Appropriate Catheter UseEnsure that unit teams and care providers are knowledgeable in the seven appropriate indications for urinary catheters and the four inappropriate indications outlined below. Educational tools are available in the appendices of this manual. Show
Appropriate IndicationsIn 2009, the Centers for Disease Control and Prevention’s (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC) recommended a list of appropriate and inappropriate indications for indwelling urinary catheter placement.15 The list was based on a critical review of the available medical literature. Because of the lack of high-quality studies examining indications for urinary catheterization, the recommended indications for catheter use primarily represented consensus expert opinion. In May 2015, refined guidelines for urinary catheter use were published in a special supplement to Annals of Internal Medicine, “The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients.”16 Four of the coauthors of these published guidelines were faculty members of the national, AHRQ-funded On the CUSP: Stop CAUTI project. The authors developed the guidelines through work with a 15-member expert panel using the RAND/UCLA Appropriateness Method,17 which combines a review of available literature with input by an expert panel to assess whether the expected benefits of a medical procedure outweigh potential harms. Refinements of the HICPAC guidelines based on the Ann Arbor Criteria are included below, for appropriate and inappropriate indications and possible alternatives to indwelling transurethral urinary catheters (commonly known as Foley catheters). Appropriate indications for indwelling urinary catheters are summarized below:
Other appropriate indications, based on the Ann Arbor Criteria, include the following:
Inappropriate IndicationsUrinary catheters should not be placed in the following situations:
Other inappropriate uses for indwelling urinary catheters, based on the Ann Arbor Criteria, include the following:
Indwelling urinary catheter use has not been found to be effective in reducing falls or reducing risk of UTI in patients with fecal incontinence or diarrhea. Consider Alternatives to Indwelling Urinary CathetersConsider alternatives to an indwelling urinary catheter based on a patient’s individual care needs. All alternative devices and procedures provide a much lower risk of infectious complications, such as urinary tract infection. Additionally, these alternative methods can reduce or eliminate noninfectious complications—such as discomfort and immobility—associated with indwelling urethral catheters. Identify alternatives to indwelling urinary catheters with consideration of the target populations. Involve the Supply Chain/Materials Management Department in the search for alternatives. Samples of products can be obtained so that staff can conduct a trial as a way to identify which products work best with the patient population. Product representatives can provide staff with guidance and instruction on how to use their devices correctly. The staff should complete product evaluations so that this information can be used to determine the best alternative product(s). When products have been procured, consider defining appropriate indications for use and sharing that information with staff. Before placing an indwelling catheter, consider if these alternatives would be more appropriate:
Engaging Patients and FamiliesIn the event that a patient (or the patient’s family) requests that a urinary catheter be placed, communicate to them the risks involved with catheter use, including urinary tract infection. One effective way to gain the support of patients and their family members in CAUTI prevention efforts is to include patients and families in unit education efforts. Consider editing CAUTI education materials to reduce jargon and frame the content to reflect the patient/family perspective. Emphasize the role of patients and families as partners in care. Another approach is to talk with patients and/or their family members during rounds about the team’s efforts to reduce CAUTIs. Listen to their concerns and suggestions and report your findings at team meetings. Proper Catheter Insertion and MaintenanceProperly Trained CliniciansEnsure that only staff members trained in aseptic technique for catheter insertion are given responsibility for catheter placement. The trained staff should have their proficiency documented prior to independent catheter insertions. Consider using two staff members to perform all catheter insertions. The second staff member can function as a “helper” assisting with patient positioning or serving as a runner if more supplies are needed during catheter placement. Involve frontline staff in assessing compliance with maintenance of aseptic technique during insertions using a checklist. Aseptic InsertionTechniques for catheterization of female and male patients vary. The New England Journal of Medicine has published two widely referenced articles with accompanying instructional videos on catheterization of females and males.23, 24 Evaluate your facility’s policy/procedure for placement of indwelling urinary catheters to ensure that the policy follows evidence-based practice. If the policy does adhere to the evidence base, then ensure that the policy is followed consistently. Use audits and observations of practice and ensure that collected data are reported back to staff doing this procedure. Appropriate MaintenanceImplement a policy/procedure for care of patients’ urinary needs that delineates catheter care and maintenance guidelines. Catheter maintenance requires knowledge of proper aseptic technique and the mechanics of drainage. Staff should be aware of the following considerations:
Only health care workers, family members, or patients themselves who know the correct technique of aseptic insertion and maintenance of the catheter should handle catheters. Health care workers and others who take care of catheters should be given periodic education (e.g., annual education on insertion and maintenance with competency testing), stressing the correct techniques and potential complications of urinary catheterization. Prompt Catheter RemovalNurses and physicians should be aware of the indications for urinary catheter use and should continually monitor the patient’s ongoing need for a catheter. Nurses evaluating their patient’s catheter use and finding no current indication should contact the physician to promptly discontinue the catheter or independently remove it if their hospital has a nurse-driven removal protocol. Physicians should promptly order the discontinuation of catheters that are no longer needed if the hospital does not have a nurse-driven removal protocol. One prominent reason for inappropriate catheter use is a lack of awareness among clinicians of current catheter use. In a study published in 2000, 18 percent of medical students, 22 percent of interns, 28 percent of residents, and 35 percent of attending physicians were unaware that the patients for whom they were responsible had an indwelling catheter.25 Reminders and Stop OrdersReminders that a urinary catheter is in use and stop orders are low-cost/high-impact methods for reducing the duration of catheter use. Reminders can be written, verbal, or electronic (e.g., computer order entry) and may include appropriate indications for continued catheter use and alternatives to indwelling catheters. Reminders are especially useful at the time of transition of care when nurse-to-nurse communication can prompt removal of catheters that are no longer indicated. Automatic stop orders prompt removal of urinary catheters based on a specified time (e.g., within 24 hours of surgery) or clinical criteria. In a systematic review of 14 studies of urinary catheter reminder systems, daily reminders and automatic stop orders reduced the overall risk of CAUTI by 48 percent and the average duration of catheter use by 2.6 days, yet these measures were not associated with an increased rate of catheter reinsertion compared with standard care.26 Nurse-Driven Protocol for Catheter RemovalThe role of nursing is key to reducing inappropriate use of urinary catheters.27-29 Use of a nurse-driven protocol for removing indwelling urinary catheters has been proven to be effective in reducing catheter use and preventing CAUTI. A widely used protocol, available as Appendix M, utilizes an algorithm for assessment of urinary catheters and discontinuation of catheters that are no longer necessary. This protocol does not require a physician order for discontinuation of catheters. Unit team leaders can take steps to encourage use of a nurse-driven protocol for catheter removal through the following:
Having physician champions engaged in the development of the protocol and process is key. A champion may be an epidemiologist, infectious disease physician, urologist, chief medical officer, or someone in a physician leadership role. Characteristics to look for when identifying a physician champion can be found in Appendix A. Share information on the outcomes of using the nurse-driven protocol. The outcomes often demonstrate that this approach reduces infections. These data can be used to garner support from the medical staff and often are most effectively disseminated to physicians by the physician champion. It is also important to address the noninfectious harms of unnecessary urinary catheters such as discomfort and immobility related to the urinary catheter. The medical executive committee and nursing leadership should approve the criteria for nurse-driven removal prior to implementation. Use of the nurse-driven catheter removal protocol does not preclude the need for nurses and physicians to discuss individual circumstances. Education about evidence-based practices to prevent CAUTI (e.g., use of the nurse-driven protocol) is one of the first actions the CAUTI prevention team can use to begin the CAUTI prevention journey with the staff. Provide education on the approved indications for the use of urinary catheters, and distribute posters, name tag cards, and other tools listing the indications. Use case scenarios to teach best use of the nurse-driven protocol for removal of catheters. Create an acute urinary retention protocol to govern nursing decisions if a patient is unable to void after an indwelling urinary catheter is removed. A sample protocol is as follows:
Involving staff in matters related to reducing catheter use increases ownership of the CAUTI prevention effort. Including bedside staff at the inception allows them to gain ownership and buy-in to embed the new practices into their daily work. Consider using a train-the-trainer format for staff education around proper use and removal of urinary catheters. Peer-to-peer education increases buy-in. Support staff in designing and piloting new systems to decrease the use of catheters and CAUTI, such as performing daily safety huddles to decide which catheterized patients no longer have an approved indication for an indwelling urinary catheter. Involve bedside or frontline staff in assessing the hospital’s supply and unit’s supply of urinary equipment and in testing new equipment used to care for the urinary needs of the unit’s patients, (e.g., incontinence equipment: female urinals, superabsorbent pads, barrier creams, condom catheters made of silicone in different sizes). Provide bedside staff with an evaluation tool to record their perceptions of new processes and equipment and provide feedback to frontline staff on the evaluation results. Inform staff of the decisions that were made using their feedback and about all considerations included when making new equipment purchases (e.g., safety and efficacy published, cost comparisons, ease of use). Teach about appropriate care of acute urinary retention that may occur. Check the adequacy of the supply of bladder scanners on the unit and ensure staff understanding of how best to use them. A sample bladder scan policy is available as Appendix C. If the unit supply area has new equipment to care for incontinent patients without using a catheter, ensure that staff are proficient in use of this equipment. Using new equipment to care for incontinent patients requires that staff be given time to adjust. Change can be challenging, and there is a learning curve to mastering new items such as a female urinal. Ensure staff members are fully supported in removing unnecessary urinary catheters. All nurses who remove a patient’s catheter based on the nurse-driven protocol should be supported by their charge nurse, nurse manager, and the CUSP-CAUTI team’s physician