Introduction of the UroShield® in district nursing: a case study

Introduction

This case study documents the introduction of the UroShield® to a small group of patients receiving care for management of their long-term indwelling urinary catheter (IUC) (urethral and suprapubic) within a District Nursing Service (DNS). This case study summarises the impact UroShield® may have on problematic long-term urinary catheters, and evaluates any ongoing benefits for patients, the DNS, and the entire organisation.

Health New Zealand MidCentral’s DNS provides comprehensive specialist community nursing across the entire region; approximately 8912 km², with a population of 188,830.¹ The service is available 7 days a week, 08:00–23:00 hours, with registered nurses and enrolled nurses providing home-based or clinic-based care. The main District Nurse (DN) hub is in Palmerston North, with six outlying centres across the region.

Management of long-term IUCs makes up 34–37% of the workload for the MidCentral DNS. Each patient with an IUC has an individualised plan of care around the management regime for their catheters – this ranges from weekly to twelve weekly changes, with routine bladder irrigations introduced as deemed appropriate by the visiting DN. A study amongst community nursing services in the United Kingdom (UK) discovered that 20% of unscheduled visits were catheter-related; 72% of which were blocked or leaking IUCs.² Each intervention requires DN time (including travel), consumables, sterile equipment, and ongoing supply deliveries. Any after-hours call outs add to the day-to-day cost to the service, with potential trips to the Emergency Department (ED) and admission to hospital for urosepsis all adding to the burden to the organisation. Extra callouts for catheter-related complications cause frustration for the patients; such as having to wait for the nurse, or cancel plans, as well as an added pressure on nurses with already high workloads.³

It is estimated that 30–50% of long-term catheter patients suffer from blockages, making it one of the most common complications affecting quality of life (QoL).⁴–⁶ In 2023, MidCentral DNS introduced UroShield® as a quality improvement (QI) project, to reduce the burden of complications and unscheduled care for patients and the service/organisation. UroShield® clips onto the IUC and produces surface acoustic waves which prevents microbial attachment within the catheter lumen. This case study will examine the incidence of catheter-associated urinary tract infection (CAUTI) and blockage while UroShield® is in situ and determine any potential enhancement to QoL for patients. The case study will also assess any reduction to the burden on the DNS and organisation as a whole; including reduction of workload and urgent callouts, reduced resource use and prevention of CAUTIs requiring primary health care input or hospital assessment/admission.

Background

In New Zealand (NZ) currently, there is no national reporting for CAUTI or other complications of IUC, and no tracking of long-term IUC use. NZ is one of the few developed countries in the world without a comprehensive national healthcare-associated infection (HAI) surveillance system. In the United Kingdom (UK) and some states in the United States of America (USA) it is mandated by law.⁷ In 2021, the first national Point of Prevalence Survey (PPS) for all HAI was conducted, which determined urinary tract infections (UTIs) made up 19% of HAIs detected in the 24-h period of the survey. Forty-nine percent of these had an IUC within the 7 days prior.⁸ There is no data available around financial cost of CAUTI within NZ. From this PPS, the NZ Health Quality and Safety Commission have set the goal to reduce all HAIs from medical devices, including commitment to develop a programme around IUC management.⁸

IUCs are one of the most frequently used invasive clinical devices globally³ with significant costs associated.⁴ It is estimated that every case of CAUTI in the USA costs approximately US$600, equating to a total of US$131 million cost burden annually.⁹ Modelling from the National Health Service (NHS) in the UK estimates an annual CAUTI rate of 52,085 nationally, costing UK£27.7 million.¹⁰ CAUTI have one of the highest prevalence of HAI worldwide, with the risk increasing the longer the IUC remains in place.^11,12 A lack of robust evidence has led to conflicting recommendations in international guidelines, with no clear consensus on managing long-term IUCs or preventing complications.¹³–¹⁵ Until the recent publication of new evidence-based guidelines from the European Association of Urological Nurses (EAUN),¹⁶ there were no specific best practice recommendations for the day-to-day management of IUCs. The UK National Institute for Health and Clinical Excellence (NICE) guidelines were the only catheter management guidelines available, although they focused on infection prevention. These guidelines determine that avoiding interruption to the closed drainage system is the most effective CAUTI prevention method.¹⁷ ‘Breaking the seal’ is a term coined to describe disruption of the sterile closed-drainage system, which unavoidably increases the risk of bacterial invasion.¹⁸

