Frequently Asked Questions About the Use of and Care for Leg Bags in the Long-Term Care Setting

Disclaimer: Answers to the following frequently asked questions (FAQs) are based on consensus of experts from a national project team of clinical faculty, and do not represent the official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

General Recommendations

Maintaining a reusable disposable leg bag requires clean technique, and compliance with the United States Food and Drug Administration and manufacturers required product labeling and instructions for use. Prior to handling the leg bag, health care personnel should first perform hand hygiene and then put on (don) clean gloves. Upon completion of care, remove the gloves and discard in the trash. Perform hand hygiene again.

LTC facilities should determine their optimal approach (leg bag vs. a continuous, large-capacity urine collection bag) and each care practice recommendation based on national recommendations, evidence-based practices, this FAQ, their own facility risk assessment and best practices in shared decision-making with residents and/or families. References should be added to the policy and procedure, as needed.

In the absence of clear cleaning and storage instructions for the manufacturer or national guidelines, it is critical to assure that staff handling these devices can demonstrate knowledge of basic aseptic technique.

Using Leg Bags

1. What is the recommendation for using leg bags?

   Residents and patients with an indwelling urethral urinary catheter will sometimes break a closed urinary drainage system (with its large urine collection bag) in order to use a smaller leg bag for mobility, dignity and comfort issues. The leg bag can be concealed under clothing and may assist with optimizing independence with activities of daily living.

   This practice requires a break in the closed urinary drainage system when the collection bag is changed to a smaller leg bag and conflicts with recommendations in Centers for Disease Control and Prevention (CDC) Guideline¹ and the Society for Healthcare Epidemiology of America (SHEA) Compendium² that recommend maintaining a closed drainage system following aseptic insertion. However, the evidence supporting these recommendations comes from investigations among acute care, short term use catheters. To avoid breaking the closed system at the indwelling catheter level, some products attach the larger drainage bag to the end of the leg bag for nighttime drainage.

   While there is no compelling evidence to recommend discontinuing the use of leg bags, the facility should perform an infection risk assessment prior to initiating leg bag use and assure there are policies and procedures in place to aseptically maintain the leg bag.

2. How often should the leg bag be changed?

   Leg bags that are labeled by the manufacturer as reusable may be reused for a single resident in the LTC setting for convenience, cost savings and decreased environmental waste. Following the manufacturer's instructions for use is imperative. If the manufacturer recommends its product for single use only, it should not be used off-label due to a potential safety risk to the resident (e.g., infection, compromised structural integrity leading to device failure). In the event of a product-related incident such as infection, there may be liability issues for the user and the LTC facility.

   An alternative approach is to perform a multi-disciplinary risk assessment that addresses the benefits and disadvantages of reusing leg drainage bags labeled by the manufacturer as reusable. The assessment should be documented and approved by the appropriate facility committee(s), such as a safety committee. Risk Management perspective may be helpful. If leg bags labeled as reusable by the manufacturer will be used more than once for the same person, it is important to develop a policy and procedure that follow the manufacturer instructions for use including:
   • Performing hand hygiene and wearing personal protective equipment (PPE)
   • Step-by-step instructions to adhere to aseptic technique
   • When and how to wipe all connecting tips with an alcohol wipe
   • Ensuring the connecting tips are kept covered and clean while being stored
   • Cleaning the exterior of the bag and leg straps
   • Rinsing the interior of the bag
   • Storing the bag
   • Replacing the leg and drainage bag on a schedule (e.g., weekly), and as needed (e.g., urinary tract infection, bag cleanliness is compromised).