champion. Recognize staff for changes in their behavior. Consider giving “Catheter Removal Star of the Month” awards for those who excel at appropriately choosing to quickly remove catheters no longer needed. Hold staff accountable if they are reluctant to try new systems of caring for catheterized patients. Plan for succession of CAUTI team members and physician champions (e.g., term limits with automatic transfer of team leader and physician champion role every year). Sharing process (catheter use and appropriateness) and outcome (CAUTI rate) data with frontline staff is an effective motivator and is key to sustaining project gains over time. To motivate and encourage staff to continue to improve, post a graph in the nurse’s station illustrating progress made in decreasing catheter days. Reward staff for their work in reducing unnecessary urinary catheters. Consider hosting a pizza party or other event that includes the hospital leaders thanking the staff for embracing the new processes of care and demonstrating a reduction in CAUTI. Teams that set goals, make progress toward goals, and then reach their CAUTI prevention goals should be appreciated by managers, physician leaders, and administrators. Patients and their families may also be interested and appreciative. Plan for celebrations along the journey to thank staff for the wonderful patient safety culture improvements they have made. Antimicrobial StewardshipInadvertent increases in antimicrobial use that result from overuse of urine cultures and treatment of asymptomatic bacteriuria can lead to antimicrobial resistance, Clostridium difficile infection, and adverse drug events. Antimicrobial stewardship measures such as improved processes around urine culturing are crucial to patient safety. Eliminating use of unnecessary urinary catheters is the best defense against inadvertent increases in antimicrobial use. Among patients who do need a urinary catheter, following proper guidelines for urine culturing and understanding the signs and symptoms of CAUTI can reduce antibiotic overuse.30, 31 Avoiding Excessive Urine CulturesObtaining urine cultures in patients with indwelling urinary catheters without a valid reason can lead to inadvertent increases in antimicrobial use. The following are appropriate conditions for urine culture use:
Inappropriate conditions for urine culturing are as follows:
To reduce unnecessary urine cultures, evaluate current processes for obtaining urine cultures (e.g., avoid urinalysis or urine cultures as part of standing orders, laboratory triggers to do urine cultures based on urinalysis results, screening urine cultures on admission in an asymptomatic patient—including those arriving with an indwelling urinary catheter). Engage infection preventionists and infectious disease physicians in evaluating reasons given for urine cultures, and avoid having automated orders for urinalysis or urine cultures unless there is an appropriate reason, such as urinary tract infection symptoms. Evaluate practice patterns for certain physician groups, specialties, or units. Ordering cultures should be based on the clinical evaluation of the patients for potential sources of sepsis. Preoperative urine cultures in patients who are not undergoing urologic surgeries are discouraged.32 Educate physicians, midlevel providers, and nurses on when it is appropriate to obtain urine cultures in patients with an indwelling urinary catheter. You may consider implementing institutional guidelines or algorithms. Have periodic audits on urine culture use in intensive care units to look for trends, especially if CAUTI rates there are not dropping with interventions focused on improving insertion and maintenance. Not Treating Asymptomatic BacteriuriaThe best way to avoid inappropriate antimicrobial use in catheterized patients is to refrain from obtaining a urine culture unless indicated by signs and symptoms of urinary tract infection. When a urine culture is positive in a catheterized patient who has no symptoms of infection, do not treat that patient with antimicrobials. Guidelines by the Infectious Diseases Society of America strongly discourage the use of antimicrobials for asymptomatic bacteriuria except for patients who are undergoing urologic procedures or who are pregnant.33 One or more of the following symptoms should be present before treating a patient for CAUTI:
ToolsAppendix B. Urinary
Catheterization – Sample Policy Appendix C. Sample Bladder Scan Policy Appendix D. Poster on Indications for Urinary Catheters Appendix E. Poster on Urinary
Catheter Risks and Indications Appendix F. Urinary Catheter Decision-Making Algorithm Appendix G. Urinary Catheter Project Fact Sheet Appendix H. Urinary Catheter Pocket Card Appendix I. Catheter Care Pocket Card Appendix J. Urinary Catheter
Brochure Appendix K. Infographic Poster on CAUTI Prevention Appendix L. Intensive Care Unit Infographic Poster Appendix M. Example of a Nurse-Driven Protocol for Catheter Removal Appendix N. Skin Care in the
Incontinent Patient Appendix O. CAUTI Event Report Template Which instructions would the nurse provide a client needing to collect a clean catch urine specimen?Urinate a small amount into the toilet bowl, and then stop the flow of urine. Then collect a sample of urine into the clean or sterile cup, until it is half full. You may finish urinating into the toilet bowl.
Which instruction would the nurse teach a patient about obtaining a voided urine specimen for urinalysis?Instruct the patient (or nurse) to collect all voided urine during the 24-hour collection period and add it to the collection container. The collection should end exactly 24 hours after it began, by having the patient empty his or her bladder, or catheter bag, and adding this specimen to the collection container.
What does the term residual urine refer to quizlet?urine remaining in the bladder after voiding.
Which action would the nurse perform when collecting in midstream urine specimen?Explanation: When collecting a midstream urine specimen, the client voids a small amount, stop, and discards it; the first small amount helps to flush away organisms near the urinary meatus. The midstream urine specimen is a sterile specimen so it is not collected in the hat in the toilet bowl.
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