Preventing Catheter Associated Urinary Tract

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PREVENTING CATHETER ASSOCIATED URINARY TRACT

INFECTIONS: IMPLEMENTATION OF A NURSE

DRIVEN CATHETER REMOVAL PROTOCOL

AND EDUCATION PROGRAM

A Project Presented to the Faculty of California State University, Stanislaus

In Partial Fulfillment of the Requirements for the Degree of Master of Science in Nursing

By Jessica Fisher May 2015

CERTIFICATION OF APPROVAL

PREVENTING CATHETER ASSOCIATED URINARY TRACT

INFECTIONS: IMPLEMENTATION OF A NURSE

DRIVEN CATHETER REMOVAL PROTOCOL

AND EDUCATION PROGRAM

by Jessica Fisher

Signed Certification of Approval Page is On File with the University Library

Dr. Debbie Tavernier EdD, MSN, RN Date Professor of Nursing

Stephanie Lambert BSN, RN, CIC Date Infection Preventionist

Evelyn Eubank MSN, RN, CIC Date Infection Preventionist

DEDICATION

This project is dedicated to my husband, he is a stud muffin.

ACKNOWLEDGEMENTS

Thanks to all of the professional nurses in this world, who work tirelessly to improve the quality of healthcare we all deserve. Additionally, I would like to give a special thanks to Dr. Debbie Tavernier, Stephanie Lambert, Evelyn Eubank, and the entire faculty of the CSU Stanislaus Nursing Department.

TABLE OF CONTENTS PAGE

Dedication ...... iv

Acknowledgements ...... v

Abstract ...... vii

Catheter Associated Urinary Tract Infections: A Priority for Prevention ...... 1

Review of Literature ...... 4

Physician Reminder Projects ...... 5 Nurse-Driven Protocols for Removal of Foley Catheters ...... 7 Alternatives to Catheterization ...... 9 Catheter Maintenance ...... 12

Theoretical Framework ...... 14

Application of Mezirow’s Transformative Learning Theory ...... 15 Application of Peplau’s Nurse-Patient Relationship Theory ...... 19 Summary of Theory Application ...... 21

Methodology ...... 23

Project Development ...... 23 Discussion ...... 33

Evaluation ...... 34

References ...... 38

Appendices

A. Nurse-Driven Protocol ...... 44 B. Online Education: Part 1 ...... 46 C. Online Education: Part 2 ...... 68 D. Policy and Procedure ...... 75 E. Online Education: Part 3 ...... 86 F. Competency ...... 97 G. Learner Pre-Assessment...... 103

ABSTRACT

The purpose of this project is to reduce the catheter associated urinary tract infection rates (CAUTI) in a 209 bed acute care facility located in California’s central valley.

Catheter associated urinary tract infections are responsible for up 380,000 infections,

9,000 deaths and $451million in health care costs per year in the United States. It is also estimated that up to 50% of urinary catheters are used unnecessarily. Nursing driven discontinuation protocols are an effective means of decreasing catheter days and subsequently decreasing CAUTI rates. Each day a catheter remains in place the risk for infection increased by 7%. The CAUTI rates for the project facility have been ranked as the fourth worst in the state of California. To promote CAUTI prevention an online education module is introduced. The education module includes proper techniques for catheter insertion and maintenance, patient education strategies and the directions for using the nursing driven catheter discontinuation protocol. The online module is mandatory paid training. Nurses must complete a learner pre-test, assessment, and post-module competency. Supplemental education is provided for all staff during rounds and staff meetings using simulation and case studies. Education has also been provided for physician staff during unit rounding, online forum and presentation at physician meetings. Future CAUTI prevention strategies to enhance prevention at this facility will include policies and education to improve emergency department catheter utilization, critical care catheter utilization and nursing assistant education.

vii

CATHETER ASSOCIATED URINARY TRACT INFECTIONS:

A PRIORITY FOR PREVENTION

Illness causes a vulnerable state for many. It is because of this vulnerability, that people need the reassurance that healthcare will be delivered safely and efficiently. Unfortunately, the healthcare system does not always provide such reassurance. The groundbreaking report “To Err is Human” released in 2000 by the

Institute of Medicine’s Committee (IOM) on Quality of Health Care in America revealed how health care system errors have contributed to increased morbidity and mortality rates, prompting the public’s demand for improvement in the quality of health care and legislative action. As outlined in this report a significant health care system failure that occurs is Hospital Acquired Infections (HAI). Although some progress has been made since the release of this report, HAI’s continue to occur. A multi-state point prevalence survey for 2011 found that one out of every 25 patients within the acute care setting had at least one HAI on any given day (Magill et al.,

2014). The estimated total number of HAI is 721,000 with 75,000 deaths occurring during hospitalization (Magill et al., 2014).

Urinary tract infections (UTI) are the most commonly reported HAIs in the

United States, accounting for 32% of all infections (Weber et al., 2011). The biggest risk factor for acquiring a UTI is the presence of an indwelling urinary catheter

(Weber et al., 2011). Each day an indwelling catheter is in place increases the risk of infection an estimated 3% to 7% (Lo et al., 2014). Urinary tract infections that occur

2 as a result of an indwelling urinary catheter are referred to as catheter associated urinary tract infections (CAUTI). Distinct epidemiological criteria for defining

CAUTI are outlined by the Centers for Disease Control’s National Health Care Safety

Network (NHSN). The NHSN is the nation’s largest database for tracking HAIs

(Centers for Disease Control and Prevention, 2013).

Not only does CAUTI cost lives, it also creates huge financial implications for the health care system. Federal initiatives affecting financial reimbursement related to CAUTI for hospitals receiving Medicare and Medicaid are the most significant of these financial implications. The Value Based Purchasing Program (VBP) was established in 2010 by the Affordable Care Act (ACA). The VBP was added to the

Social Security Act 1886(o). Historically, hospitals would receive payment for a procedure or event for a given patient and would also have been reimbursed for a given amount to treat a urinary tract infection if the patient had acquired one.

Currently, if a patient acquires a CAUTI during hospitalization, the reimbursement for the infection will not be paid leaving the hospital to absorb the cost of the infection as well as the associated cost of the length of stay associated with such an infection (Meddings et al. 2012). Attributable costs associated with CAUTI range from $758 to $1,006 (Zimlichman et al. 2013). Hospitals that perform well and have a CAUTI rate less than the national average are paid a higher reimbursement than the average or lower performers (U.S Department of Health and Human Services, 2012).

Currently up to 1% of total reimbursement can be lost associated with poor

3 performance using the VBP, future initiatives will further reduce payment up to 2%

(U.S. Department of Health and Human Services, 2012).

Clearly, CAUTI is a matter of concern, and focus on prevention should be a high priority. Many methods of CAUTI prevention have been researched with attention to three focuses: insertion, maintenance, and discontinuation or prevention of insertion. These recommendations for prevention are summarized in The

Association for Professionals in Infection Control and Epidemiology “Guide to

Preventing Catheter-Associated Urinary Tract Infections” (Felix, Bellush, & Bor,

2014). This proposed CAUTI project focuses on infection prevention. The project involves educating registered nurses working in a 209 bed acute care facility located in California’s central valley. Education regarding CAUTI reduction will also be provided for key stakeholders such as patients, families, physicians, and administrators. Emphasis will be placed on reduction of unnecessary use of urinary catheters with the utilization of a nursing driven protocol. The literature used to support these recommendations will be discussed in detail in the literature review.

REVIEW OF LITERATURE

A literature search was performed on the topic of catheter associated urinary tract infection (CAUTI) prevention. Literature supports that the most important methods for CAUTI prevention are preventing the unnecessary placement of catheters and decreasing the duration of catheter use (Lo et al., 2014). It is estimated that 16-

25% of adult hospitalized patients will have an indwelling urinary catheter at some point during their stay (Lueck et al., 2012). The risk of developing bacterial growth related to catheter use increases by 3-7% each day (Lo et al., 2014). Saint et al.

(2000) found that many physicians caring for patients in the acute care setting are unaware of their patient’s urinary catheters being in place until urinary catheter complications occur. It is also estimated that one third of catheter use in this study was unnecessary. The Centers for Disease Control and Prevention (CDC) Healthcare

Infection Control Practices Advisory Committee (HICPAC) 2009 published guidelines are the standard criteria used when determining need for catheterization.

The guidelines are as follows:

 Acute urinary retention or obstruction

 Accurate measurement of urinary output in critically ill patients

 Perioperative use in selected surgeries

 To assist in healing of perineal and sacral wounds in incontinent

patients

 For comfort in palliative care

 For immobilization related to trauma or surgery

Catheter associated urinary tract infection prevention methods which focus on decreasing catheter use and duration were reviewed. Projects selected for review focused on physician reminders to discontinue catheter use, and nurse-driven removal protocols. The Society for Healthcare Epidemiology of America (SHEA), Infectious

Diseases Society of America (IDSA), the Association for Professionals in Infection

Control and Epidemiology (APIC), the American Hospital’s Association (AHA) and

The Joint Commission support the document released by Lo et al. (2014), which provides recommendations for CAUTI prevention. This document supports implementation of an organization-wide program to identify and remove unnecessary catheters via daily reminders for nurses or physicians. This process of CAUTI prevention is rated by the authors as being level of evidence two, which means:

The true effect likely to be close to the estimated size and direction of the effect, but there is a possibility that it is substantially different. Evidence is rated as moderate quality when there are only few studies and some have limitations but not major flaws, there is some variation between studies, or the confidence interval of the summary estimate is wide (Lo et al, 2014, pp. 468).

