1. Urinary Catheter Removal Protocol Nurse Driven Protocol: Go Live June 24, 2014

2. 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])

3. 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

4. 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.

5. 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.

6. 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”.

7. 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.

8. 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.