Title:
Indwelling Urinary Catheter Protocol
Protocol
Saint Francis Hospital and Medical Center
Mount Sinai Rehabilitation Hospital
Saint Francis Medical Group, Inc.
Saint Francis Care Medical Group, P.C.
Asylum Hill Family Medicine Center, Inc.
Saint Francis Behavioral Health Group, P.C.
Saint Francis Emergency Medicine Group, P.C.
Proponent
Department
Patient Care
Number
Level
CLIN.0171
Category
Published Date
System
Division
Department
Review Cycle
Administrative
Clinical
HR
EOC
12/28/2012
1 year
3 years
PURPOSE
To implement best practices to prevent catheter-associated urinary tract infections.
SCOPE
Clinicians responsible for ordering, inserting, maintaining and discontinuing indwelling urinary
catheters.
POLICY
1. Indwelling urinary catheters will be inserted by a licensed practitioner only when necessary with
an Physician/APP (Advanced Practice Practitioner) order.
2. When ordering an indwelling urinary catheter, the physician or APP (Advanced Practice
Practitioner) will document the necessity for the catheter by using the insertion criteria listed.
3. Clinicians inserting and maintaining a catheter will have knowledge of aseptic technique and
procedures for catheter and drainage system maintenance.
4. Consideration will be given to alternatives to indwelling catheters, such as external drainage
device or intermittent catheterization.
5. An assessment of catheter necessity will be performed and the catheter removed as soon as
possible.
6. In the event of post operative urinary retention (POUR), bladder scanning will be performed and
the results reported to the physician/APP. Intermittent catheterization will be considered.
7. If Physician/APP states the urinary catheter cannot be removed, the rationale for need for urinary
catheter must be documented by the Physician/APP and RN.
8. A Physician/APP order for indwelling catheter removal is not needed when protocol removal
criteria are met.
POPULATION OR CLINICAL CONDITION
Patient whose clinical condition warrants the insertion of an indwelling urinary catheter.
PROTOCOL:
Indwelling Urinary Catheter Protocol
Date: 12/28/2012
Page 1 of 4
I. CAUTI PREVENTION BUNDLE-CRITERIA FOR INSERTION
1. Use of an indwelling urinary catheter is assessed using the following insertion criteria:
a. Requires accurate monitoring of urine output in the hemodynamically unstable patient.
Examples include (but not limited to):
 Severe hypotension
 Neurological impairment
 Multi-system trauma
b. Requires management of acute urinary retention and urinary obstruction confirmed by clinical
exam, bladder ultrasound, palpable urinary bladder and/or patient symptoms.
c. Assistance in Stage III or IV pressure ulcer or wound healing in the incontinent patient unable
to use alternative measures.
d. Patient comfort during end-of-life care.
e. Urinary catheters will be inserted in the operating room for selected surgical
procedures:
 Expected duration of operation greater than or equal to 3 hours
 Expected intraperitoneal urologic, gynecologic, pelvic, colorectal dissection or extensive
extraperitoneal anorectal dissection with or without anastomosis
 Critically ill patients requiring emergent surgery and in need of physiologic monitoring and
volume resuscitation
f. Physically deconditioned patient who experiences significant pain due to unstable fractures if
unable to use alternative methods e.g. external drainage device, urinals, etc.
II. INSERTION OF URINARY CATHETER
1. Urinary catheters will be inserted using aseptic technique.
2. Follow link for insertion of catheter in female
a. Female
b. Male
3. Document insertion date, time and initials in the medical record
4. Apply label with insertion date, time and initials to the drainage tubing
5. Provide patient and family education
III. CAUTI PREVENTION BUNDLE-URINARY CATHETER MAINTENANCE
1. Maintain urinary catheters and closed system as outlined in attached procedures.
http://procedures.lww.com/lnp/view.do?pId=5487&s=p&fromSearch=true&searchQuery=uri
nary+catheters
2. Perform hand hygiene and use standard precautions prior to any urinary catheter care
3. Routine Maintenance includes the following
a. Perineal care with hospital approved bath product
b. Daily and as needed when soiled
c. Catheter is cleaned from the perineum outward
d. Prevent looping or kinking of drainage tube by using the linen clip
e. Secure catheter to leg
Indwelling Urinary Catheter Protocol
Date: 12/28/2012
Page 2 of 4
2.
3.
4.
5.
6.