Within hours of an IUC being inserted, microorganisms begin to attach to the catheter’s surface and build a protective matrix known as biofilm.^3,19,20 Biofilm creates a microcolony of bacteria within the catheter which is shielded from the body’s innate immune response and is resistant to the force of urine flow to dislodge it.^18,21,22 The most frequent bacteria isolated in urine from IUCs is Proteus mirabilis – a urease producing bacteria that leads to raised pH of the urine which in turns causes crystallisations to develop and adhere to the surface of the catheter.^3,19 As the crystallisations build up, blockages occur which further increases CAUTI risk if improperly managed and can cause life-threatening situations amongst certain patient populations.²³ Autonomic dysreflexia is a life-threatening episode of sudden hypertension, experienced by people with spinal injuries above the T6 level. It is the result of noxious stimuli below the level of the injury, with around 85% being related to infection, bladder distention or blocked IUCs.^24,25 Untreated CAUTIs can lead to urosepsis, which has a high mortality rate of around 10%.⁹

The European Association of Urology (EAU) recommends antibiotic therapy as the first line treatment for any CAUTI that are symptomatic.²⁶ Misdiagnosis of asymptomatic CAUTI from the detection of normal bacteriuria within IUCs, has led to an overuse of antibiotics and an increasing prevalence of antibiotic resistant pathogens.^27,28 Antibiotic resistance has become a global concern associated with prolonged hospital stays, higher mortality and increased financial burden.^28,29 A study found that 23% of hospital-acquired sepsis cases, were due to UTIs; mostly from patients with IUCs.³⁰ The most effective method of reducing antibiotic resistant pathogens, is removing the need for antibiotic use.²⁸

Eradication of established biofilm is complex, and various attempts to overcome it have been developed.^20,21 Table 1 provides a summary of existing CAUTI prevention methods.

UroShield® in district nursing

The UroShield® is proven to have good efficacy from multiple international clinical trials,^21,31,37,38 with NICE developing a guidance document for its use.³⁹ The Surface Acoustic Waves (SAW) produced by UroShield® prevent biofilm formation within the catheter lumen, preventing bacterial attachment. In turn, this reduces incidence of CAUTI and blockage, relieving many of the associated complications.^21,31,38 It is an external device that clips around the catheter after insertion, making it fully non-invasive, without need to disrupt the sterile closed system as per best practice recommendations. UroShield® has not been adopted for routine IUC care within NZ, as far as the author is aware.

In 2023, a quality improvement (QI) project was conducted within MidCentral DNS, to introduce UroShield® within usual practice. UroShield® is not intended to be used on all patients with IUCs, only those experiencing frequent complications. For a patient to be appropriate for UroShield®, DNS decided on the following requirements: patients to be experiencing UTIs and/or blockages bimonthly; evidence of excess debris; and a regular regime of bladder irrigations in between catheter changes. For patient safety, patients must be cognitively aware and able to understand the instructions around management of UroShield®, be independent or have appropriate caregiver availability and not be a falls risk.

Five patients involved in this project were used for this case study, with written consent obtained for examination of clinical interventions before and after use of the device.

Results/Analysis

Patient outcomes

Fig. 1 shows incidence of UTI and blockage and any resulting interventions in the periods before and after use of UroShield®. The clinical findings show significant improvement in the number of interventions required for all five patients, with only one UTI amongst the group.

Fig. 1.

Patient clinical outcomes.

There were two catheter related hospital admissions in the pre-UroShield® period, resulting in a total of 5 days total in hospital; there were none during the 5 months of use.

