Urinary catheter removal protocol
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Urinary Catheter Removal Protocol. Nurse Driven Protocol: Go Live June 24, 2014. Urinary Catheter Removal Protocol. Summary : Protocol that empowers the nurse to drive the removal of urinary catheter based on evidenced based guidelines .

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Urinary Catheter Removal Protocol

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Urinary catheter removal protocol

Urinary Catheter Removal Protocol

Nurse Driven Protocol: Go Live June 24, 2014


Urinary catheter removal protocol1

Urinary Catheter Removal Protocol

  • Summary: Protocol that empowers the nurse to drive the removal of urinary catheter based on evidenced based guidelines.

  • 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 maintaining

Evidenced-based reasons for insertion and maintaining

  • Urinary catheter placement criteria:

    • Accurate I/O in critical ill patient

    • Bladder or urinary tract surgery

    • Gross hematuria, bladder irrigation

    • Hemodynamically unstable

    • Monitor intraoperative urinary output

    • Open perineal/ wound in incontinent pt.

    • Open sacral wound in incontinent pt.

    • Palliative care for terminally ill

    • Pelvic surgery (i.e. GYN and Colorectal)

    • 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 irrigation

    • Immobilized patient due to unstable fractures.

    • Neurogenic bladder dysfunction

    • Palliative care for terminally ill

    • Patient is hemodynamically unstable

    • Recent bladder or urinary tract surgery

    • Recent pelvic surgery (i.e. GYN and Colorectal)

    • Urinary obstruction

    • Urinary retention


Urinary catheter removal protocol in the emr

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 insertion.

  • 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

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 daily.


Emr process cont d1

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 d2

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 d3

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 Assessment:

  • 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 so.

      • 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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