7.
f. Drainage tubing is labeled with the insertion date, time and initials
g. Maintain the drainage bag below the bladder with all activities
h. Maintain a closed system
i. Do not place the drainage bag on the floor
Emptying bag at least once every 8 hours and when clinically indicated
a. Separate/labeled graduate for each patient
b. Label graduate with room number, patient initials & “Urine only” with permanent marker
c. Avoid touching sides of the graduate with drainage spigot
Clean sample port with chlorhexidine wipe for 15 seconds and let air dry prior to obtaining sample
(Scrub the hub)
a. Obtain urine specimens from indwelling urinary catheter using sterile technique to prevent
catheter contamination.
http://procedures.lww.com/lnp/view.do?pId=5381&s=p&fromSearch=true&searchQuery=uri
nary+catheters
Do not routinely clamp prior to removal
Bladder scan first before irrigating if no urinary output (no routine irrigation)
If system integrity becomes compromised, the entire system including catheter will be changed
Use aseptic technique if system needs to be opened in order to change bag
IV. CAUTI PREVENTION BUNDLE ONGOING NEEDS ASSESSMENT CRITERIA
1. Nurse will assess and document the need for an indwelling catheter every shift
2. If criteria is not met, the catheter will be removed per protocol
V. CAUTI PREVENTION BUNDLE- CRITERIA FOR CATHETER REMOVAL
1. Nurse will consult the PHYSICIAN/APP before removing catheter if patient:
a. Has gross hematuria
b. Had extensive urologic, gynecologic, pelvic or colorectal surgery
c. Is urology patient or Urology Service inserted urinary catheter
2. Nurse will remove indwelling urinary catheter without a Physician/APP order:
a. Within 48 hours after insertion for post-operative patients
b. When any single criteria listed below is met for non-surgical patients:
 A stable patient no longer requires frequent monitoring of urine output.
 No longer exhibits signs and symptoms of urinary retention or obstruction
Note: If catheter was inserted due to a problem with mechanical obstruction,
please communicate with the appropriate attending prior to removal.
 Pressure ulcer or wound not impacted by not using an indwelling catheter
 Physician/APP order specifies date and/or time of urinary catheter removal
3. If no exclusion factors are noted, the RN will discontinue the catheter and document date and time
of removal and monitor urinary output every 8 hours x 24 hours.
4. If patient is unable to void within 6-8 hours or patient is incontinent, assess patient (clinical exam,
palpable urinary bladder, bladder ultrasound, patient symptoms) to determine if straight
catheterization is needed.
a. Intermittent/straight catheterization is preferable to indwelling urethral or suprapubic catheters
in patients with bladder emptying dysfunction. Frequency of straight catheterization is
determined by nursing assessment and patient comfort.
Indwelling Urinary Catheter Protocol
Date: 12/28/2012
Page 3 of 4
VI. CAUTI PREVENTION BUNDLE CRITERIA FOR CONTINUED CATHETER USE
1. The urinary catheter may be continued if one of the following criteria is met:
a. Requires accurate monitoring of urine output in the hemodynamically unstable patient.
b. Management of acute urinary retention and urinary obstruction
c. Assistance in Stage III or IV pressure ulcer or wound healing for incontinent patient unable to
use alternative measures
d. Comfort during end-of-life care
e. Meets criteria for peri-operative use for selected surgical procedures.
f. Physically deconditioned patient who experiences significant pain due to unstable
fractures if unable to use alternative methods e.g. condom catheters, urinals, etc.
2. If there is a need to continue use of the indwelling urinary catheter, the rationale for
continuation must be documented.
REFERENCES:
SHEA-IDSA – Society for Healthcare epidemiology of America/Infectious Disease of America
CDC – Centers for Disease Control
ACS- NSQIP Best Practice for CAUTI Prevention NHS – National Health Service
IHI-How to Guide: Prevent Catheter- Associated Urinary Tract Infections
HICPAC-Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009
CROSS REFERENCES:
Applicable Lippincott Procedures
REVIEWED BY: CAUTI Committee 12/12
APPROVED BY: See policy for required approval(s).
Title:
Rebecca L. Burke, RN, MS,
NEA-BC
SVP, Clinical Services,
Chief Nursing Officer
Rolf Knoll, M.D.
Senior Vice President,
Medical Affairs
Chief Medical Officer
Date:
12/28/2012
Committee(s), if applicable:
Date:
12/18/2012
REPLACES:
Foley Catheter Associate UTI Prevention Guideline – CAUTI Bundle 12/2010
KEY CHANGES: Addition of Urinary Catheter Maintenance; Specific criteria for insertion and
continuation of indwelling catheter; Need assessment
Indwelling Urinary Catheter Protocol
Date: 12/28/2012
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