Physician Reminder Projects

Courzet et al. (2007) found that implementation of a discontinuation reminder for physicians after day four of a patient being catheterized decreased catheter use from 10.6 to 1.1 per 100 patients (p = 0.003). This intervention decreased the hospital’s CAUTI rate from 12.3 to 1.8 per 1000 catheter days (p = 0.03). In this study the nursing staff was responsible for reminding physicians to discontinue the catheter on day four after the catheter had been in place and daily thereafter. The

Infection Control nurse reviewed catheterized patients with the nursing staff during daily rounds to identify which were catheters were no longer appropriate and emphasize the need for removal.

Reilly et al. (2006) implemented a multi-disciplinary approach to reducing catheter days in a 22 bed intensive care unit (ICU). After an education program was implemented for the critical care nurses, the nurses were then responsible for using a checklist to assess for continued necessity for Foley catheter. If the patient did not meet the criteria for continued use, the nurse would contact the physician to recommend discontinuation of the catheter. The charge nurses were responsible for ensuring the daily checklists were utilized. This project reduced the facilities’ catheter days from 4.72 to 2.98. Another finding with this study was that prior to the intervention, 6% of Foley catheters were removed from patients before transfer out of the ICU, and after the project, this number increased to 20%.

Fakih et al. (2008) implemented a multi-disciplinary team approach for reminding physicians to discontinue catheter use in 12 medical-surgical units of a 608 bed teaching hospital. This project involved an educational intervention for nursing staff, which empowered them to encourage physicians to discontinue unnecessary urinary catheters. The pre-existing multi-disciplinary team which included a social worker, case manager, nurse manager and staff nurses would conduct daily rounds to evaluate the need for continued catheter use based on the CDC’s criteria. Physicians and physician assistants were not involved in the daily rounding. This intervention led

7 to an overall 20% reduction of urinary catheter days (UCD) in the intervention group

(p=.002).

Apisarnthanarak, Damronglerd, Meesing, Rutjanawech & Khawcchareonporn

(2014) studied the relationship between physician mindfulness of urinary catheter placement and incidence of catheter utilization at one hospital. The authors found that physicians who did not elect to order urinary catheter placement were more mindful, compared with physicians who ordered urinary catheters. Mindfulness was measured as awareness of appropriate indication of catheterization, consideration of essential patient factors and consideration of behavioral or therapeutic alternative options.

In summary, a physician reminder system is effective in reduction of unnecessary urinary catheter utilization; however most programs require nursing staff to be the driving force to prompt the physicians for removal. Considering that nurses act as the primary force in assessing patients for catheter utilization criteria, they are in a great position to ensure catheter utilization is minimized. It is likely that physician reminder systems delay timely removal of catheters. This is why nurse- driven protocols that do not require a physician order to discontinue catheter use have become a popular choice at many institutions.

Nurse-Driven Protocols for Removal of Foley Catheters

Mori (2014) implemented a nurse-driven indwelling urinary catheter protocol at a 150 bed community hospital. The project involved a three month retrospective chart review of catheter utilization and compliance with maintenance standards prior to the implementation. One month prior to initiating the intervention, education was

8 provided via an online learning module, posters, and one-on-one education. The results were followed three months after the intervention. Catheter utilization prior to the intervention was 37.6% with a mean dwell time of 3.35 days and CAUTI rate of

0.77%. After the intervention the catheter utilization rate decreased to 27.7% with a mean dwell time of 3.46 days and CAUTI rate of 0.35%.

Adams, Bucior, Day, and Rimmer (2012), implemented a nurse-driven protocol in three hospital wards located in England. This intervention used HOUDINI as an acronym to remember hematuria, obstruction, urologic surgery, decubitus ulcer, input and output measurement, nursing end of life care, and immobility. Nurses were given the ability to discontinue the urinary catheters without a physician order if the patient did not meet the HOUDINI criteria. Education was provided via poster boards and during ward meetings. The data collected included catheter prevalence and growth of non-duplicative Escherichia coli (E.coli) in urine samples. E.coli is the most common pathogen associated with urinary tract infections. This intervention led to a decrease in catheter prevalence by 17%. The non-duplicative E.coli urine samples decreased by 70%.

Alexaitis, and Broome (2014) implemented a CAUTI prevention intervention which incorporated a nurse-driven catheter removal protocol in a 30-bed adult neurosurgical intensive care unit. This intervention involved comprehensive staff education which included daily reinforcement, an online learning module and the use of simulation. Catheter utilization, CAUTI rates using NHSN definitions, length of stay (LOS) and costs associated with CAUTI were measured for outcomes. This

9 intervention led to an average catheter day decrease by 2.5%, CAUTI rate decrease by 20.5%, and cost savings of 40.7%. Post implementation data paradoxically showed an increase in catheter utilization from 74.14% to 76.2% and a 8.14% increase in

LOS for those patients diagnosed with CAUTI.

Nurse driven protocols are effective in CAUTI reduction, thus improving quality of care for patients in the hospital setting. Nurse driven protocols are beneficial over physician reminder systems because there is less delay in removal of the catheter. Nurses are at the forefront of care and require education, empowerment and support for a nurse driven protocol to be most effective.

Alternatives to Catheterization

To avoid unnecessary catheterization, it is important to evaluate all possible alternatives. A literature search was performed to discover alternatives to catheterization in relation to CAUTI reduction. The search included condom catheters, and clean intermittent catheterization.

Bladder Scanning and Intermittent Catheterization

The SHEA/IDSA guidelines (Lo et al., 2014) rate the consideration of alternative methods of bladder management, such as intermittent catheterization, when appropriate, as level of evidence two. These guidelines also list the development of a protocol for management of postoperative urinary retention, including nurse-directed use of bladder scanners and intermittent catheterization (IC), as level of evidence two. (Lo et al., 2014).

Miller et al. (2013) performed a randomized prospective study of patients undergoing total hip arthroplasty. The objective of the study was to determine if urinary catheterization is necessary for all patients undergoing total hip arthroplasty under spinal anesthesia. The intervention involved a protocol for the management of post-operative urinary retention by monitoring for urinary retention, bladder scanning and IC for the intervention group. A maximum of two intermittent catheterizations were used over a period of up to twelve hours prior to insertion of indwelling Foley catheter. The control group received an indwelling Foley catheter during surgery and postoperatively for up to forty-eight hours. Of the two-hundred patients studied, three patients in the indwelling catheter group developed a urinary tract infection during the hospital stay, with one requiring urologic consult because of hematuria. None of the patients in the IC group developed an infection (p=.25). The authors concluded that patients undergoing hip arthroplasty under spinal anesthesia are not at risk for urinary retention and therefor urinary catheterization is not required.

Mori (2014) utilized bladder scanning and intermittent catheterization as part of the post removal routine after utilizing the nurse-driven protocol for catheter removal. Alexaitis and Broome (2014) also incorporated bladder scanning and intermittent catheterization as routine post-catheter removal care for their nurse- driven protocol. Utilization of bladder scanning and intermittent catheterization is likely to have assisted with the success of the protocol outcomes in these two studies which demonstrated decreases in catheter days and CAUTI rate.

Condom Catheters

Saint et al. (2006), conducted a randomized trial testing usefulness of condom catheters in comparison to indwelling Foley catheters for participants. The objective of the study was to compare infection risk and patient satisfaction. The hypothesis that a condom catheter might not be beneficial for cognitively impaired was also tested. A total of seventy-five men were randomized (age 40 and above), over a period of three and a half years. The main outcome measure was presence of bacteruria; therefore, patients receiving systemic antibiotics were excluded. Other clinical measures were: patient mortality during hospitalization and the development of symptomatic UTI. A standardized questionnaire was developed to assess patient satisfaction with the urinary device used. The incidence of adverse outcomes was higher in the indwelling Foley catheter group (131/1,000 patient days vs 71/1,000).

The median time to adverse outcomes was a shorter duration for the catheter group (7 vs 11 days). Patients without dementia were five times more likely to develop bacteruria, symptomatic UTI or die if the indwelling catheter was used in comparison to the non-catheterized group. The adverse events in the condom catheter group were more likely to occur in the patients with cognitive impairment, leading the authors to conclude that there may not be a protective benefit in using condom catheters for this group of patients. Lastly, patients reported that condom catheters were more comfortable and less painful than indwelling Foley catheters.

Catheter Maintenance

It is unrealistic to for some patients to be without indwelling urinary catheters; therefore review of catheter maintenance was performed. The SHEA/IDSA recommends the following catheter maintenance guidelines for CAUTI prevention

(Lo et al., 2014).

 Practice hand hygiene immediately before and after any manipulation of the

catheter site or apparatus.

 Insert catheters with aseptic technique and using sterile equipment.

 Use sterile gloves, drape, and sponge; a sterile or antiseptic solution for

cleaning the urethral meatus; and a sterile single-use packet of lubricant jelly

for insertion.

