Cover slide
Reduction in Urinary Catheter Utilization
Emory Johns Creek Hospital
Marcia Postal-Ranney, RN, CIC, Infection Prevention
Karen Tatoy, RN, Shift Nurse Manager Medical Unit
Lynn Talmadge, RN, Charge Nurse, Emergency Department
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Emory Johns Creek Hospital
 110 Bed Community Hospital in Johns Creek, GA
 Opened February 2007
 Medical Unit
 Surgical Unit
 ICU
 Women’s Services with level 3 NICU
 Cardiac Catheterization lab with PCI
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Team Members
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Physician Champion
– Brenda Friedman, MD
Administrative Champion- Hassan
Shabbir, MD, Chief Quality Officer
4 Surgical– Roselyn Laxama
– Stephanie Liffick
3 Medical
– Sayea Vardier
– Maila Rallos
– Karen Tatoy
– Anu Thomas
– Muta Okparaocha
emoryjohnscreek.com
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Women’s Services
– Melissa Donovan
– Lydia Balbuena
ICU
– Allison Tomy
– Donna Dyer
Emergency
– Lynn Talmadge
– Lindsey Meixner
Infection Prevention
– Marcia Postal-Ranney
Newnan Hospital
– Dr. Karen Clarke
Medical Executive Committee Approval
– Physician champion brought indications for indwelling
catheter insertion to MEC
– Cardiology Chairman approved guidelines for cardiac
patients will not require indwelling catheter for
accurate I&O outside of the ICU
– Nephrology Chairman approved guidelines for dialysis
patients to not require indwelling catheter for
accurate I&O outside of the ICU
– Alternative methods of daily weights and number of
wet sheets per day would suffice
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Emergency Room Catheter Insertion Indications
Indication for urinary catheter insertion (Why are you inserting this catheter)
Check all that apply
 Hemodynamically unstable
 Precise measurement of urinary output needed in ICU
 Acute urinary retention or obstruction
 Stage three or four sacral decubitus in incontinent patient
 Select surgical procedures- urinary and GYN
 Prolonged immobilization
 End of life care- Hospice
 Epidural/ Lumbar catheter in place
 Replacement of current indwelling catheter
 Continuous bladder irrigation
 Other-Obtain from provider_________________
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Posters for Approved Use of Indwelling Catheters
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Daily Review for Necessity
Appropriate Reasons for Indwelling
Catheter
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Hemodynamically unstable- accurate
I&O in ICU
Obstruction of urinary tract
Need to monitor accurate urine output
in ICU
Preoperative catheterization
Urinary tract hemorrhage
Palliative care
Continuous lumbar epidural anesthesia
Incontinent patient with stage III or IV
decubitus
Chronic Foley catheter prior to
admission
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Inappropriate Reasons for
Indwelling Catheter
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Nursing convenience
Not checking daily to see if catheter
can be discontinued
Urinary incontinence with no skin
breakdown
No clear reason for placement of
catheter
Intermittent catheterization is
possible
Patient request
Patient Brochure
Laminated card in the patient room
explaining the EJCH philosophy for
not using an indwelling catheter
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Nurse Attitude
• Nurses want to make sure that the patient does
not get a CAUTI
• Importance of a faster recovery to get the patient
up to bedside commode or toilet
• Purple pad helps by absorbing one liter of fluid
without patient feeling wet. Pads improve ease
of changing the bed
• SIBR rounds requires nurse to pick a designated
indication to keep the indwelling catheter in place
emoryjohnscreek.com
CAUTI Slide
Catheter Associated Urinary Tract Infection (CAUTI)
14.00
Infections per 1000 Catheter Days
12.00
10.00
8.00
6.00
4.00
2.00
0.00
Se Oc No De
Fe Ma Ap Ma
Au Se Oc No De
Fe Ma Ap Ma
Au Se Oc No De
Fe Ma Ap Ma
Au Se Oc No De
Jan
Jun JulJan
Jun JulJan
Jun JulJan
p- t- v- cb- r- r- yg- p- t- v- cb- r- r- yg- p- t- v- cb- r- r- yg- p- t- v- c-11
-11 11
-12
-12 12
-13
-13 13
-14
10 10 10 10
11 11 11 11
11 11 11 11 11
12 12 12 12
12 12 12 12 12
13 13 13 13
13 13 13 13 13
Series1 11. 0.0 7.5 7.8 6.9 0.0 4.4 7.2 2.5 8.6 6.1 5.8 5.8 7.1 12. 6.0 2.5 0.0 0.0 2.7 4.6 2.2 0.0 4.7 0.0 3.4 3.4 6.1 0.0 0.0 0.0 10. 3.9 0.0 6.0 0.0 3.4 7.9 3.4 3.8 2.7
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Urinary Catheter Utilization
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Nurse-Driven Indwelling Urinary Catheter Removal Algorithm
Catheter Removal Diagram
Daily assessment: Does the
patient have at least one
indication for an indwelling
urinary catheter?
No
Yes
Remove indwelling urinary catheter,
utilizing alternatives if needed
Continue indwelling
urinary catheter. Assess
indications daily.
(see list)
Symptoms of urinary
retention? (see list)
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Yes
No
Indwelling Urinary Catheter Alternatives
• External catheters
• Toileting schedule
• Bladder scan
• Intermittent catheterization
Bladder scan
Continue to
assess
>300 ml residual, begin intermittent
catheterization Q 6 hours
< 300 ml, wait 2 hours and re-scan
Continue to assess for
symptoms of retention
LR 12-13
Notify provider after
intermittent catheterizations x 3,
continue to assess for symptoms
of retention
Symptoms of Urinary Retention
Urinary pain, fullness, or distention
Change in voiding pattern
Failure to void in past 6 hours in spite
of adequate hydration
Frequent voiding with volumes <100
ml
Ultimate Outcome- culture change
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Each adult unit is seeing a reduction in
catheter utilization
Indwelling catheters are not placed
immediately in the Emergency Room for
every admitted patient
Staff convenience is no longer a reason for a
catheter
Attitudes changed and staff felt truly
concerned when a CAUTI occurred
Culture was changed to see this and other
aspects of preventable harm as a patient
safety issue
Each employee felt committed to personal
responsibility for prevention of hospital
acquired conditions.
emoryjohnscreek.com
“Many infections are
inevitable;
some might be
preventable”
“Each infection is potentially
preventable, unless
proven otherwise”