A Nurse Driven Protocol for Urinary Catheter Removal

Objectives:1.Describe the benefits of a standardized

urinary catheter removal process.2.Outline the essential elements of a

Nurse Driven Protocol for urinary catheter removal

3.Discuss barriers to implementing a Nurse Driven Protocol and how they can be overcome.

IMPLEMENTING A URINARY CATHETER DISCONTINUATION PROTOCOL AND OTHER SHORT STORIES

Marti Shaver, RN, CIC, Infection Preventionist

“We’re off to see the wizard …”

Lions, Tigers and Bears, Oh my! The Process The Barriers The Benefits

Process – “The Little Red Hen-Who will help me develop a protocol?”

2009 sought Medical Executive Committee (MEC)approval of the protocol

concept Infection Prevention Championed the process

with Clinical Informatics and the Clinical Manager of Materials Management

Reviewed literature & looked for other protocols Developed the protocol

Process –We are, the champions!”

Decision of where to place the protocol online for nursing access Tagged onto the Insertion & Removal of a Urinary Catheter Policy and Procedure

P&P needed a review and update Sent to approving committees

Process – “Marooned”

2010 Approved by MEC Clinical Policy and Procedure

Committee Infection Prevention and

Management Committee

2011 Encountered major delays due to system wide IT initiatives for revenue cycle conversion

Process – Back on Track, “I think I can, I think I can”

IT revised 45 order sets to include the protocol

To CMIO for approval To MEC for final approval IT governance for priority approval

Nurse Educators developed teaching tools and included in the annual competency check off

Process – “meanwhile back at the ranch”

Quality staff worked on the SCIP core measure to discontinue a catheter at 48 hours post op

April 2012 After a long journey, the Discontinuation Protocol goes live.

Not the End…go back and get the broomstick !

IP worked with IT to develop an electronic count of catheter days Developed an electronic report

to evaluate the use of the order and protocol Used report to validate the

electronic counting

The Results

ED placing catheters with orders Inconsistent nursing documentation for

specific criteria Inconsistent documentation for output Ignoring the Protocol Nursing not embracing a nurse driven

protocol 20% reduction in CAUTI and excess

patient days in first 6 months

The Benefits

Electronic report accessible to nursing Daily rounding and assessment of

catheter need conducted by nursing – Clinical Coordinators

Electronic counting of catheter days Electronic report for ongoing audits of

order and protocol usage 48 hours electronic alert to remind

nursing

Urinary Catheter Discontinuation Protocol

Adult Urinary Catheter Discontinuation ProtocolA. Purpose: To decrease the incidence of hospital acquired catheter associated urinary tract infections (CAUTI) and to provide guidelines for the daily

reassessment for the continued need for the urinary catheter. B. A physician order is required to initiate this protocol. C. When the following urinary catheter indicators are present:

1. The urinary catheter discontinuation protocol should not be initiated2. The nurse should verify that the “initiate urinary catheter discontinuation protocol” order in Acute Care has not been selected. 3. The urinary catheter should not be discontinued without a physician’s order.4. The nurse will assess the patient daily for the presence of these indicators. 

Urinary Catheter Indicators Is the urinary catheter in place for any of the following indicators; 1. Renal/Urologic or Gynecologic surgery 8. Pelvic fracture 2. Incontinence with a sacral/perineal wound 9. Chemically paralyzed or sedated 3. End of life care 10. Head/Spine injury 4. Urinary retention or obstruction 11. Crush injury 5. Need for strict/frequent urine output monitoring 12. Peritoneal trauma 6. Acute renal or respiratory failure 13. Bladder rupture 7. Presence of an epidural catheter 14. ICU patient receiving diuretics                         

D. Protocol: 1. Each day, the nurse will assess the patient for presence of urinary catheter indicators. If none are present, the catheter should be discontinued within 48 hours. Refer to the Urinary Catheter Assessment of Need Algorithm CPR-098B 2. The nurse will document daily the urinary catheter indicator present to explain why the indwelling catheter is not discontinued. 3. A physician/physician assistant (PA)/nurse practitioner (NP) must provide daily documentation for leaving the urinary catheter in place beyond 48 hours.   E. After discontinuation of an indwelling catheter, the patient is assessed for adequate bladder emptying 1. Palpate bladder at suprapubic area after patient voids 2. As needed, obtain order for straight catheterization to assess post void residual; If greater than150cc, call physician for further orders. 3. If patient is discharged home immediately after indwelling catheter is discontinued, the nurse should inform the patient to call physician if he/she does not return to normal urination habits within 8 hours voids, small amounts frequently, has bladder discomfort or bladder distention.  

Protocol Flow Diagram

Elements of the Protocol

Physician order - select new or maintain an existing catheter and reason

Protocol is prechecked on all order sets (except GYN and GU surgery order sets)

Nurse will discontinue catheter at 48 hours unless patient develops a need that is predefined

or Physician can uncheck the protocol Prompted to enter one of the predefined criteria Nurse reviews and carries the selected criteria

forward into the assessment and charting

More Elements

Nurses documentation should always reflect the criteria selected by the physician unless a new reason has developed

Nurse notifies MD and documents new criteria

Protocol discontinued by MD or by nurse as a

verbal order

Other characters in this story Terri Dozier, MSN,RN Clinical Informatics Debbie Perry, RN, Clinical Manager, Materials Management

QUESTIONS?