 Use the smallest catheter possible for insertion.

 Properly secure catheters to prevent movement and urethral traction.

 Maintain a sterile, continuously closed drainage system

 Replace the catheter and the collection system using aseptic technique when

breaks in aseptic technique, discontinuation or leakage occur.

 When sampling urine, use a needleless system and ensure cleaning of the

sampling port with a disinfectant.

 Obtain large volumes of urine for analysis from the drainage bag.

 Maintain unobstructed urine flow

 Keep the collection bag below the level of the bladder at all times; do not

place the bag on the floor.

 Keep catheter and collecting tube free from kinking and coiling.

 Empty the collecting bag regularly using a separate collection container for

each patient. Avoid touching the draining spigot to the collecting container.

 Employ routine hygiene; cleaning the meatal area with antiseptic solutions is

unnecessary.

The APIC 2014 CAUTI update supports the maintenance interventions described by

Lo et al., with the addition of one recommendation, which is do not change the indwelling catheter at arbitrary fixed intervals. These are also the maintenance interventions found in the 2009 HICPAC Guidelines.

In review, nurse-driven protocols for catheter removal have the most potential for decreasing catheter utilization and reducing CAUTI. Success of a nurse-driven protocol will be dependent on successful program implementation. Program implementation requires comprehensive education, which includes criteria for catheterization, alternatives to catheterization, use of bladder scanning when appropriate and proper catheter maintenance. Nurses must be empowered and supported by physicians, administration and the infection control team. Further review on program implementation methods will be reviewed in chapter three.

THEORETICAL FRAMEWORK

Implementing evidence based practice guidelines in the acute care setting can be presumed to come with many challenges. Simply developing a policy and order set will not be sufficient to ensure accurate interpretation and expert clinical application.

In order for nurses to optimize a nurse-driven urinary catheter protocol, education and support will be needed. Nurses must feel confident with their skills, and empowered to use their own clinical judgment. There must also be a “buy-in” for nurses to want to remove catheters. Unfortunately, nurses are often overburdened with physical work-load and charting demands, and it is likely a nurse-driven catheter removal protocol will increase work load in the early implementation period. This may render a nurse driven protocol for a catheter removal undesirable by some. For success, nurses will need to understand the importance of this project and a behavioral change must take place. To assist with the needed behavioral change, Transformative

Learning Theory was chosen to assist with development of this project. This theoretical framework was chosen because it is known for helping adult learners develop autonomous thinking, which is essential for the success of a nurse-driven protocol.

Not only will this CAUTI prevention project significantly affect the way patient care is delivered by nurses; it will affect the way patients perceive their care.

Patients and caregivers will need to be educated and willing to collaborate for true success to take place. Often, the nurse-patient relationship can significantly impact

15 the success of such nursing interventions, which is why the addition of a nurse patient relationship theory should be incorporated. Hildegard Peplau was the first nursing theorist to emphasize the importance of the nurse-patient relationship. Peplau, known for her contributions to psychiatric nursing, theorized that nursing cannot occur unless there is a relationship or connection between the patient and the nurse (Peden, Staal,

Rittman, and Gullet, 2015). Peplau’s Nurse-Patient Relationship Theory will be utilized as the theoretical framework for implementation of patient education for this project.

Application of Mezirow’s Transformative Learning Theory

Jack Mezirow developed the Transformative Learning Theory, which has evolved to a sophisticated manner to summarize how learners construct, value and reformulate the meaning of their experience. Learners are thought to have preexisting beliefs, attitudes, and emotions. These preexisting beliefs are referred to as a person’s

‘frame of reference’. The frame of reference is thought to be composed of two dimensions, the ‘habits of mind’ and the ‘point of view’ (Mezirow, 1997). Habits of mind are defined as broad or abstract ways of thinking, which are influenced by a set of codes. The codes can be social, psychological, political, educational or economical. According to Mezirow habits of mind shape our point of view. Mezirow theorizes that “we transform our frames of reference through the process of critical reflection on the assumptions upon which our interpretations, beliefs, and habits of mind or points of view are based” (Mezirow, 1997, p.7).

When applying the concepts of ‘frame of reference’ and ‘point of view’ to the implementation of a nurse driven catheter removal protocol and CAUTI prevention program, it can be assumed that nurses may find a nurse driven protocol to be burdensome or intimidating. This might be because nurses with less contemporary training may have been trained to rely solely on physician judgment for critical decision making, which may inhibit their self-confidence and ability to act autonomously. It is also possible that nurses may have preconceived notions based on unguided past work experience, which will lead them to believe early catheter removal is not possible for certain patients. For the purposes of teaching and learning it will be necessary to explore the various habits of mind and points of view of those involved. Achieving this may be possible through use of a pre-assessment questionnaire incorporated into the online learning module. Exploring this could also be possible with use of open dialogue during rounds, staff meetings, and educational presentations.

According to Mezirow, there are four processes for learning or transforming the frame of reference. The first process is to elaborate on an existing point of view.

The second process is to learn to establish new points of view. The third process involves the way we learn to transform our point of view, and the fourth processes is becoming aware and critically reflective of one’s generalized bias or view point.

(Mezirow, 1997). Following Mezirow’s four step process for transformation of the frame of reference may be of some help with the CUATI prevention program. The

CAUTI prevention program and nurse driven protocol will require that all nursing

17 staff receive education and training. The most logical way to obtain this requirement is by providing a mandatory online training module. The online module will involve use of a self-pre-assessment, learning module, self-post assessment and competency.

With use of the self-assessment tools, the online module may help learners elaborate and become more critically reflective of their own points of view. Presentation of the material, which will include an elaborate case scenario, will help staff members gain new points of view, which will enhance the learner’s critical reflection. It is realized that online learning may have some limitations, therefore to enable true transformative learning to take place, ongoing supplemental education will be necessary.

Mezirow emphasizes that effective discourse is necessary for the transformative learning process. Effective discourse can be achieved with the application of simulation learning. Mezirow writes that “Education that fosters critically reflective thought, imaginative problem posing, and discourse is learner- centered, participatory, and interactive, and it involves group deliberation and group problem solving” (Mezirow, 1997, p. 10). Mezirow also writes that techniques such as role play, case studies and simulation are methods associated with transformative learning. Ongoing focused infection control rounds, as well as presence of the project leader at staff meetings will present opportunities for staff to engage in educational exercises which incorporate transformative learning activities.

Another important concept for transformative learning theory is that of autonomy. Mezirow writes that learning must prepare a responsible worker which is

18 empowered to think individually as an autonomous agent (Mezirow, 1997). Mezirow defines autonomy as “the understanding, skills, and disposition necessary to become critically reflective of one’s own assumptions and to engage effectively in discourse to validate one’s beliefs through the experiences of others who share universal values” (Mezirow, 1997, p. 9). The goal of the CAUTI prevention program is for all learners to gain the universal value of patient safety. Nurses must be able to act autonomously and be willing to be the driving force in catheter removal to achieve this value. Although, clearly written, it can be assumed that some may interpret the criteria for catheter removal loosely, and leave catheters in place longer than necessary. Emphasis will need to be placed on collaboration with patients and applying the protocol safely for it to work effectively. Additionally, nurses must be critical thinkers, able to trouble shoot, and problem solve as autonomous agents.

As an important concept in developing autonomy, Mezirow emphasizes that learning needs to be recognized for the short-term objectives and long-term goals.

Mezirow emphasized that adult educators need to realize that competency or short- term goal attainment is essential for learners, however the long term goal should be to assist with the development of socially responsible autonomous thinkers (Mezirow,

1997). This will require ongoing education and support. Annual competency will assist with refreshing the short-term goal attainment, however for long term autonomy, more will be needed. Presenting infection rate and catheter utilization data and real life case scenarios is one way to present feedback to staff. With routine data updates, staff will see that they are contributing in some way to the patient population

19 and overall outcomes. Staff will see first-hand how their actions result in improved patient outcomes.

Application of Peplau’s Nurse-Patient Relationship Theory

Hildegard Peplau’s Theory describes nursing as a “significant, therapeutic process that acts as an educative instrument which promotes forward movement of personality to be more constructive and productive” (Peplau, 1952, p. 16). In the case of CAUTI reduction, and catheter removal, the nurse promotes the forward movement of the patient to a functioning urinary elimination pattern. According to

Peplau, the nurse’s role is important because it brings the professional expertise and necessary knowledge to the relationship (Peden et al., 2015). Patients are usually not aware of the dangers associated with indwelling catheters, and therefore may not feel an urgency for removal. Additionally, patients may find the catheters convenient or they may be too embarrassed to discuss a matter which they consider very private.

The nurse’s role is to act as the resource person and the teacher, and it will be essential that nursing introduces the concept of early removal at the time of catheter placement, and continues to emphasize the need for doing so as care progresses.

According to Peplau, in order for the therapeutic nurse-patient relationship to occur in full, the nurse must possess intellectual, interpersonal and social skills.