Nursing/service outcomes

District nursing time is logged using units which is coded against various interventions, according to the care provided/contracts. Each unit equates to 10 min of time; in the before device period 2420 min of nurse time was spent in total for all five patients. After use of UroShield®, 1390 min was needed, which included the extra time and two nurse visits for education/support when first commencing use of the device. Fig. 2 shows the comparison data for each patient.

Fig. 2.

Service outcomes – nursing time.

Twenty-five feedback forms were sent out amongst the nursing team, with requests in newsletters and in-person reminders to complete them; only one was returned which was from a nurse who had not had any input to any of the patients’ care which prevented analysis of nursing thoughts on UroShield®.

Organisational outcomes

In the 5 months pre-UroShield®, total costs were NZ$8666.68, reducing to NZ$3160.82 over the 5 months post implementation, as per Fig. 3. These improvements included visits with no need for clinical interventions, as they were for extra education/support for patients and/or caregivers in the early stages of usage. It is worth noting that the initial expense of purchasing UroShield® has not been included in the analysis, as they are not single person use so are a long-standing asset to the service/organisation overall. Each UroShield® comes with one actuator clip and costs NZ$874.50 (+GST 15%), with further individual actuators costing NZ$83.73 (+GST 15%); these are changed every 6 weeks, or with each IUC change.

Fig. 3.

Organisational outcomes.

There were no hospital admissions in the time UroShield® was in use.

Discussion

Incidental findings

There were several incidental findings from initial review of the five patients. Documentation around description of usual urine output or visual appearance is lacking. Task focused care is frequently evident for urgent call outs, with patients often phoning in with a blockage or leakage and the immediate action is to perform an irrigation without investigation into why the blockage occurred. Care plans often lack clinical indications or rationale other than patient prefers the current regime or ‘the doctor said’ resulting in potential over visiting and wasted resources.

Accurate documentation is a core requirement of the Nursing Council of New Zealand (NCNZ) which protects patients’ outcomes and ensures high quality care.⁴⁸ Documentation of all catheter care helps anticipate care needs and identify new patterns indicating change of condition, allowing for accurate care planning.⁴ Many of these findings could be tackled through the roll-out phase if UroShield® is adopted, to improve care and produce a gold standard protocol within the service.

Limitations

There were several limitations to this project. The cohort of patients was from one small urban area within the DNS; none of them lived rurally. Spinal injury patients were not included in the clinical audit/patient selection due to strict protocols set by the spinal unit post initial injury; these patients are potentially the most likely to benefit from the device and lead to the biggest cost saving long-term; the specialists at spinal units will need to be consulted in the roll-out to these patients. Feedback from nurses was minimal; completion of the paper-based questionnaire may have impacted this, as it was another thing to-do within their busy day.

Conclusion

This case study documents the implementation of UroShield® on five patients with regular catheter-related complications within the DNS, with the aims of improving incidence of clinical interventions, and potential for improved QoL for patients. Moreover, the project aimed to improve DN workloads and reduce resource expenditure across the organisation.

Improvement to patient QoL is likely, simply from less reliance on the DNS for the cohort of patients examined. A formal ethics approved randomised controlled trial (RCT) is needed to examine the full effectiveness of UroShield® on QoL amongst this population.

The number of DN visits, and time spent with each patient was greatly reduced, which has the potential to have a vast impact on nurse workload service wide, particularly if implemented amongst the spinal injury patients within the service. A need for more support and education of nurses around best-practice for catheter management was discovered, as there were inconsistencies found around the current regime and clinical need. Lack of nurse feedback provided inadequate insight into how things could have been done better from their perspective.

The reduction in clinical interventions and nurse time, resulted in a significant cost saving for the organisation, with complete avoidance of any catheter-related hospital admissions. The initial expense of purchasing UroShield® is outweighed by the fact that they are reusable for multiple patients and can be utilised by others if not suitable once commenced.

The success of this QI project led to UroShield® being incorporated into regular long-term catheter management plans within the DNS. This could potentially inspire uptake of UroShield® further across NZ, improving QoL for IUC patients nationwide.