LIBERTY REGIONAL
MEDICAL CENTER
I.
TITLE: URINARY CATHETER CARE
Original Date:
04/01/1995
Effective Date:
05/10/2012
Next Review Date: 05/10/2014
DEFINITION OF POLICY:
It is the policy of Liberty Regional Medical Center (LRMC) to adhere to guidelines as recommended
by the Centers for Disease Control and Association for Professionals in Infection Control and
Epidemiology to prevent or minimize urinary tract infections.
II.
PURPOSE OF POLICY:
A. To provide evidence-based practice guidance for the prevention of catheter-associated urinary
tract infection (CAUTI) in acute and long-term care settings.
B. To maintain urinary drainage from the bladder as a continuous, unobstructed, and unidirectional
flow.
III.
DEPARTMENTS TO WHICH THIS POLICY APPLIES:
All departments within the organization and the Medical Staff via Infection Prevention Policy Manual
IV.
DEFINITION:
Indwelling urinary catheter – A drainage tube that is inserted into the urinary bladder through the
urethra, is left in place, and is connected to a closed collection system. It is also called a Foley
catheter.
V.
PROCEDURE(S):
A. Physician order is required to insert indwelling urinary catheter.
B. Patient/resident and/or family will be educated on the purpose of urinary catheter and prevention
of catheter-associated urinary tract infection (Attachment 4).
C. Only credentialed personnel will insert urinary catheters.
D. Personnel who insert urinary catheters will be required to attend yearly educational recredentialing.
E. Alternatives to indwelling catheters will be considered:
1. External condom catheters for male patients without urinary retention or bladder outlet
obstruction.
2. Intermittent catheterization (preferred to indwelling urethral catheter in patient with bladder
emptying dysfunction).
F.
Urinary catheters will be inserted using sterile technique. The smallest catheter allowable for
adequate urinary drainage (or the size specified by the physician) will be inserted.
G. If it breaks in the sterile technique, disconnection, or leakage occur, replace the catheter and
collecting system using sterile technique and sterile equipment.
H. Personnel will perform hand hygiene prior to insertion, prior to and after any manipulation of
catheter sites or apparatus.
1
I.
Indwelling urinary catheters will be managed as a closed sterile drainage system. The following
will be observed:
1. Drainage bags will not touch the floor.
2. If drainage bag has a spigot, do not allow it to touch the clean graduate container.
3. The closed drainage system will not be interrupted unless the catheter must be irrigated.
J.
Free flow of urine will be maintained by adherence to the following:
1. Preventing the catheter or tubing from kinking.
2. Emptying the drainage bag prior to patient/resident transport, when bag is approximately ¾
full and/or every 6 hours.
3. Maintaining the drainage below the level of the patient’s/resident’s bladder (e.g. do not put
the catheter drainage bag in the bed during transport).
K. Urine specimen collection from indwelling urinary catheter:
1. Under no circumstances should a urine sample be taken from the drainage bag for culture
analysis after the initial insertion with immediate sampling.
2. Fresh urine specimens will be aspirated from the sampling port using aseptic technique.
3. If a CAUTI is suspected, remove the old catheter before obtaining the specimen. If
indications for urinary catheterization still exist, obtain the urine specimen after replacing the
old urinary catheter.
L. Indwelling catheters will be properly secured after insertion to prevent movement and urethral
traction.
M. Long term indwelling catheters will not be changed on a routine/scheduled basis but only as
needed (e.g. suspicion of urinary tract infection), unless otherwise ordered by the physician.
N. Routine catheter care will be performed twice daily (morning and night), after each bowel
movement, and as needed for soiling using soap and water (See Procedure for Foley Catheter
Routine Care Attachment 3). This will be documented in the Nursing Progress Notes.
O. Catheters will be irrigated by physician’s order only. Continuous irrigation solutions and tubing
will be changed every 24 hours. Equipment for manual irrigation will be discarded after single
use.
P. Nursing will document the following information in the patient’s record:
 Indications for catheter insertion
 Date and time of catheter insertion
 Individual who inserted indwelling urinary catheter
 Daily assessment of need to continue indwelling urinary catheter
 Number of foley days(e.g. foley day 3)
 Date and time of catheter removal
Q. Acute Care (Hospital care)
1. Indwelling Urinary Catheter Daily Assessment will be placed on the chart for physician
review by night shift nursing personnel during chart checks (Attachment 1), unless for the
following:
a. The physician has already ordered a urinary catheter discontinuance on a designated date
and time (e.g. remove Foley on post-op day 1 in the a.m.)
b. The patient is determined to have a chronic indwelling urinary catheter that cannot be
removed.
2. Indwelling Urinary Catheters will be removed if within 24 hours unless:
a. The physician continues the order (Attachment 1).
b. The physician has already ordered urinary catheter discontinuance on a designated date
and time (e.g. remove Foley on post-op day 1in the a.m.).
c. The patient is determined to have a chronic indwelling urinary catheter that cannot be
removed.
2
d.
Med-Surg Department: The Daily Monitoring Urinary Catheter Surveillance Form will
be completed by unit’s charge nurse/designee and forwarded to Infection Prevention each
day (Attachment 2).
R. Long Term Care (Nursing Home care)
Nursing will notify Long Term Care Infection Prevention Nurse of all urinary catheters. Long
Term Care Infection Prevention Nurse will notify Director of Infection Prevention
VI.
REFERENCE(S):
Gould, C, Umscheid, C., Agarwa, R., Kuntz, G., Pegues, D. and the Healthcare Infection Control
Practices Advisory Committee (HICPAC). Guidelines for prevention of catheter-associated urinary