Peplau did not encourage nurses to engage in meaningless conversations, rather she emphasized that all interactions should be therapeutic and promote forward movement (Peden et al., 2015). Nurses must also be aware of how their own behavior affects patients. These concepts will be emphasized during the CUATI program

20 implementation through use of online instruction, unit rounds, staff meetings and one on one counseling. Peplau identified that weekly supervised meetings by a clinical expert are effective for improving the nurse-patient relationship. Meetings should focus on the interpersonal interactions nurses have had with patients. Peplau emphasized that active listening on the part of the nurse is considered crucial. When nurse-patient interactions do not go well, nurses should be expected to reflect on their own behaviors and emotions that may have interfered with the interaction. These meetings, according to Peplau, will promote slow but certain growth of the professional nurse. (Peden et al., 2015)

Exploring Peplau’s theory further there are three phases to the Nurse-Patient

Relationship. The first phase is the orientation phase, which is an important phase because it is the establishment of the relationship. The orientation phase takes place when the nurse begins to assess the patient. During the assessment, the patient expresses their needs and the nurse is to evaluate those needs. Trust must first be established during this phase, then working together the nurse and the patient can establish goals and outcomes (Peden et al, 2015).

The working phase is the second phase of Peplau’s theory and is be described as the exploitation phase (Peden et al, 2015). During this phase the patient may exploit the nurse to meet their needs. The patient may act dependently, interdependently or independently. The nurse must act as the resource person to assist to help balance the dependency and independency. In the case of CUATI prevention and early catheter removal, patients must be encouraged to set goals which are safe

21 and attainable. Alternatives to catheters and available human resources must also be present to assist the patient with urinary elimination needs. Proper hygiene must also be emphasized. The nurse will be responsible to establish a reasonable care plan for proper hygiene and urinary elimination, which may require a significant amount of dependence during the initial phase. Patients need to feel comfortable depending on nursing and relying on nursing expertise to allow for forward movement toward independence, which leads to the last phase.

The last phase of the Nurse-Patient relationship theory is the resolution phase.

This is when the patient moves forward from dependence to independence. New goals may be established which promote patient independence (Peden et al, 2015). In the case of CAUTI prevention, the nurses will be encouraged to establish the patient’s independent urinary elimination habits until full independence or plan for discharge care is established.

Summary of Theory Application

In summary, the simple application of written instructions will not have enough impact to promote behavioral change on an already overwhelmed healthcare system. Ongoing feedback and support will be essential, and should be presented on a regular basis. The use of statistics, charts, and positive feedback will be helpful. Staff will also need to be empowered and granted room for autonomy. Administrative, project leader and peer support will be needed to assist with developing autonomy.

Staff will also need to develop essential competencies to be able to apply a nurse- driven protocol safely and effectively. Establishment of an online training program

22 will be required; however supplemental training exercises are essential for a transformative learning experience to take place. The content of this subject matter may be considered a very private matter by some patients and the nurse must establish a relationship of trust as well as exhibit expertise. Collaboration with patients and care givers as well as education must be included through all phases of the patient stay.

METHEDOLOGY

A catheter associated urinary tract infection (CAUTI) prevention program was initiated at a 209 bed acute care facility located in the central valley of California after the Infection Control department and the administrative team determined it was a priority. Historically, this hospital has not scored well against the national benchmarks for CAUTI rates. The 2012 CAUTI data is ranked as the fourth worst in state for hospital acquired infections (Campbell, 2015). The 2013 data has shown some improvement, according to internal assessments, however it is still above the national average. Due to these findings and the associated financial penalizations, full administrative support was given for the development of a CAUTI prevention project.

Project Development

The hospital currently has criteria in place for assessing the daily need for catheterization, which closely resembles the standard criteria as outlined in chapter two. Nurses are responsible for completing a computer charted assessment every 12 hours, in which they select which criteria is met to keep the catheter in place or select the option to follow up if not indicated. The current catheter criteria listed includes:

 Terminally Ill/Comfort Care

 Has epidural Catheter

 Major Surgery/Lower extremity fracture

 24 hour urine collection in incontinent patient

 Intake and output in the critical patient

 Neurogenic Bladder

 None, Nurse to follow up

 Other

 Ordered by urologist

 Open sacral/perineal wound

 Urinary catheter inserted by doctor

 Urinary tract obstruction

The nurse is responsible for asking the physician for a discontinue order if the catheter is no longer indicated per criteria. Auditing has shown that two main problems have arisen from this process.

First, nurses often either misinterpret the catheter criteria or convolute the assessment to keep the catheter in place. For example, the most common problem found during auditing is the use of the criteria “other”. This option allows the nurse to essentially fabricate a reason for keeping the catheter in place. There is a comment section to add a note if one does select the option of “other”. The most common comment found is “MD order”. A second common problem, found with auditing of the current nursing assessment process, is that physicians are not always informed about catheter removal in a timely manner. Often, a nurse may miss the physician during the daily rounding due to work demands or break schedules, and the request to discontinue the catheter may be delayed an extra calendar day or more.

It was decided that a nurse-driven protocol would be initiated, because the physician reminder system is not effective for this facility. A comprehensive CAUTI

25 prevention program has been developed and the approval process is currently taking place. This chapter discusses the necessary evaluations and processes which have occurred and are taking place for the implementation of this project. Key elements of the project that will be discussed include: electronic charting, engaging physicians, the policy and order set approval process, and designing a comprehensive education and evaluation process.

Electronic Charting

To accommodate the nurse driven protocol, changes have been determined for the existing nurse charting process for urinary catheters as well as the physician documentation system. All nurses charting is done via computerized charting. The nurses add “interventions” to their patient’s electronic charts as the patient care plans are developed. The current computer intervention for Foley catheter will be altered to reflect the needs for the nurse driven protocol. The protocol was developed so that nurses are still responsible to assess their patients for catheter criteria at least once per shift. The selection criteria will be changed to the following:

 Bladder outlet obstruction

 Acute neurogenic bladder

 Related to perioperative use for selected surgical procedures/epidural

 Evidence of gross hematuria

 Presence of stage 3 or 4 pressure ulcers or necrotizing wounds located

in the coccyx/hip area for incontinent patients

 Anticipation of prolonged immobilization related to issues such as an

unstable fracture

 Need for strict I/O for the critically ill

 To provide comfort for a terminally ill/comfort care patient

 None, nurse to follow up

If none of the criterion is met, the nurse chooses the option of “none, nurse to follow up”. Next, there is a section within the intervention that the nurse can select a box indicating the catheter is being discontinued according to the Nurse Driven

Catheter Removal Protocol. There is also a reminder present in the intervention that the nurse must ensure that the physician did not discontinue the Nurse Driven

Catheter Removal Protocol. Of note, an intermittent catheterization intervention currently exists in the computer charting system. No changes will be made to this intervention. Nurses are to add this intervention to the electronic chart if needed according to the protocol directions.

The hospital is currently transitioning to physician order entry via electronic orders (CPOE). Information technology support was utilized to construct an electronic order set initiation whenever a Foley catheter order is placed by a physician. At the point when a physician places a Foley catheter order into the electronic ordering system a “hard-stop” screen is initiated, which inhibits the physician from completing the order until specific information has been completed.

Here the physician will be reminded that the Nurse Driven Catheter Removal

Protocol (NDCRP) will be automatically implemented unless a discontinue protocol

27 order is received. Physicians are also given an electron warning that by discontinuing the nurse driven protocol they must remember to discontinue the catheter in a timely manner or they will be placing the patient at and increased risk for CAUTI.

A paper version of the physician order set was also created to supplement those orders for catheters not placed via electronic orders and for when computer down times occur. Nurses will be trained to initiate the NDCRP unless the physician discontinues the order. If a telephone, verbal or written order is received for a Foley catheter, then the nurse will remind the physician that the NDCRP will be initiated unless there is a special circumstance in which it should not be used. Nurses will be trained to discourage physicians from discontinuing the order set.

Engaging Physicians

For a successful nurse driven protocol to take place, the physicians need to be educated and engaged. The hospital employs many physicians known as

“hospitalists”. The hospitalists see a majority of the patient population. Engaging the hospitalist has been a key initiative for success of this program. Physician education regarding the project and order set has been initiated. Physician meetings, including the hospitalists’ quarterly meeting and The Critical Care Medicine/Family Practice meeting were attended to ensure awareness of the policy and order set as the physician approval process continues. Additionally, the policy and order set has been posted for 60 days for medical executive review prior to vote for passing. A literature review packet has been to the provided for the physicians as supplemental reading to support the policy and protocol.

Policy and Order Set Approval Process

There is currently a nursing policy entitled “Catheter insertion and

Maintenance” that is in place in the hospital’s policy and procedure manual. This policy includes the appropriate criteria for catheterization, proper insertion procedural instructions for aseptic insertion, procedure for discontinuation of the catheter and the charting requirements. This policy was used as a framework for developing the new policy which is called “CAUTI prevention program”. This policy includes the steps needed to use the NDCRP and the associated follow up process. Alterations were also made to the catheter removal criteria and catheter maintenance methods. The scope of practice for registered nurses was reviewed during the policy development to ensure compliance with scope of practice. The California Board of Registered Nursing standardized procedures guidelines where used to determine the protocol is within the registered nursing scope of practice. The Board of Vocational Nursing and

Psychiatric Technicians was contacted to clarify if Licensed Vocational Nurses

(LVN) would be able to use the nurse driven protocol. A nurse driven protocol cannot be utilized by a LVN without the direct guidance of a registered nurse (S. Clayworth, personal communication, December 5, 2014).

The first step in the policy approval was approval by the Professional Practice

Council (PPC). The PPC is made up of representatives from all nursing units and an additional nurse from the quality services department. All representatives are registered nurses. A short presentation was given for the PPC and open forum

29 allowed for discussion and suggested improvements. The policy was passed and order set was passed without any changes.

The second step of the policy and order set approval involved getting approval from Forms Committee (FC) and Nurse Executive Committee (NEC). The FC is made up of a multi-disciplinary team from legal, information technology, administration, and medical records. The NEC includes all of the nurse managers, the

Vice President (VP) of Patient Care Services and the director of the education department. Full Administrative support was given by the VP of patient care services and quality services department. The policy and order set was approved without any changes and full approval was given to fund the education process for nurse training.

Currently the policy is still in the 60 day review process for physicians. The education module for nursing will be implemented after the physician approval process has been completed.

Education Module

To begin the development of the CAUTI prevention education module for nursing staff an analysis was performed on the current education process. The CAUTI prevention education module that is currently in place consists of a one-time online learning module which includes information about CAUTI prevention techniques and appropriate catheter criteria. It is not an annual competency. There is not an additional supplemental educational process. The new CAUTI prevention educational module will include an online learning module, which will be mandatory on an

30 annual basis and continuous supplemental education activities will be provided by the infection control department.

The hospital’s education department uses an online power-point based learning system for all online education modules. After reviewing the available resources for online learning the following options were presented: the existing power point could be used, a power point available in the corporate data base could be used or a new power point could be developed. The existing power point for

CAUTI prevention includes very valuable information, however it is not presented in a visually appealing way and it is missing a few key elements. It was decided that a new module would be developed. The new education module has been developed to include more visual enhancements such as graphs, pictorial examples of catheter utilization criteria, and pictures including the hospital staff to make the learning process more personal. After each section is presented in the online education module, a formative review of learning is presented. There are a total of three learning sections in the module which include: CAUTI facts and key points for prevention; appropriate catheter utilization criteria; and instructions for the NDCRP.

These activities include multiple choice questions, true or false selection and case scenario examples. Additionally, a data base search of the parent corporation education data files was conducted looking for CAUTI prevention resources. A video entitled “Jerri’s Story” was selected to be incorporated into the module. Jerri’s story depicts a comprehensive case scenario involving a surgical patient who experiences complication from a CAUTI which lead to a surgical site infection which catapults

31 the patient into a series of hospitalizations and eventual deterioration of health and financial turmoil. This video appeals to the emotions and may help change the frame of reference for many learners.

The proposed online module will also include a pre-assessment and post-test.

The pre-assessment uses a five level Likert scale to assess nursing attitudes towards use of a nurse driven protocol. The pre-assessment also includes multiple choice questions to test the nursing knowledge base. The competency is a multiple choice quiz, which includes case scenario examples and appropriate selection of nursing interventions.

Simulation activities with case scenarios will be provided for supplemental educational activities. Simulation will include use of a mannequin to practice skills such as aseptic Foley and straight catheterization insertion technique, condom catheter placement and bladder scanning. Refreshments and snacks will be provided as incentives for participation. Poster boards will be created depicting the implementation of the NDCRP for each nursing unit. These poster boards will emphasize key concepts in the roll out process and serve as an easy reference guide for staff members. Each unit will also be provided with a reference binder during the implementation period and the binder will remain available after the implementation period for future use. The binder will show elaborate definitions of the criteria, trouble shooting and assessment techniques, the protocol, the policy, and patient education materials.

Evaluation Process

Routine daily audits must be performed to ensure all patients are assessed adequately for catheter removal. Charge nurses will be asked to run an audit log for catheter removal candidates and remind staff nurses every shift. Infection control in collaboration with quality services staff will oversee all audits on a daily basis and double check to ensure all patients are evaluated properly and all appropriate catheters are removed. Night shift charge nurses will be expected to complete a device utilization count as part of their routine and turn this data into the infection control department on a monthly basis. The infection Control staff will review all positive urine culture reports and assess all positive urine cultures for CAUTI criteria.

Catheter associated urinary tract infections are tracked using the National Health and

Safety Network (NHSN) definitions and data base. Monthly reports that publish all pertinent CAUTI data, which includes catheter utilization and CAUTI rates, will be displayed on each nursing unit’s performance improvement board. Along with the data, any pertinent feedback and learning lessons will be displayed. Random audits will be performed during patient rounds to assess how well patient education has been implemented, and will include any patient complaints. Staff meetings will be attended regularly by the infection control team to report progress and discuss any issues.

Committee meetings including the performance improvement, professional practice council, critical care medicine and medical staff meetings will be attended for any issues that need to be addressed. Charge nurse meetings are held daily and meetings will be attended at least bi-weekly by the project leader to discuss progress, address

33 issues, and answer any questions. Infection Control staff including the project leader will also be available by phone and email to address any issues.

Evaluation of Supplies and Stock

Materials must be readily available for a launching and maintaining a successful program. The Materials Management department was consulted to ensure the level of stock items can be readily available for each unit. Inventory arrangements were made to ensure that nursing has adequate access to Foley catheters, straight catheters, condom catheters, urinals and bedpans. The inventory assessment also involved assessing the availability of bed side commodes, gait equipment, and bladder scanners. Currently evaluations are being made for new products, including super-absorbent incontinence pads, scales for weighing liquid soaked adult diapers, and a female urinal.

Discussion

Overall, the development and approval process has moved along successfully and without any major setbacks. The implementation and follow up process will likely have many challenges, however with good planning and consistent follow up, those challenges will not become detrimental to the success of the CAUTI prevention program.

EVALUATION

The implementation period for the CAUTI prevention program begins after the physician approval process is complete. It is anticipated that the implementation period will present some challenges. Consistency and promptness in response to issues will be an essential role of the project manager. The project manager must also be open to criticism and flexible with proposed changes. Additionally, continuous process evaluation and improvement must be prioritized for a successful program to occur.

Up to this point, only two minor challenges have occurred. The first issue is related to physician concerns. One physician is concerned about the implications for renal monitoring in certain patients. It is common practice at the hospital for renal specialists to extend orders for urinary catheters to “measure accurate intake and output”. This is not always in the setting of a critical patient receiving large quantities of fluids or diuretics, in fact, it is often the opposite. Renal monitoring may be desired in those patients with acute renal failure, who are producing very little urine output.

The national guidelines do not address criteria for monitoring for intake and output in the non-critical patient. To address this issue, education for nurses will be reinforced for measuring accurate intake and output and renal monitoring. For non-critical patients, accurate intake and output can be measured without the use of a catheter, however if not done vigilantly can be inaccurate. Incorporation of alternative methods for catheterization for monitoring intake and output will be addressed during the

35 implementation and education sessions. Purchase of digital weight scales to measure output in adult incontinence pads and diapers will be discussed as a future options as well. The project leader of this project is discussing the necessity of adding an assessment element of serum creatinine monitoring. Serum creatinine is a blood marker for monitoring kidney. One physician is asking to add this element to the protocol as part of the criteria. Application of this is under discussion at this time.

The second challenge that has occurred with the development of this project is related to limitations of available technologies. Computer technology is used for the education implementation and for the application of the nurse driven protocol orders within the physician order entry system. The computer technology used for education has many limitations related to inflexibility of designing interactive quiz questions and activities. The physician order entry system is currently in the implementation phase at the project facility. Not all physicians are using computer order entry at this time. Systems have been developed to capture all physicians ordering Foley catheters both in the paper format and the computer entry format. The information technology team and project leader have developed a computer order set, it was a timely task which required a few revisions.

Implementation of large scale projects at this facility will require tactful implementation for success. It is easy to give in to pressure and sloppily complete a project due to external pressure, however if a project is not thoroughly developed it leaves significant room for error. The entire project processes, such as education for nurses and patients, implementation, stock, key players, charting, and evaluation must

36 be vigilantly monitored, assessed and improved. Improvement is not only essential for the success of this project, it is essential for the patients that rely on the health care system to help them rather than harm them.

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APPENDICES

APPENDIX A

NURSE DRIVEN PROTOCOL

Date/Time/ Assessment for need of indwelling urinary catheter will be performed by the Registered Nurse Int every shift. Supervisor RNs must assess those patients being cared for by LVN staff for need for discontinuation of catheter per protocol. A physician must continue this order set if it should not be applied to the individual patient.

Criteria for indwelling catheter use:  Bladder outlet obstruction, e.g., enlarged prostate, clots (CBI) edematous scrotum or penis.  Acute neurogenic bladder not manageable by other means, e.g., with clean intermittent catheterization.  Related to perioperative use for selected surgical procedures i) Anticipate prolonged duration of surgery ii) Intraoperative monitoring of urinary output iii) Prolonged effect of epidural anesthesia iv) Surgery on contiguous structures/GU tract v) Undergoing urological surgery vi) Temporary placement for procedure (removed in recovery room) vii) Large-volume infusions or diuretics  Evidence of gross hematuria  Presence stage 3 or stage 4 pressure ulcers or necrotizing wound located in the coccyx/hip areas for incontinent patients  Anticipation of prolonged immobilization related to issues such as unstable fractures, e.g. spine, pelvis or multiple trauma injuries.  Need for strict intake and output monitoring related to a procedure, administration of large volume infusions or diuretics, hemodynamic instability, or critical care management.  To provide comfort for a terminally ill/comfort care patient

If none of the above criteria are met, discontinue the indwelling Foley catheter. Document the date and time of the discontinuation in the Meditech intervention and continue to assess the patient for urinary function. Frequently offer assistance to the bathroom/bedside commode/bedpan or with use of urinal.

If the patient is unable to void within 4 hours after removal of the catheter, then perform a bladder scan.

Date/Time Signature Print Name

M.D. M.D. Patient Identification

Nurse Driven Removal of Indwelling Foley Catheter

Form # draft (1/15) Page 1 of 2 Original – Chart Scan to Pharmacy

If bladder scan reveals < 400ml urine, follow If bladder scan reveals > 400ml urine, follow the the algorithm below algorithm below - Wait an additional 2 hours - Perform a one-time intermittent catheterization and continue to monitor for the next 4 hours. - If after a total of 6 hours has passed - If patient does not void within the next 4 and the patient has not voided and hours and bladder scan reveals < 400ml bladder scan reveals > 400ml, then urine, wait an additional 2 hours. If there is perform a one-time intermittent still no voiding after a total of 6 hours or the straight catheterization and continue bladder scan reveals > 400ml urine when to monitor the patient for urinary assessed, then perform an intermittent- retention over the next 4 hours. catheterization for the second time. - If the patient still has not voided after - Continue to monitor over the next 4 hours. 4 hours, perform a bladder scan. If the patient still cannot void or bladder - If > 400ml, perform a one-time scan reveals > 400ml, insert an indwelling intermittent catheterization. Foley catheter. - If < 400ml, wait an additional 2 hours. After 2 hours, if patient still has not voided or bladder scan reveals > 400ml urine retention, perform a one- time intermittent catheterization for the second time. Continue to monitor for the next 4 hours. - If the patient continues to have - A total of two straight catheterizations will urinary retention over the next 4 occur before reinsertion of an indwelling hours, insert an indwelling Foley Foley catheter. If any complications occur catheter. during the implementation of this process, notify the physician for further instruction. - A total of two straight catheterizations - If a Foley catheter was inserted, inform the will occur before reinsertion of an physician when the patient is next indwelling Foley catheter. If any evaluated. The patient will need to be re- complications occur during the evaluated for chronic bladder issues and implementation of this process, notify the Nurse-Driven order set for the physician for further instruction. discontinuation of the indwelling Foley catheter may need to be discontinued.

APPENDIX B

ONLINE EDUCATION: PART 1

APPENDIX C

ONLINE EDUCATION: PART 2

APPENDIX D

POLICY AND PROCEDURE

Patient Care Services Administration No. 18-94- 01 Page: 1 of 13 Catheter Associated Urinary Origination Date: 12/7/10 Tract Infection (CAUTI) Effective Date: 6/2/15 Retires Policy Dated: 5/1/12 Prevention Program Previous Versions Dated: 1/7/10 NEC P&P, 2/25/15 CNO, 2/25/15 Executive, 4/24/15 PPC,

I PURPOSE To provide evidence based practice guidelines for insertion and discontinuation of indwelling Foley catheters performed by RN and LVN using aseptic technique to minimize incidence of infection, trauma and complications.

II POLICY In the event that temporary urinary catheterization with an indwelling Foley catheter is necessary, the recommended guidelines will be utilized, monitored and evaluated.

III OUTCOME A. The patient will have an indwelling Foley catheter for continuous bladder drainage for the minimal period of time necessary related to the disease process or medical procedure. The patient will remain free of unnecessary indwelling catheterization, urethral trauma, and urinary tract infection related to catheterization. B. Catheter care and maintenance will be provided at least once daily, and as needed for incontinence care. Assessment for patency, and signs of infection, trauma and/or complication will be performed at least once per shift. C. Assessment will be performed for appropriateness of insertion/continuation/discontinuation of Foley Catheter at least once per shift. RN staff must complete the educational competency prior to use of the Nurse Driven Removal of Indwelling Foley Catheter Protocol. The Foley catheter will be discontinued by a RN or a LVN

under the supervision of the RN, Nurse Driven Removal of Indwelling Foley Catheter Protocol criteria unless a physician order supersedes the protocol.

IV CRITERIA FOR INSERTION/CONTINUED USE OF INDWELLING FOLEY CATHETER A. To provide relief of urinary tract obstruction not manageable by other means. B. To permit drainage in patients with neurogenic bladder dysfunction and urinary retention not manageable by other means (i.e., with clean intermittent catheterization). C. To obtain accurate measurements of urinary output in critically ill patients. D. To obtain 24 hours urine collection when patient is incontinent. E. To assist in healing of open sacral or perineal wounds in incontinent patients. F. Anticipation of prolonged immobilization related to issues such as unstable fractures (i.e. Patients with crush injury, pelvic fracture or hip fracture, or unstable spine). G. Management of terminally ill patients/comfort care patients. H. Perioperative use for selected surgical procedures (e.g. perineal/lower anterior resections/urological/gynecological procedures) 1. Anticipate prolonged duration of surgery 2. Intraoperative monitoring of urinary output 3. Prolonged effect of epidural anesthesia 4. Surgery on contiguous structures/GU tract 5. Undergoing urological surgery 6. Temporary placement for procedure (removed in recovery room) 7. Large-volume infusion or diuretics

V EQUIPMENT A. Sterile Foley Catheterization Kit includes: 1. Indwelling catheter with drainage system. 2. Sterile antiseptic solution for periurethral cleaning (providine- iodine). 3. Prefilled 10ml syringe of water-soluble lubricant. 4. Sterile gloves 5. Forceps and cotton cleaning pads 6. 10ml syringe (prefilled with sterile water) 7. Sterile specimen container for culture if needed. 8. Fenestrated drape and under pad. B. Other equipment: 1. Adequate lighting source

2. Bath blanket or sheet for draping 3. Waste receptacle

VI URINARY CATHETERIZATION OF MALE PATIENT A. Preparatory phase 1. Obtain physician order for insertion urinary catheter. Consider any alternatives to urinary catheterization (e.g. intermittent catheterization or condom catheter) and collaborate with the physician. 2. Provide privacy and explain procedure to patient. Emphasize the risk of infection with urinary catheterization and the need for prompt removal. 3. Place the patient in a supine position with legs slightly spread, draping patient with bath blanket or sheet. 4. Wash hands and don disposable gloves and cleanse the area where the catheter will enter the urethral meatus with fresh, soapy water. Rinse well and dry. a. In uncircumcised males be sure the foreskin is retracted for cleansing and replace back into position after care. 5. Remove disposable gloves, wash hands. 6. Place waste receptacle in accessible place, ensure lighting for easy visualization. 7. Prepare sterile field, opening the Foley catheterization kit using sterile technique. Put on sterile gloves.

REMEMBER: Catheterization requires the same aseptic precautions as a surgical procedure to decrease the danger of a urinary tract infection which is associated with increased morbidity. B. Performance phase of male patient 1. With sterile gloves on, gently retract the foreskin (if present) maintaining sterility of dominant hand. Wash off penis around urinary meatus with a sterile antiseptic solution (providine- iodine) using forceps to hold cleaning pads. Clean the urethral meatus from tip to foreskin in circular motion. Discard pad after each use. (If patient is sensitive to iodine, chloraprep is used.) 2. Generously lubricate the distal portion of the catheter with water-soluble, sterile lubricant. 3. Grasp shaft of penis (with non-dominant hand) perpendicular to the body and pull up gently applying gentle traction. 4. Steadily insert catheter in to the urethra; advance catheter 6-10 inches until urine flows.

5. If resistance is felt at the external sphincter, slightly increase the traction on the penis and apply steady, gentle pressure on the catheter. Ask patient to strain gently (as if passing urine) to help relax sphincter. 6. When urine begins to flow, advance the catheter another one inch. 7. Replace (or reposition) the foreskin if present. 8. Inflate the retention balloon with prefilled 10ml syringe of sterile water. 9. Instruct the patient to immediately report discomfort or pressure during balloon inflation. If pain occurs, discontinue the procedure, deflate the balloon, and insert the catheter farther into the bladder. 10. Gently pull the catheter until the retention balloon is snug against the bladder neck. 11. Keep drainage bag in a dependent position below the level of the bladder to prevent reflux. 12. Secure the catheter with a leg strap or statlock catheter stabilization device. 13. Hang bag on bed frame below the level of the bladder, coiling the tubing on the bed, allowing some slack of the tubing to accommodate patient. Assess the amount, color, odor, and quality of urine. The tubing connected to Foley drainage bag needs to be managed in a way that prevents the formation of dependent loops. Dependent loops cause increased back pressure in the bladder increasing urinary retention which leads to an increased risk for urinary tract infections. See attached figures for illustration of a dependent loop (Fig. 1A & Fig. 1B). Methods for preventing the formation of dependent loops include: frequently emptying the drainage bag, using the green clip to secure the drainage bag, and hanging the bag towards the end of the bed. 14. Remove gloves, dispose of equipment, wash hands, help patient to reposition.

VII URINARY CATHETERIZATION OF FEMALE PATIENT A. Preparatory phase 1. Obtain physician order for insertion of urinary catheter. Consider any alternatives to urinary catheterization (e.g. intermittent catheterization) and collaborate with the physician. 2. Provide privacy and explain procedure to patient. Emphasize the risk of infection with urinary catheterization and the need for prompt removal.

3. Place patient in a supine position with legs slightly spread, draping patient with bath blanket or sheet. 4. Wash hands, don disposable gloves and cleanse the area where the catheter will enter the urethral meatus with fresh, soapy water, rinse well and dry. 5. Remove disposable gloves, wash hands. 6. Place waste receptacle in accessible place, insure lighting for easy visualization. 7. Prepare sterile field, opening the Foley catheterization kit using sterile technique. Put on sterile gloves.

B. Performance phase of female patient. 1. With sterile glove on separate the labia minora so urethral meatus is visualized. (The non-dominate hand is to maintain separation of the labia until catheterization is finished.) With dominant hand, using forceps to hold cleaning pad, cleanse the periurethral mucosa with sterile antiseptic solution (providine- iodine), cleaning with downward strokes from anterior to posterior. Discard pad after each use. (If patient is sensitive to iodine, chloraprep is used.) 2. Generously lubricate the distal portion of the catheter with water-soluble sterile lubricant. 3. Using sterile technique, insert the catheter into urethral meatus until urine is noted. Continue inserting for 1-3 additional inches. Females are at higher risk than makes of developing a urinary tract infection than males due to having a shorter urethra and the closer proximity to the anus. 4. Inflate the retention balloon with prefilled 10ml syringe of sterile water. 5. Instruct the patient to immediately report discomfort or pressure during balloon inflation. If pain occurs, discontinue the procedure, deflate the balloon and insert the catheter farther into the bladder. 6. Gently pull the catheter until the retention balloon is snuggled against the bladder neck. 7. Keep drainage bag in a dependent position below the level of the bladder to prevent reflux 8. Secure the catheter with a leg strap or statlock catheter stabilization device. 9. Hang bag on bed frame below the level of the bladder, coiling the tubing on the bed, allowing some slack of the tubing to accommodate patient. . Assess the amount, color, odor and quality of urine. Assess the amount, color, odor, and quality of urine. The tubing connected to Foley drainage bag needs to be

managed in a way that prevents the formation of dependent loops. Dependent loops cause increased back pressure in the bladder increasing urinary retention which leads to an increased risk for urinary tract infections. See attached figures for illustration of a dependent loop (Fig 1A & Fig 1B). Methods for preventing the formation of dependent loops include: frequently emptying the drainage bag, using the green clip to secure the drainage bag, and hanging the bag towards the end of the bed. 10. Remove gloves, wash hands. Help patient to reposition.

C. DOCUMENTATION Add the Meditech intervention for a Foley catheter to the patient’s plan of care. Document the date, time of insertion, size of catheter, the location where the catheter was placed and any pertinent supplemental text in the comment box provided. Note weather the Nurse Driven Removal of Indwelling Foley Catheter Protocol was discontinued or continued. Report any complications to the patient’s physician.

VIII MAINTENANCE A. Catheter care: 1. Explain procedure to the patient. 2. Cleanse the area where catheter enters the urethral meatus at least once daily and as needed with fresh, soapy water. Rinse well and dry. Avoid direct application of creams, ointments or powders. a. In uncircumcised males be sure the foreskin is retracted for cleansing and reduced back into position after care. 3. Take care to avoid pulling on the catheter. 4. Keep drainage bag in a dependent position below the level of the bladder to prevent reflux. 5. Secure the catheter with leg strap or statlock catheter stabilization device. (Be sure it is strapped to an unaffected leg.) Allow some slack of the tubing to accommodate patient’s movements. 6. Hang bag on bed frame below the level of the bladder, coiling the tubing on the bed. Avoid dependent loops. 7. Drainage bag is to be emptied per scheduled “I&O” collecting time or as needed ensuring that the drainage spout is not contaminated. Do not allow more than 1000ml to collect in bag. The amount is recorded on the patient’s “I&O” sheet and documented as an intervention in Meditch.

8. Use a separate, clean graduated cylinder for each patient, labeled with the patient’s name. 9. Catheters are to be changed after 28 days or if they become blocked, contaminated, or a malfunction occurs. 10. When it is necessary to clamp and disconnect a catheter from the tubing, both ends at the juncture must be capped with a sterile cover. Sterile caps and plugs are in the supply cart. This should not be done routinely and only in cases in which another closed system catheter cannot be inserted for the intended purposes, i.e., switching to a leg bag or for special catheter types that do not come pre-connected to a bag).

IX REMOVAL OF INDWELLING FOLEY CATHETER A. Ensure the physician did not discontinue the Nurse Driven Removal of Indwelling Foley Catheter Protocol. B. Criteria for removing an indwelling Foley catheter per The Nurse Driven Removal of Indwelling Foley Catheter include Protocol. 1. The patient does not have acute urinary retention 2. The patient does not have a bladder outlet obstruction (e.g. enlarged prostate, clots (CBI), edematous scrotum or penis). 3. The catheter use is not related to perioperative use for selected surgical procedures (e.g. perineal/lower anterior resections/urological/gynecological procedures) a. Anticipate prolonged duration of surgery b. Intraoperative monitoring of urinary output c. Prolonged effect of epidural anesthesia d. Surgery on contiguous structures/GU tract e. Undergoing urological surgery f. Temporary placement for procedure (removed in recovery room) g. Large-volume infusion or diuretics 4. No evidence of gross hematuria. 5. If a patient presents with a urinary catheter in place, such as from a nursing home, investigate the reason for the catheter. Promote removal of the catheter if no legitimate criterion is met. 6. For incontinent patients, presence of wound such as a stage III or IV pressure ulcer or necrotizing wound located in coccyx/hip areas may require prolonged catheterization to promote healing. 7. There is not an anticipation of prolonged immobilization related to issues such as unstable fractures (e.g. spine, pelvis) or multiple trauma injuries.

8. The patient is hemodynamically stable and does not require strict intake and output monitoring related to a procedure, administration of large volume infusions or diuretics or critical care management. 9. The patient is not terminally ill and receiving palliative measures requiring catheterization for comfort. C. Remove the Indwelling Foley Catheter if all of the above Criteria is met. D. Equipment 1. 10ml syringe 2. Gloves 3. Towel E. Procedure 1. Assess the patient using the Pre-Printed Order Set for Nurse Driven Removal of Indwelling Foley Catheter at least once per shift. 2. Explain procedure to patient including any potential symptoms they may experience following removal such as urgency, frequency and/or discomfort. 3. Wash hands and put on gloves. 4. Provide privacy and place patient in supine position with legs slightly apart. Place towel between patient’s leg to protect bed linen. 5. Cleanse the area where catheter enters the urethral meatus with soapy water, rinse well and dry. Release leg strap or statlock catheterization stabilization device for easier removal of catheter. 6. Change gloves and attach syringe to catheter valve to deflate balloon. Do not pull on syringe, but allow the solution to come back naturally. 7. Ask patient to relax and to breathe in and out. As the patient exhales, gently remove catheter. Inspect the removed catheter. 8. Remove gloves and dispose of equipment appropriately. Wash hands. 9. Make patient comfortable. Inform patient and assess for any signs of voiding difficulties. Frequently offer assistance to the bathroom/bedside commode/bedpan or use of urinal. Encourage activity and adequate fluids if not contraindicated. F. DOCUMENATION 1. Under Meditech intervention for Foley catheter, document date, time of removal and checkbox indicating that all of the criteria for discontinuing the Foley catheter have been met. Any pertinent text may be provided in the comment box

provided or in the nurses’ narrative notes. Report any complications to the patient’s physician.

X BLADDER MONITORING AND INTERVENTIONS AFTER CATHETER REMOVAL A. If the Nurse Driven Removal of Indwelling Foley Catheter Protocol was not discontinued by the physician, then the following actions will be taken after removal of the indwelling urinary catheter. 1. Patient will be closely monitored for urinary retention or inability to void. If the patient does not void within 4 hours after removal of the indwelling urinary catheter, then a bladder scan will be performed. Based on the bladder scanning results the following algorithms will be followed:

If Bladder Scan Reveals < 400ml urine follow If Bladder Scan Reveals >400ml urine follow the algorithm below the algorithm below - Wait an additional 2 hours - Perform a one-time intermittent catheterization and continue to monitor for the next 4 hours.

- If after a total of 6 hours has passed and - If patient does not void within the next 4 the patient has not voided and bladder hours and bladder scan reveals <400ml scan reveals >400ml then perform an urine, wait an additional 2 hours. If there one-time intermittent straight is still no voiding after a total of 6 hours catheterization and continue to monitor or the bladder scan reveals >400ml urine the patient for urinary retention over the when assessed then perform an next 4 hours intermittent-catheterization for the second time.

