Implementation of a Nurse-Driven Foley Catheter Removal Protocol: A Patient Safety and Quality Improvement Project

Urinary tract infections (UTIs) are the most prevalent healthcare associated infections (HAIs) with incidence rates topping 30%, and can lead to increased hospital cost, length of stay, morbidity and mortality ^(1,2). Inserting urinary catheters causes most UTIs ⁽²⁾, suggesting that preventing catheter use or removing the catheters as soon as possible would decrease UTI rates. Urinary catheter removal may be overlooked by the medical team when considering all other patient issues. Placing nursing in control of noting inappropriate or unnecessary catheters and then empowering nursing staff to remove those catheters has been recommended to decrease catheter dwell time, leading to reductions in catheter-associated UTIs (CAUTIs).

Noting an increase in CAUTIs, the infection prevention department nurses formed a team to look at CAUTIs and devise a plan of action. As noted in the literature, keeping catheters out or removing them quickly has been proven to decrease catheter-associated problems. A physician champion from the urology service line (utilizing Centers for Disease Control guidelines) assisted the team with an approved list of indications for catheter placement and maintenance. A literature review completed by team members showed several other catheter removal protocols; however, none had all of the components that the team deemed necessary for a complete protocol.

The team utilized part of a protocol designed by Tufts Medical Center (shared via slide) to form a protocol that would meet all of the patient’s needs. This included the indications for placing or maintaining a catheter, the removal protocol, and guidelines for bladder ultrasound combined with intermittent catheterization after catheter removal. The protocol was taken to several medical and administrative committees for approval prior to trial initiation.

Baseline data for CAUTI and device utilization rates was obtained from infection prevention prior to initiation of this patient safety and quality improvement trial. The nurse-driven catheter removal protocol was then conducted for 6 months on 2 medical-surgical units with a combined average census of 32 patients. Utilizing the criteria in the protocol, unnecessary catheters were removed by nursing staff per the protocol (without a call to the provider). Protocol instructions include a bladder ultrasound every 6 hours if the patient had not voided, with intermittent catheterization if post-void residuals exceeded 400 milliliters. Perineal care post-removal was also an essential part of the infection prevention process.

Education of nursing staff and practitioners was essential to the success of the trial. Topics included general CAUTI information, proper catheter and perineal care, criteria for catheter insertion and maintenance, as well as protocol use. Education was completed utilizing many methods including on-line computer modules, presentations at staff meetings, hands-on practice at skills fairs and one-on-one coaching with staff and providers alike. Initially there was some pushback from the surgical group, but that was alleviated utilizing more one-on-one sessions with each surgeon to address their concerns. Overall the protocol appears to be a physician satisfier, with fewer calls regarding patients with retention, and issues with catheter care and removal.

Data was collected via daily rounding by infection prevention, nurse managers and clinical nurse specialists to assess catheters present on each unit for necessity and duration. This time was also utilized for coaching and answering questions that may arise regarding the process. A log was kept on the floor and was updated daily as possible. Data collected during the trial included device utilization rate (DUR), catheter reinsertion rate, number of CAUTIs, the CAUTI rate and device days.

Data collected showed that fewer catheters were being placed inappropriately and kept unnecessarily, while the reinsertion rate on both units remained steady throughout the trial, with many patients requiring catheter reinsertion being referred to urology for follow-up. DUR, CAUTIs and device days (approximate) for both units decreased (unit 1 DUR decreased from 35.48 to 34.48, CAUTIs fell from 3 to 2 and device days declined from 2400 to 2200; unit 2 DUR was reduced from 25 to 18.82, the number of CAUTIs decreased from 2 to 1, with the device days being cut from 4050 to 3300). The actual CAUTI rates of both units increased (unit 1 from 1.57 to 1.76 and unit 2 from 0.57 to 0.92). This was primarily attributed to low catheter numbers during the trial period.

The protocol was initiated hospital-wide in September of 2013, with preliminary data from the recently surveyed areas (notably the intensive care and progressive care units) indicating a continued successful process. The DUR for all inpatient units has declined noticeably since hospital-wide protocol initiation, as have the number of CAUTIS and reinsertion rates. There will be considerably more data by the conference, with the hope being that other hospitals and nursing areas can adopt and utilize the protocol to decrease urinary infection rates and device days while increasing patient safety.