Urinary Catheter Updates

1. Urinary Catheter Updates

2. UTIs at Mission • We had over 300 catheter associated UTIs last year, and the rate has not improved • UTI’s cause 36% of hospital-acquired infections at Mission • Cost is $3500 per catheter-associated UTI. Mission does not get reimbursed for this. • We can reduce this number and cost

3. UTI Prevention is in Your Hands The most important risk factor for a UTI is prolonged catheterization Please--remove urinary catheters (foleys) as soon as possible!

4. Isn’t a foley better than in & out caths for preventing UTIs? • No, research demonstrates that having a constant direct route for bacteria to enter the urinary tract leads to more infection than intermittent caths. • The presence of a catheter interferes with normal host defenses Association for Professionals in Infection Control & Epidemiology. (2008) Guide to the Elimination of Catheter-Associated Urinary Tract Infections

5. Catheter Associated UTIs: • By day 5 of catheter use, one half of all catheterized patients will be colonized with bacteria • By day 30 INFECTION IS NEAR UNIVERSAL • Let’s not give bacteria a chance!

6. Foley Related Policy Changes To support evidence based practice, we have updated the following nursing policies: • Urine Specimen collection • Indwelling Bladder Catheter Insertion and Removal

7. Specimen Collection • If the catheter has been in for >72 hours, the catheter must be removed and changed before a specimen is collected • WHY? Because a biofilm of bacteria forms on the catheter within 72 hours, and the specimen will be contaminated • We do not want to treat patients for UTIs unnecessarily

8. Specimen Collection • If the catheter was placed < 72 hours ago, collect the urine sample from the specimen port. Never collect urine from the drainage bag. • Do not send for a UA/culture if there are no symptoms. Symptoms of a UTI are: fever, urgency, frequency, and suprapubic tenderness. Cloudy urine is not a symptom. Asymptomatic bacteruria should not be treated. • Delirium may be a symptom of a UTI, particularly in elders

9. Catheter Insertion and Removal • Do not test the balloon —they are already pretested—if done prior to insertion “ridges” will remain after deflation and cause discomfort, irritation and an increased chance of UTI • Label the drainage bag with insertion date • Post Urinary Catheter Removal Care has been added to the policy for reference

10. UTI Prevention Reminder: Utilize correct technique 1. Wash your hands 2. Wear gloves 3. Use sterile technique for insertion 4. Secure catheter to avoid tension.

11. UTI Prevention Reminder The designated foley hook on the new Stryker beds allows the foley bag to touch the floor. DO NOT USE. Keep the Foley bag off the floor

12. On the new Stryker beds: Upper restraint holder is high enough to keep the foley bag off the floor The space at the knee bend joint is also high enough to keep the foley bag off the floor

13. Urinary Catheter Removal Protocol • Goal: to reduce the number of days foleys are in place at Mission. • Foley Removal protocols are evidence based, and have been proven to reduce UTIs at other hospitals • Nursing assesses daily for appropriate use of urinary catheters

14. Urinary Catheter Removal Protocol • Physicians have an option to chose the Urinary Catheter Removal Protocol when they order a foley catheter • This has been added to selected power plans based on the patient population • If it is added to your patient’s power plan or it is ordered with the foley, you will get automatic prompts to remove the catheter

15. Surgical Powerplans and Foley Orders • The surgeons have opted NOT to use the urinary catheter removal protocol. WHY? • Surgeons need to direct when to remove the foleys due to a variety of surgical concerns. • Many of the surgical plans have orders directing the nurse to discontinue foleys. These details are found in the comment field of the foley order.

16. OThe surgery plans will be defaulting to NO for using the urinary catheter protocol

17. Urinary Catheter Removal Protocol • D/C urinary catheter within one day following insertion unless patient meets one of the following criteria: • Need for accurate I & O in critically ill patients or patient undergoing aggressive diuresis • Relief of urinary tract obstruction/urinary retention • Patients in whom catheter has been inserted for a urologic or pelvic surgery • Management of urinary incontinence in patients with stage 3 or 4 pressure ulcers or wounds • Promote comfort in terminally ill patients or patients who have significant pain when moved

18. Meds May Contribute to Urinary Retention • Urinary Retention is a side effect of many medications • Often these are anticholinergic meds such as: antispasmotics, antihistamines, antidepressants, muscle relaxants and antiemetics • Discontinuing or reducing the dose of such meds may be helpful • See a full list of these meds on the Urology MOD site

19. Post Urinary Catheter Removal Care • Document time of removal and amount of urine in bag on I&O • Encourage oral fluid intake (unless contraindicated) • Scheduled toileting q 2-3 hours to provide opportunity to urinate—OOB or BSC if possible • Goal is not to exceed bladder volume >500 ml

20. Post Urinary Catheter Removal Care If patient spontaneously voids within 4 hours ≥ 250 ml, continue to measure urinary output X 24 hours.

21. Post Urinary Catheter Removal Care • If pt. does not void, or voids < 250 ml within 4 hours: • Perform bladder scan every 4 hours until spontaneous voiding resumes. • If bladder volume ≥ 350 ml, perform straight cath. • If bladder volume < 350, rescan in 2 hours if patient has not voided; cath when volume > 350 ml. • If straight cath is required X 2, call MD for further orders • Call MD if urinary output < 250 ml over 8 hours • If bladder volume < 250 ml and pt voiding, continue to monitor I & O

22. Cerner Changes to Support the Reduction of UTIsat Mission

23. The process starts when a Foley Catheter is ordered… The ability to initiate the new Protocol is linked to the Order.

24. A selection of Yes/No is offered..

25. Process continues in “Shift Documentation” Currently, Nurses have a q 12-h shift responsibility to assess Fall Risk, Braden Score, CVC Necessity, Nutritional Needs, etc… Another box has been added to document Urinary Catheter present.

26. Selection of “YES” on Urinary Catheter Present then presents a requiredfield….

27. The box lists the criteria to maintain a Urinary Catheter from the Urinary Catheter Removal Protocol

28. The number of “Indwelling Catheter” days are clearly displayed to increase awareness of UTI risk. The count increases daily if documented presence of “Indwelling Catheter” via assessment.

29. The choice of “none” triggers a “Discontinue Foley Catheter” order IF the provider answered “Yes” to the Protocol…

30. Summary • The longer a foley catheter stays in, the more chance there is of a UTI • We now have a Urinary Catheter Removal Protocol to facilitate early removal of foley catheters • If none of the conditions of foley necessity are met and the protocol has been ordered, the nurse will receive a prompt to dc the foley • We can now keep track of “foley days” for our patients to be aware of their risk for a UTI