A Nurse Driven Protocol for Urinary Catheter Removal

1. 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.

2. Implementing A Urinary Catheter DisContinuation Protocol and other Short stories Marti Shaver, RN, CIC, Infection Preventionist

3. “We’re off to see the wizard …” Lions, Tigers and Bears, Oh my! • The Process • The Barriers • The Benefits

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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

10. 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

11. 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

12. Urinary Catheter Discontinuation Protocol Adult Urinary Catheter Discontinuation Protocol A. 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 initiated 2. 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 ifhe/she does not return to normal urination habits within 8 hours • voids, small amounts frequently, has bladder discomfort or bladder distention.

13. Protocol Flow Diagram

14. 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

15. 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

16. Other characters in this story • Terri Dozier, MSN,RN Clinical Informatics • Debbie Perry, RN, Clinical Manager, Materials Management QUESTIONS?