Lowering infection risk for spinal cord injury patients

Spinal cord injury (SCI) can result in the loss of voluntary control of the urinary bladder, rendering people with SCI reliant on urinary catheters to empty, or void, their bladder.

Catheterisation involves the risk of experiencing urinary tract infections (UTIs), which is the most frequent condition that sees SCI patients present to hospital emergency departments.

People with SCI can use two types of catheters; indwelling and intermittent catheters. Both catheters drain urine from the bladder. However, indwelling catheters (IDCs) remain in the bladder for an ongoing period, compared to intermittent catheters (IMCs) that are removed after each void (typically by the person, rather than a health professional). Using IMCs instead of IDCs has been shown to decrease the risk of people with SCI experiencing a UTI.

Best evidence-based practice for catheter use by people with SCI involves providing them with an IMC rather than an IDC when they are ready and capable of using one (e.g. after the acute injury period). Unfortunately, evidence from an audit of SCI patients within the Victorian Spinal Cord Service demonstrated that the transition from IDC to IMC was taking too long – 67 days based on an audit of 143 patients. This needed to change to prevent UTIs and, consequently, improve the quality of life of people with SCI relying on catheterisation for voiding.

What did we do?

To address the issue, the Victorian Spinal Cord Service, based at Austin Health in Melbourne, engaged BehaviourWorks Australia to explore the behavioural aspects of catheter management and trial an approach to reduce the number of days between people with SCI being converted from using an IDC to using an IMC.

The research team began by conducting a ‘deep dive’ investigation with several spinal injury consultants, doctors, nurses, people with SCI and allied health professionals. Investigations like this involved interviewing participants about their experiences with catheter management for people with SCI. We conducted one forum of 66 people and 21 interviews. The aim was to identify the attitudes, drivers and barriers to implementing evidence-based recommendations for bladder and catheter management for people with SCI.

Despite clinicians recognising that prompt and clinically appropriate conversion from IDC to IMC is optimal practice, the interviews revealed several barriers to optimal bladder management for people with SCI. Some barriers included:

beliefs about patient readiness and inability to independently use IMCs;
access to information and resources to support the transition; and
inconsistencies in knowledge around best practice.

These findings provided valuable insights into current catheter management for people with SCI, as well as what might be needed to support all relevant stakeholders to effectively transition people with SCI from using an IDC to an IMC sooner than at 67 days.

We used the findings from the interviews to design and trial a multi-faceted behaviour change intervention that included:

Mandatory training for all nursing staff on evidence-based catheterisation practice (including the development of hospital posters [Fig 1]),
The recruitment of ‘change champions’ to encourage best evidence-based practice; and
The development of an online patient information resource – mybladdermylife.com - to empower people with SCI to understand and ask for the catheter care that is recommended (Fig 2).

Each intervention component was co-designed with clinicians and other end-users to support appropriateness, feasibility and acceptability of each component in the ‘real world’.

*Figure 1: Developed algorithm based on qualitative interview (taken from* *Nunn, A. et al, p. 14*)

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What did we achieve?

The intervention was implemented over three months, where we engaged with clinicians, nursing teams, allied health and people with a newly acquired SCI in the acute and rehabilitation units. Pleasingly, we saw a large reduction in the time taken to convert people with SCI from using an IDC to using an IMC for bladder voiding. Instead of it taking 67 days, by the end of the intervention the median time to IDC removal was 19.5 days. That’s a huge improvement in the clinical care of people living with SCI, which will also likely reduce the incidence of UTIs experienced by this group and the number presentations to hospital, allowing people with SCI to continue to live their best life.

Want to read more about our work helping people with SCI to live their best life? Stay tuned for our report on ‘Leading your best life: Optimising the wellbeing of young men living with SCI’, led by our Co-Director of Health & Social Programs, Dr Denise Goodwin, due to be completed in 2023 (here’s a taste of what’s to come!).

We think it’s important to share the findings of our work with the world to ensure people everywhere can successfully change behaviour and see excellent outcomes. That’s why we publish our work whenever we can. Check out our publications related to our work in SCI: