Transcript NURSE DRIVEN FOLEY CATHETER PROTOCOL

NURSE DRIVEN FOLEY
CATHETER PROTOCOL
BACKGROUND
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There are over 1.7 million hospital-acquired infections in US
hospitals annually, 40% of which are urinary tract infections.
80% of hospital-acquired UTIs are attributable to indwelling
urethral catheters.
Between 12% and 25% of all hospitalized patients in the US will
have a urinary catheter during their hospital stay, almost half of
which are not placed for an appropriate indication.
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The duration of catheterization is directly related to risk for
developing a UTI. The daily risk of developing a catheterassociated UTI (CA-UTI) ranges from 3-7%.
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TJUH began working on reducing CA-UTIs in 2008.
NDFP is the next step in this process
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Centers for Medicare and Medicaid Services estimates
that the cost of CA-UTI is between $424 and $451
million annually.
 Beginning on October 1, 2008 CMS no longer pays for
“preventable hospital-acquired complications”
including CA-UTI.
 CA-UTI received a high priority because of its high
cost, high volume, and because it can be reasonably
prevented through application of accepted evidencebased prevention guidelines.
GOALS
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Reduce the number of catheter associate urinary tract
infections (CA-UTIs), as well as reduce catheter days.
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Improve patient care and outcomes at TJUH.
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Reduce length of stay (LOS) and increase costeffectiveness.
IMPLEMENTATION
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All inpatients admitted to Jefferson who
have or may require indwelling urinary
catheters, excluding those with NDFP
protocol exceptions , will have Nurse
Driven Foley Protocol orders.
Several components of care can be uniformly
recommended for all patients to prevent or
reduce risk of CA-UTI. These components are:
 Avoid unnecessary urinary catheters,
 Insert using aseptic technique
 Maintain catheters based on recommended
guidelines,
 Review urinary catheter necessity daily and
remove promptly.
INSERT WHEN APPROPRIATE
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Appropriate indications include:
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Urinary retention/obstruction
Close monitoring of urinary output
Pre/Peri/Post Operative Management (epidural in
place; femoral sheath in place.)
Bladder Training
Unstable Hip or Spinal Injury
Incontinence with Stage III or IV skin breakdown
(perineal or sacral)
Palliative Care/End of Life Care
Urology Service patients
ALTERNATIVES TO FOLEYS
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Intermittent straight
catheterization with
the aid of bladder
scanning
 Use of external
catheters for male
patients.
ASEPTIC INSERTION
Wash hands thoroughly before and after
insertion
 Use barrier precautions during insertion
 Use smallest catheter possible to help
prevent trauma
 Follow insertion procedure
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CATHETER MAINTENANCE
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Assess need for Foley daily and document in JeffChart
and/or progress note.
Daily AM Care: Cleanse around catheter and meatus
with soap and water daily and prn. Limiting
manipulation of the catheter reduces infection.
Secure the catheter with a leg band: Leg bands help
keep the catheter in place and decrease pulling and
twisting.
Avoid bladder irrigation unless obstruction has
occurred.
Keep Drainage Bag BELOW the Bladder: This
prevents retention and reflux back into the bladder,
which can increase infection
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Keep Drainage bag OFF the Floor: To avoid
contaminating the spout.
Use individual graduated container for EACH
Patient/label with name
EMPTY the drainage bag before transport to avoid
reflux
Maintain a Closed System:
 Take urine samples through the port
 Always scrub the hub first before taking a sample
 If a urimeter is needed, change just the bag. It is
better to disconnect in this case rather than insert a
new catheter
REVIEW AND REMOVE
SHEA/IDSA compendium October 2008: “The
duration of catheterization is the most
important risk factor for development of
infection.”
 The necessity of a bladder catheter should be
addressed by physicians daily as a part of
rounds, and by nursing as part of their
assessment.
 Nursing is empowered to remove catheters
when protocol patients no longer meet the
appropriate indications
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FOLEY CARE BUNDLE
The Foley Bundle
incorporates the
elements of Foley
catheter insertion
and maintenance,
and should be
referred to each shift
to help decide
whether or not a
Foley is indicated.
Nurse Driven Foley Catheter Protocol
Criteria for Inserting/Continuing a Foley Catheter
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All patients who need a Foley catheter inserted will have an order placed in Jeffchart .
One of two orders will be chosen:
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Urologic patients and some surgical patients with special needs will have Foley Orders
for Urology/Nonprotocol Orders entered.
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All other patients will have Foley Protocol Orders entered.
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Thereafter, the RN is responsible to continually assess the need for the catheter and
properly monitor catheter use. If any of the following criteria is met, the foley
catheter will remain in place:
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Urinary retention/obstruction
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Close monitoring of urinary output required
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Pre/Peri/Post Operative Management (epidural in place; femoral sheath in place.)
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Bladder Training
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Unstable Hip or Spinal Injury
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Incontinence with Stage III or IV skin breakdown (perineal or sacral)
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Palliative Care/End of Life Care
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Urology service Patients (as ordered)
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Physician order to remain
Criteria for Removal by RN without a
separate Physician order
 If the patient does not meet any of the
above criteria, the RN may discontinue
the foley catheter when the following
criteria are met:
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The patient is awake, alert and oriented and/or can
verbally express that they had no trouble voiding
before the catheter was placed.
 Patient is able to resume their normal voiding position,
or at least one that is presently comfortable.
 A physician order for strict I&O is discontinued or the
patient is able to cooperate with strict I&O monitoring
 If a foley is present post invasive cardiac or
radiological procedure, confer with physician to
remove foley unless there is a clear reason for not
discontinuing the foley.
 Epidural catheter is removed.
NOTE:
A physician order is required for discontinuing the
foley for patients who have had recent urologic
surgery, bladder injury, pelvic surgery (i.e. GYN,
colorectal surgery) and/or recent surgery
involving structures contiguous with the bladder
or urinary tract. These patients should NOT have
Foley Protocol orders but rather Foley Orders for
Urology/Non-protocol Patients.
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The staff nurse will then need to discontinue
the present order by putting “Protocol user”
in the “ordered by” and “signed by” fields,
and changing the Order Mode to Protocol
order or Written order.
The patient will subsequently be monitored
according to the “ Post Foley Removal
Assessment and Care” guidelines listed
below.
Post Foley Removal Assessment and
Care Guidelines
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After removal of the foley catheter, the patient
will be continually assessed by the RN for the
following
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Patient is spontaneously voiding.
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Patient is not voiding however is comfortable
and expresses no need to void
A bladder scan should be done for any of the
following:
 If the patient is uncomfortable at anytime,
whether voiding or not
 If the patient has an urge to void but is unable
to do so
 The patient has not voided for 6 hours post
foley removal
 If the patient is incontinent at anytime
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If the bladder scan volume is >400cc,
the RN will notify the MD and obtain an
order for straight catheterization q6
hours and prn
The volume of each bladder scan and
output with catheterization must be
recorded in the I and O record.
NOTE:
If the patient once again meets the criteria
for foley placement, a new physician
order is required.
QUESTIONS?
Feel free to ask your
CNS/Educator for
guidance as we
implement this new
protocol
MONITORING
Infection Control will provide monthly CAUTI rates and
catheter utilization rates to the patient care units.
These rates will be used to monitor success with the
implementation of this protocol.
• CNSs/Educators will continue monthly Point
Prevalence collection on Foley Bundle compliance.
We want YOU……..
To get the
foley out!
References
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CDC Guideline. (1981). Prevention of Catheter-Associated Urinary Tract
Infections, CDC website
Hansen, B. (2006). Reducing Nosocomial Urinary Tract Infections through
Process Improvement, Journal of Healthcare Quality, Web Exclusive, 28(2),
p.2-7.
Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health
care-associated infection and criteria for specific types of infections in the acute
care setting. Am J Infect Control. 2008;36:309-332.
Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health careassociated infections and deaths in U.S. hospitals, 2002. Public Health Rep.
2007 Mar-Apr;122(2):160-166
Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and
economic costs. Am J Med. 2002 Jul 8;113 Suppl 1A:5S-13S.
Centers for Medicare & Medicaid Services. Medicare program: changes to the
hospital Inpatient Prospective Payment Systems and fiscal year 2008 rates.
Fed Regist. 2007;72(162):47129-48175.
Lo E, Nicolle L, Classen D, et al. Strategies to prevent catheter-associated
urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol.
2008 Oct;29 Suppl 1:S41-50 http://www.sheaonline.org/about/compendium.cfm