Cleaning and Storing Leg Bag Materials

Leg Bag Care

1. How should the exterior of the leg bag and straps be cleaned, and how often?
   1. Manufacturer instructions should be followed for products and methods of cleaning all parts of the reusable disposable urinary leg bag. Not all straps are cleanable (e.g., Velcro, fabric), and not all products can be cleaned with bleach or vinegar.
   2. Both the exterior of wipeable leg bag and the leg straps, which have prolonged skin-to-skin contact, should be cleaned using basic aseptic technique
      1. Wiped down during routine, daily bathing care with the resident's preferred bathing method (e.g., soap, brand skin cleaner).
      2. Rinsed and promptly dried. Do not allow prolonged skin-to-skin contact with wet/damp materials.
2. How should the interior of the leg bag be cleaned?
   1. Both diluted vinegar (1 part vinegar to 3 parts water (1:3)) and bleach (1 part bleach to 10 parts water (1:10)) have bactericidal properties and may be used to clean the interior of the leg bag if consistent with manufacturer's instructions. Either agent disinfects to reduce infection and may reduce odor and lessen embarrassment. When using any chemical such as vinegar or bleach, ensure a consistent dilution protocol is developed. Alternatively, a ready to use bleach agent may be preferred.
   2. It is very important to have a facility policy and procedure for cleaning the leg bag especially if you are requiring CNA's to mix caustic solutions (bleach) for cleaning due to the potential for occupational health injury. Also, appropriate personal protective equipment (PPE) should be worn to prevent a splashing injury.
   3. Appropriate aseptic steps to take to clean the interior of the leg bag include:
      1. Don appropriate PPE.
      2. Fill the leg bag with the preferred agent.
      3. Ensure both caps are secured and the inside components are covered with the chemical.
      4. After the soaking time, don appropriate PPE and carefully empty the contents into the toilet; avoid potential splashing.
      5. Rinse the bag and caps, using tap water.
      
      NOTE: While there are many types of soap with varying bactericidal properties, soap is generally recommended to be used on the skin and not as a disinfecting product for the interior of the bag, per manufacturer's instructions.
3. How should the leg bag be stored?
   1. The manufactures instructions for storage of reusable leg bags should be followed if available.
   2. Prior to initial use and when storing the leg bag, ensure a resident identifier (e.g., name, initials) is on the leg bag.
   3. Allow the leg bag and caps to air dry by:
      1. Placing upright in a clean container¹ (e.g., bath basin with a resident identifier)
      2. Place a clean paper towel in the bottom of the container and change daily.
      3. Storing container, leg bag, straps and caps in the bathroom when not in use.²

Leg Bag Nozzle and Cap Care

1. How should the leg bag caps be cleaned?
   1. Leg bag caps can be cleaned the same way the interior leg bag is cleaned. For more information, go to the "Leg Bag Care" section, question 2.
   2. The manufacturer's instructions for cleaning leg bag caps on reusable leg bags should be followed if available.
   3. Alternatively, the inside of the cap can be disinfected with alcohol prep pad for 5 seconds and allowed to air dry. Store the leg bag cap in a clean container or on a clean paper towel, in the bathroom.
2. How should the following be cleaned/disinfected prior to connecting the leg bag to the indwelling catheter?
   1. The manufacturer's instructions for cleaning and disinfection and storage of nozzles, and caps for reusable leg bags should be followed if available.
   2. Nozzle: Use appropriate hand hygiene and don gloves. Remove leg bag caps and drain fluid into the receptacle (i.e., urine collection container or toilet). Disinfect the nozzle by rubbing an alcohol prep pad on the leg bag nozzle for 5 seconds and allow it to air dry. Then insert the leg bag nozzle into the urinary catheter.
   3. Cap: Change when contaminated and when the entire system is changed, per policy. Disinfect the cap by rubbing an alcohol prep pad on and in the cap for 5 seconds and allow it to air dry.
   4. Storage Containers: Clean/disinfect the container when soiled or discard. Change the basin per facility policy. Store the leg bag in the resident's bathroom in a clean labeled container. This minimizes contamination (from aerosols, dust, etc.) and also prevents cross-contamination to clean items in the resident's room and other resident's equipment in a semiprivate setting.

References

¹Gould CV, Umscheid CA, Agarwal RK, Kuntz G., Pegues DA, and the Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Accessed November 29, 2015.
²Lo E., Nicolle LE, Coffin SE, Gould C., Maragakis LL, Meddings J., Pegues DA et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 Update. Accessed November 29, 2015.