Urinary Catheter Removal ProtocolNurse Driven Protocol: Go Live June 24, 2014

Urinary Catheter Removal Protocol• Summary: Protocol that empowers the nurse to drive the

removal of urinary catheter based on evidenced based guidelines.

• Purpose: Reduce urinary catheter days and help prevent catheter associated urinary tract infections (CAUTI), while maintaining compliance with the Surgical Care Improvement Project (SCIP) Core Measure.

• Scope: Indwelling urinary catheter that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system.

(Does not apply to suprapubic catheter.)• Approved through Medical Executive and Medical Quality

Committees (still piloting at IBBHC [Enid])

Evidenced-based reasons for insertion and maintaining• Urinary catheter placement criteria:• Accurate I/O in critical ill patient• Bladder or urinary tract surgery• Gross hematuria, bladder irrigation• Hemodynamically unstable• Monitor intraoperative urinary

output • Open perineal/ wound in

incontinent pt.• Open sacral wound in incontinent

pt.• Palliative care for terminally ill• Pelvic surgery (i.e. GYN and

Colorectal) • Unstable ortho / spine• Urinary obstruction• Urinary retention

• Reasons to maintain urinary catheter:• Accurate I/O in critical ill patient• Assist healing open perineal/sacral

wound in incontinent patients• Bladder irrigation or drug instillation• Epidural catheter or intrathecal still in

place, or in effect• Gross hematuria or continued

irrigation • Immobilized patient due to unstable

fractures.• Neurogenic bladder dysfunction • Palliative care for terminally ill• Patient is hemodynamically unstable• Recent bladder or urinary tract surgery• Recent pelvic surgery (i.e. GYN and

Colorectal) • Urinary obstruction• Urinary retention

Urinary Catheter Removal Protocol in the EMR

• A new order for “Urinary Catheter Insertion/Maintain” will be available and also replace the current insertion order in the relevant PowerPlans.

• The type of catheter must be indicated.• The choice of utilizing the “Urinary Catheter

Management Protocol” (“Yes” is defaulted) may be modified.

• The provider will need to indicate the reason for insertion.

• If the provider does not want to utilize the protocol, then the provider will need to manage urinary catheter removal, as appropriate, and place the discontinue order.

• If the protocol is not utilized, nursing will no longer receive the “indications to continue” task.

EMR process cont’d• If the protocol is being used,

and the catheter indwelling, orders will automatically be placed for nursing tasks of “Foley Care” and “Reason to Maintain Urinary Catheter”.

• The tasks will be for 0600 daily.

EMR process cont’d• Nursing will assess the reason to

maintain the urinary catheter on a daily basis at 0600. When the patient does not meet criteria to continue, the nurse will document “Patient does not meet criteria, discontinue catheter within 2 hours”.

EMR process cont’d• With that nursing documentation for

not meeting criteria, the “Foley care” order and the “Reason To Maintain Urinary Catheter” orders will be canceled automatically.

• Orders for “Urinary Catheter Discontinuation” and “Urinary Catheter Post-Removal Assessment” be entered automatically entered as well.

EMR process cont’d• Once the

catheter has been removed, the nurse will follow the existing protocol to assess for urinary retention.

• Urinary Catheter Post-Removal Assessment:

• After removal of the Foley catheter, the patient will be assessed by the RN for the following parameters:• Patient is spontaneously voiding. • A bladder scan should be done for any of the

following:• Patient is uncomfortable at any time, whether

voiding or not.• Patient has an urge to void but is unable to do so.• Patient has new onset incontinence.• Patient has not voided > 6 hours.

• Straight Cath if:• Bladder scan volume > 600mL in non-voiding

patient, or• Bladder scan volume > 300mL post void

• Document results of bladder scan in I-view I&O under genitourinary.