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IDC-IMPROVE: Protocol for a Cluster Randomised Feasibility Trial of a Care Bundle to Improve Indwelling Catheter Care (IDC) in Residential Aged Care Homes in Australia - Beyond the Abstract

Indwelling urinary catheters (IDC) are often used inappropriately and improperly inserted and managed, resulting in significant and avoidable morbidity.1 Around 7% of people living in long-term aged care homes have an IDC, and many remain catheterized for extended periods, ranging from several weeks to months or even years.2 Researchers in Sweden reported a mean catheterisation duration of 30 to 32 months across seventy-eight nursing homes.3 These individuals are three times more likely to die within a year compared to medically similar residents without an IDC.4

The risk of developing a catheter-associated infection (CAUTI) is well established. In hospital settings, most CAUTIs are preventable.5 To reduce the risk and costs associated with CAUTIs, most research on IDCs focuses on hospital efforts to minimise their use. However, there is very limited research on this topic in a long-term aged care setting.

In addition to being at risk of developing a CAUTI, people with a long-term IDC are at risk of experiencing other related complications, such as urethral trauma,6 encrustation, catheter blockage, leakage, bladder spasms, and pain, often leading to repeated emergency department visits and hospital admissions.7,8 The longer their IDC remains in place, the higher their risk of these complications. Up to 34% of long-term catheter users experience bypassing or blockage8. Delays in treatment for catheter blockage contribute to injury to the bladder and/or kidneys due to ureteric reflux from high bladder pressure, especially when bladder spasms are present.9

Although most hospitals now prioritise avoiding IDCs and removing them early, these strategies do not meet the needs of people who require long-term IDCs, and where IDC removal may not be an option. Many of these individuals live in long-term aged care homes and have multiple comorbidities, including cognitive and physical impairments that limit their ability to perform and manage activities of daily living. Their IDC care is typically performed by nurses and nursing assistants.

Undergraduate programs for nurses usually include education about caring for people with IDCs; however, nurses working in long-term aged care homes often lack the opportunity to consolidate their skills related to inserting and removing catheters and managing IDC-related complications. Moreover, compared to hospital-based nurses, their access to medical expertise is variable. These factors, combined with workforce constraints, pose clinical risks to aged care residents with IDCs.

A consultation conducted by our team with managers and nurses working in long-term aged care homes in Australia and with clinicians employed by external agencies that provide acute care services to this sector identified the need to improve communication processes about catheter care in this setting, increase professional development opportunities for staff, strengthen nurse and managerial leadership, and improve access to guidelines and resources to inform care.10 Following from this consultation, our team was funded under the Australian Government Medical Research Future Fund to improve knowledge and skills in IDC care of the long-term aged care workforce in Australia.

We anticipate our research project, titled the ‘IDC-IMPROVE Project’, will support Australia’s aged care nurses to perform routine uncomplicated IDC exchanges on site; identify, prevent, and manage IDC-related problems; and recognise and address the inappropriate use of an IDC. Over a period of 18 months, we consulted with key stakeholders to design and validate an IDC-IMPROVE Catheter Care Bundle that is based on guidelines from the European Association of Urological Nurses,11 and which reflects the core principles of person-centred care. It is also underpinned by ten core principles that align with the Australian Aged Care Quality Standards.

The IDC-IMPROVE Catheter Care Bundle is specifically designed for the long-term aged care environment in Australia. Arguably, information and guidance for this sector should take account of not only the different types of complications associated with long-term IDC use, but also the differences between acute and long-term care settings in terms of staff education levels, skills mix, turnover, access to resources, equipment, professional development opportunities, variable levels of medical/specialist support, and regulation.

The Bundle is now being evaluated in a multi-centre, facility-level, clustered randomised control feasibility trial across 24 aged care homes around Australia. Employing both qualitative and quantitative methods of research, we are evaluating if the trial is feasible to conduct, if the bundle is fit-for-purpose, and the preliminary effects of the education on staff knowledge and confidence to deliver person-centred, evidence-based catheter care. To the best of our knowledge, this is the first trial on IDC care in Australian long-term aged care homes.

Sponsorship:
The IDC-IMPROVE Project is funded with a grant from the Medical Research Future Fund (MRFF): Clinician Researchers Initiative- 2022 Clinician Researchers: Nurses, Midwives and Allied Health Grant Opportunity, Stream 1 (MRFF2023825). It is being run by the National Ageing Research Institute (NARI) in partnership with Continence Health Australia (CHA), the University of Melbourne, the University of South Australia, Flinders University, the University of Alberta (Canada), Central Queensland University, the Australian Prostate Centre, Austin Health, Regis Aged Care, Darling Downs Health Service, the Australian Nursing and Midwifery Federation, the Continence Nurses Society Australia, and the Australian and New Zealand Urological Nurses Society.