tract infections 2009.
Umscheid, C., Gould C., Pegues, D.A. (2008). Guidelines for preventing catheter associated urinary
tract infections. Centers for Disease Control and Prevention.
An APIC Guide (2008). Guide to the elimination of catheter-associated urinary tract infections
(CAUTIs).
Yokoe, D.S. , Mermel, L.A., Anderson, D.J., et. Al (2008). A compendium of strategies to prevent
healthcare-associated infections in acute care hospitals. Infection Control and Hospital Epidemiology,
29(1):S12-S21.
INI. Getting Started Kit: Prevent catheter-associated urinary tract infections. How-to-Guide.
Originating Department/Committee/Team: Infection Control Committee
Approval History:
April 10, 2012
April 5, 2012
March 4, 2010
February 23, 2010
April 30, 2009
April 14, 2009
April 14, 2009
February 19, 2009
February 11, 2009
June 26, 2008
June 24, 2008
May 3, 2007
April 24, 2007
February 24, 2005
February 8, 2005
April 26, 2001
December 12, 2000
NCR PIC
Medical Staff
Policy Committee
Infection Prevention and Control Committee
Policy Committee
Infection Prevention and Control Committee
NCR PIC
Policy Committee
Infection Control Committee
Policy Committee
Infection Control Committee
Policy Committee
Infection Control Committee
Policy Committee
Infection Control Committee
Policy Committee
Infection Control Committee
3
Liberty Regional Medical Center
Daily Urinary Catheter Assessment
Date & Time
Indwelling Urinary Catheter Daily Assessment
 Discontinue indwelling urinary catheter now
Continue indwelling urinary catheter for the following reason(s):
 Surgical procedure with prolonged postop duration (e.g. structural repair of urethra or
contiguous structures, prolonged effect of epidural anesthesia, etc…)
 Required immobilization due to surgery or trauma (e.g., potentially unstable thoracic or
lumbar spine, multiple traumatic injuries such as pelvic fractures)
 Strict Intake & Output in critically ill patient (patient cannot use urinal or bedpan)
 Urinary obstruction (prostatic hypertrophy, clots with obstruction, etc.)
 Acute urinary retention and the patient cannot be intermittently catheterized
 Assistance in sacral or perineal wound healing with incontinent patient
 Patient/Resident comfort for end of life.
 Patient/Resident with chronic indwelling urinary catheter
Physician Signature:
Attachment 1
“Urinary Catheter Care”
05/10/2012
PATIENT IDENTIFICATION
4
Daily Monitoring Urinary Catheter Surveillance Form
Fax to Infection Prevention Daily 408-9500
Date
Shift
Patient Label
Patient Label
Patient Label
Patient Label
Foley
Days
Indications- Circle indication or contact physician to remove Foley
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Required immobilization due to surgery or trauma
Strict Intake & Output in critically ill patient (pt can’t use bedpan/urinal/condom cath)
Urinary obstruction
Urinary retention and pat cannot be intermittently catheterized
Assistance in sacral, perineal wound healing with incontinence
Patient comfort for end of life
Pt with chronic indwelling urinary catheter
Required immobilization due to surgery or trauma
Strict Intake & Output in critically ill patient (pt can’t use bedpan/urinal/condom cath)
Urinary obstruction
Urinary retention and pat cannot be intermittently catheterized
Assistance in sacral, perineal wound healing with incontinence
Patient comfort for end of life
Pt with chronic indwelling urinary catheter
Required immobilization due to surgery or trauma
Strict Intake & Output in critically ill patient (pt can’t use bedpan/urinal/condom cath)
Urinary obstruction
Urinary retention and pat cannot be intermittently catheterized
Assistance in sacral, perineal wound healing with incontinence
Patient comfort for end of life
Pt with chronic indwelling urinary catheter
Required immobilization due to surgery or trauma
Strict Intake & Output in critically ill patient (pt can’t use bedpan/urinal/condom cath)
Urinary obstruction
Urinary retention and pat cannot be intermittently catheterized
Assistance in sacral, perineal wound healing with incontinence
Patient comfort for end of life
Pt with chronic indwelling urinary catheter
Attachment 2
“Urinary Catheter Care”
05/10/2012
5
LIBERTY REGIONAL MEDICAL CENTER
Procedure for Foley Catheter Routine Care
The catheter-meatal junction is a significant portal of entry for bacteria into the urinary tract, potentially causing urinary tract infections.
Therefore, it is most important that the perineum, catheter-meatal junction, and tubing be kept clean and free of fecal contamination. This
area will be cleansed twice daily and as needed with soap and water or an acceptable perineal-cleansing product as follows:

Provide patient/resident privacy.

Explain to the patient/resident on what you are about to do.

Call for assistance if you anticipate that the patient/resident may be uncooperative or if you need assistance positioning or turning
the patient/resident.

Wash hands or use alcohol hand sanitizer.

Apply PPE, at minimum gloves.

Obtain a basin of warm water. Wet washcloth with warm water. Apply soap or perineal cleansing product to cloth.

Starting at the catheter-meatal junction, wash tubing, labia, and meatus, using friction and circular motion work outwards to the
surrounding perineum. Always work from the area of least contamination to areas of more contamination and always from front
to back.

Repeat as needed. If gloves become grossly contaminated with feces, etc., gloves should be changed before continuing.

Rinse area with clean warm water and pat dry.

For uncircumcised males take special care to clean under the foreskin. After cleansing, keep the foreskin pulled down over the
glans penis.

Remove gloves and PPE and perform hand hygiene.

Immediately document and/or report any reddened, abraded, swollen or broken skin areas to the patient’s/resident’s nurse.
Reference: Centers for Disease Control and Prevention. Guideline for prevention of catheter-associated urinary tract infections. February
1, 1981.
Attachment 3
“Urinary Catheter Care”
05/10/2012
6