Urinary Catheter Removal Protocol

Urinary Catheter
Removal Protocol
Nurse Driven Protocol: Go Live June 24, 2014
Urinary Catheter Removal
• Summary: Protocol that empowers the nurse to drive the
removal of urinary catheter based on evidenced based
• 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
• Urinary catheter placement criteria:
• Accurate I/O in critical ill patient
• Bladder or urinary tract surgery
• Gross hematuria, bladder
• Hemodynamically unstable
• Monitor intraoperative urinary
• Open perineal/ wound in
incontinent pt.
• Open sacral wound in incontinent
• Palliative care for terminally ill
• Pelvic surgery (i.e. GYN and
• 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
• Immobilized patient due to unstable
• Neurogenic bladder dysfunction
• Palliative care for terminally ill
• Patient is hemodynamically unstable
• Recent bladder or urinary tract
• Recent pelvic surgery (i.e. GYN and
• 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
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
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
• 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
• 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.

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