Written by: Joan Ostaszkiewicz,1,2,3  Andrew Simon Gilbert,1,4 Caitlin Tay,1,2 Elizabeth Watt,1 David Barry,1 Wendy Taylor,1 Jessica Cecil,1 Rowan Cockerell,5 Helen Crowe,6 Liza Lau,7 Sigrid Nakrem,8 Catherine Paterson,9,10 Micah DJ Peters,11-16 Ashlyn Sahay,17 Alyson Sweeney,1 Janie Thompson,5 Julie Westaway,18 Wendy Bower,2,5 Juliana Christina,9 Alan Zana,16 Frances Batchelor,1,2

  1. National Ageing Research Institute, Royal Melbourne Hospital, Parkville, Australia.
  2. Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia.
  3. Health and Innovation Transformation Centre, Federation University, Ballarat, VIC, Australia.
  4. Department of Social Inquiry, La Trobe University, Bundoora, VIC, Australia.
  5. Continence Health Australia, Surrey Hills, VIC, Australia.
  6. Australian Prostate Centre, North Melbourne, VIC, Australia.
  7. Austin Health, Heidelberg, VIC, Australia.
  8. Department of Public Health and Nursing, NTNU Norwegian University of Science and Technology, Trondheim, Norway.
  9. Flinders University, College of Nursing and Health Sciences, Caring Futures Institute, Adelaide, SA, Australia.
  10. Central Adelaide Local Health Network, Adelaide, SA, Australia.
  11. Rosemary Bryant AO Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia.
  12. Australian Nursing and Midwifery Federation (Federal Office), Melbourne, VIC, Australia.
  13. University of Adelaide, School of Public Health, Health Evidence Synthesis, Recommendations and Impact (HESRI), Adelaide, SA, Australia.
  14. University of Southern Queensland, Office of the Pro-Vice Chancellor (First Nations Strategy), Ipswich, QLD, Australia.
  15. The Danish Centre of Systematic Reviews: a Joanna Briggs Institute Centre of Excellence, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
  16. School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia.
  17. School of Nursing, Midwifery and Social Sciences, Central Queensland University, Toowoomba, QLD, Australia.
  18. Darling Downs Hospital and Health Service, Toowoomba, QLD, Australia.
References:

  1. Gilbert B., Naidoo TL., Redwig F. Ins and outs of urinary catheters. Australian Journal of General Practice. 2018; 47(3):132-136. doi: 10.31128/AFP-10-17-4362
  2. Czwikla J, Wandscher K, Helbach J, Fassmer AM, Schmiemann G, Hoffmann F. Prevalence of indwelling urinary catheters in nursing home residents: systematic review. Int J Nurs Stud. 2023; 145:104555.
  3. Jonsson K, Emanuelsson-Loft AL, Nasic S, Hedelin H. Urine bladder catheters in nursing home patients: a one-day point prevalence study in a Swedish county. Scand J Urol Nephrol. 2010;44(5):320–3.
  4. Rogers MA, Mody L, Kaufman SR, Fries BE, McMahon LF Jr, Saint S. Use of urinary collection devices in skilled nursing facilities in five states. J Am Geriatr Soc. 2008;56(5):854–61.
  5. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011;32(2):101–14.
  6. Davis NF, Bhatt NR, MacCraith E, Flood HD, Mooney R, Leonard G, Walsh MT. Long-term outcomes of urethral catheterisation injuries: a prospective multi-institutional study. World J Urol. 2020;38(2):473–80. doi:10.1007/s00345-019-02775-x.
  7. Tay LJ, Lyons H, Karrouze I, Taylor C, Khan AA, Thompson PM. Impact of the lack of community urinary catheter care services on the Emergency Department. BJU Int. 2016;118(2):327–32.
  8. Wilde MH, McMahon JM, Crean HF, Brasch J. Exploring relationships of catheter-associated urinary tract infection and blockage in people with long-term indwelling urinary catheters. J Clin Nurs. 2017;26(17–18):2558–71.
  9. Feneley RC, Hopley IB, Wells PN. Urinary catheters: history, current status, adverse events, and research agenda. J Med Eng Technol. 2015;39(8):459–70.
  10. Ostaszkiewicz J, Batchelor F, Gilbert A, Cecil J, Vaughan M, Tay C, Hall I, Dow B. A consultation to inform a targeted response to catheter-associated care and complications in Victorian residential aged care homes. Melbourne: National Ageing Research Institute; 2024 Mar.
  11. Geng V, Lurvink H, Pearce I, Vahr Lauridsen S. Indwelling catheterisation in adults: urethral and suprapubic. Arnhem: European Association of Urology Nurses; 2024. ISBN: 978-94-92671-24-0.
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