Urinary Catheter Updates
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
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!
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
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!
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
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
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
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
UTI Prevention Reminder:
Utilize correct technique
1.
2.
3.
4.
Wash your hands
Wear gloves
Use sterile technique for insertion
Secure catheter to avoid tension.
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
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
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
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
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.
The surgery plans will be defaulting to NO for using the
urinary catheter protocol
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
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
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
Post Urinary Catheter
Removal Care
If patient spontaneously voids within 4
hours ≥ 250 ml, continue to measure
urinary output X 24 hours.
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
Cerner Changes to Support
the Reduction of UTIs
at Mission
The process
starts when a
Foley Catheter
is ordered…
The ability to
initiate the new
Protocol is
linked to the
Order.
A selection of
Yes/No is
offered..
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.
Selection of “YES” on Urinary Catheter Present
then presents a required field….
The box lists the criteria to
maintain a Urinary Catheter
from the Urinary Catheter
Removal Protocol
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.
The choice of
“none” triggers a
“Discontinue
Foley Catheter”
IF
order
the
provider
answered “Yes” to
the Protocol…
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