adhesive tape alone can loosen, leaving a sticky residue or increase the risk of skin damage. There is no validated evidence that suggests this choice of fixation is effective long term in reducing the complications associated with catheter migration (Hanchett, 2002) and therefore should only be used short term in specific situations (for example peri-operatively when the catheter is inserted and removed within a few hours).
‘Choice of which fixation device to use should be based on the individual patient's lifestyle, activity level, dexterity and ability to self-care’
Commercial options are elasticised straps or hydrocolloid adhesive devices. The elasticised straps have a silicone strip on the reverse to help the device grip the skin, thereby reducing movement. These are available in a variety of lengths and can be worn around the thigh or abdomen. The silicone can in some cases cause a skin reaction that is painful and may prohibit use in some patients. It should also be noted that (in the author's experience) many patients tie these elasticised straps in a knot around their thighs, which can lead to circulatory issues from the tourniquet effect. The straps are reusable and washable but may lose some of their elasticity over time.
There are some contraindications for the use of elasticised devices, in particular anyone with lower leg oedema, lymphoedema or peripheral circulatory issues (WOCN, 2012; RCN, 2019).
Adhesive or hydrocolloid foam plasters with a hook/loop or clamp section are useful at securing the catheter close to the inflation port at the nearest entry point to the body. This restricts unnecessary movement of the catheter while allowing some ‘sway’ to move as the patient changes position (Yarde, 2015). Many of these devices can stay in place for up to a week, depending on individual activity, hygiene and skin condition. It should be noted that some devices do specify the use of alcohol to remove the adhesive. These particular devices are effective for use in oily, hairy or heavily perspiring skin but may cause increased skin damage on removal if not managed appropriately. Some of the hydrocolloid plaster devices are repositionable to allow skin integrity checks.
Conclusion
Urinary catheters are used for a variety of reasons and in a multitude of patient groups, some of whom have significant long-term or life-limiting conditions (Spinks, 2013). Choices regarding the use of a catheter and its associated devices must be subject to careful patient assessment and include consideration of choice, lifestyle and activity level.
Catheter-fixation devices help to secure urinary catheters without applying excess tension, and can dramatically reduce adverse events, such as catheter displacement, expulsion or migration. This will ultimately lead to fewer incidents of tissue damage and a reduced risk of infection. This will help to improve patient outcomes, promote dignity and comfort and reduce the care costs associated with treating CAUTIs and recurrent catheterisation replacement visits by health professionals. Therefore the use of a suitable fixation device should be standard practice, with clear clinical reasons for any situation in which such a device is not used (RCN, 2019).