- If the patient still has not voided after 4 - Continue to monitor over the next 4 hours perform a bladder scan. hours. If the patient still cannot void or - If >400ml perform a one-time bladder scan reveals >400ml insert an intermittent catheterization. indwelling Foley catheter. - If <400ml wait and addition 2 hours. After this 2 hours if patient still has not voided or bladder scan reveals >400ml urine retention, perform a one-time intermittent catheterization for the second time. Continue to monitor for the next 4 hours.

If Bladder Scan Reveals < 400ml urine follow If Bladder Scan Reveals >400ml urine follow the algorithm below the algorithm below - If the patient continues to have urinary - A total of two straight catheterizations retention over the next 4 hours, insert an should occur before reinsertion of an indwelling Foley catheter. indwelling Foley catheter. If any complications occur during the implementation of this process, notify the physician for further instruction.

- A total of two straight catheterizations - If a Foley catheter was inserted inform will occur before reinsertion of an the physician when the patient is next indwelling Foley catheter. If any evaluated. The patient will need to be re- complications occur during the evaluated for chronic bladder issues and implementation of this process, notify the the Nurse-Driven order set for physician for further instruction. discontinuation of the indwelling Foley catheter may need to be discontinued

- If a Foley catheter was inserted inform the physician when the patient is next evaluated. The patient will need to be re- evaluated for chronic bladder issues and the Nurse-Driven order set for discontinuation of the indwelling Foley catheter may need to be discontinued.

B. If the Pre-Printed Order Set for Nurse Driven Removal of Indwelling Foley Catheter was discontinued by the physician, then monitoring for bladder dysfunction and urinary retention is to be done as indicated or per physician order. C. DOCUMENTATION 1. Document bladder scan result by adding and documenting a Meditech intervention for Bladder scan. 2. Document straight catheterizations by adding and documenting a Meditech intervention for Catheter, Straight.

3. Document under the Nurses’ Notes in Meditech for any additional pertinent information.

APPENDIX E

ONLINE EDUCATION: PART 3

APPENDIX F

COMPETENCY

Part 1: Maintenance Select True or False 1. Aseptic Foley catheter insertion and good patient hygiene can help prevent introduction of endogenous organisms into the urinary tract.

True/False Rationale: Endogenous organisms are organisms introduced from the patient’s body into the urinary tract system or catheter system. Good patient hygiene will decrease the bio burden when catheter systems are introduced. Aseptic catheter insertion technique prevents introducing endogenous organisms into the urethra and onto the catheter system.

2. Hand hygiene must be performed any time a Foley catheter is handled or manipulated.

True/False Rationale: Hand hygiene prevents the introduction of exogenous organisms to the catheter system and urinary system. 3. Hanging the catheter tubing in a “dependent loop” will decrease risk for UTI.

True/False Rationale: Dependent loops increase back pressure in the catheter system. The increased back pressure causes bladder reflux which can increase the risk for UTI.

4. A catheter kit which includes a pre-connected urometer drainage bag should be selected when inserting a Foley catheter in a critically ill patient, or a patient which will require close output monitoring.

True/False

Rationale: Selecting a pre-connected urometer drainage Foley kit for select patients is the best way to ensure an intact drainage system. Often, when patients are in critical condition, hourly output will need to be monitored. A standard drainage bag does not allow for accurate hourly monitoring, and one should never break the catheter and drainage tubing seal to connect a urometer. Breaking the connection will allow for organisms to enter the catheter drainage system.

5. Preventing unnecessary catheterizations and removing Foley catheters as soon as possible are the most important actions healthcare workers can perform to prevent CAUTI.

True/False Rationale: Yes, preventing unnecessary catheterizations and removing Foley catheters as soon as possible are the most important actions healthcare workers can perform to prevent CAUTI.

Part 2: Foley Catheter Utilization Criteria Multiple Choice: Select the best answer 1. M.M. is a 80 y/o female admitted to medical telemetry from a local nursing home. Her admitting diagnosis is ALOC. She is incontinent of urine. A Foley was placed in the Emergency Department. The admission orders include a Foley catheter with activation of the Nurse Driven catheter Removal Protocol. Nephrology is consulting for renal insufficiency and writes an order for strict Intake and Output monitoring (to assess baseline renal function) but does not discontinue the Nurse Driven Catheter Removal Protocol. The patient is on routine oral medications and a cardiac healthy renal diet. The best way to keep track of the output for this patient would be to: a. Measure output by weighing the urine soaked attends as needed b. Keep the Foley catheter in place to measure I/O. c. Assist the patient with a routine toileting schedule d. Both A and C are correct

Rationale: Accurate intake and output in a non-critical patient can be done without the use of an indwelling Foley Catheter. Fluid from adult diapers and linens can be measures for episodes of incontinence. All patients with incontinence should be placed on a toileting training schedule to promote continence. For toileting, and other needs, urine can be collected with measurements devices such as urinals, bedpans, etc.

2. K.P. is a 40 y/o male patient admitted for right foot cellulitis. Past medical history includes diabetes, paraplegia and hypertension. Physical assessment reveals that the patient is alert and oriented x4 with stable vital signs. All systems are negative except for the right foot cellulitis. A Foley catheter is in place. Upon performing the patients’ admission questionnaire, you find out that he normally uses routine clean intermittent catheterization to manage his chronic urinary retention. The hospitalist has activated the Nurse Driven Catheter Removal Protocol. The best course of action for this patient would be to: a. Remove the Foley catheter per the Nurse Driven Catheter Removal Protocol and allow the patient to perform clean intermittent self-catheterizations. b. Leave the Foley catheter in place for neurogenic bladder c. Assess the patient’s ability to perform clean intermittent catheterizations and provide instruction as needed. d. Both A and C are correct

Rationale: Catheter utilization criteria includes acute urinary retention, not chronic urinary retention. K.P. has chronic urinary retention related to paraplegia. All patients need to be encouraged to function at their baseline level of functionality if possible, to prevent deterioration or further health complications. For K.P., clean intermittent catheterization is considered his normal urinary elimination and it should be encouraged. K.P. will need to be evaluated for his ability to straight catheterize himself considering he has a new health problem which may inhibit his ability to function at baseline. K.P. should also be encouraged to maintain good hand hygiene and technique when performing self-catheterizations in a new environment with new equipment.

3. D.L. is a 38 y/o Female who was admitted to the critical care 4 days ago for pneumonia and sepsis. Past medical history includes morbid obesity, diabetes and congestive heart failure. Today the patient is doing well on nasal cannula oxygen 2L, NS IVF of 50ml per hour and antibiotic infusions. The patient has had stable vital signs for the last 48 hours and remains afebrile. Her WBCs have been trending down for the last 3 days. You anticipate the patient will be transferred out of the critical care unit today. A Foley has been in place since admission and the standing order for Nurse Driven Removal of Foley catheter remains in place. The best course of action for this patient is: a. Remove the Foley catheter per the Nurse Driven Removal of Catheter protocol. b. Provide the patient resources to void such as a bedpan or bedside commode. c. Wait until the patient is transferred out of the critical care unit and ask the progressive care staff to remove the catheter. d. Both A and b are correct

Rationale: D.L. is no longer considered “critical”. Per the Nurse Driven Removal of Indwelling catheter protocol, the catheter should be removed. When the catheter is removed, the patient will need to be educated and given appropriate resources to void.

4. T.S. is a 59 y/o male admitted to the surgical floor for an abscess located on the anterior lower thigh. T.S. is incontinent of urine. The consulting surgeon is concerned about moisture control and is suggesting a urinary catheter to keep the wound dry. When discussing the case with the physician, you should: a. Agree that an indwelling Foley catheter is indicated in this case b. Suggest that the patient remain in attends and you will keep the patient dry. c. Suggest that a condom catheter could be used to manage the urinary incontinence and keep the wound dry. d. Shrug your shoulders and let the physician decide what is best.

Rationale: The wound for this patient is located on the anterior lower thigh and not in the hip, coccyx or perineal area. It is possible that urinary

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elimination for this incontinent patient would be best managed with a condom catheter. A condom catheter would provide the same function as the indwelling catheter in this case, however there would be less risk of urinary tract infection.

5. F.T. is a 75 y/o male admitted to medical oncology with a history of bladder cancer. The patient arrives to medical oncology with a Foley in place. Assessment reveals gross hematuria with large clots in the urine drainage bag. You notify the physician. The physician asks you to irrigate the catheter with Normal saline q 4 hours. The best action to take would be: a. Kindly suggest to the physician that routine intermittent irrigations using an open urinary drainage system is not recommended by the infection control department and that continuous bladder irrigation with a three-way closed system could be used. b. Do as instructed by the physician. c. Refuse to irrigate the catheter. d. Remove the Foley per the Nurse Driven Catheter Removal Protocol.

Rationale: Gross hematuria can result in a urinary tract obstruction, which could further lead to more serious health issues, such as renal failure. Gross hematuria usually does require irrigations. Routine irrigations of Foley catheters are best managed with a closed urinary catheter system such as a 3 way catheter for continuous bladder irrigation. As a professional nurse, you should always collaborate with all members of the health care team to provide the best plan of care for patients.

Part 3: Catheter Insertion Matching: Select the best answer a. Hand hygiene- Good hand hygiene will prevent introduction of exogenous microorganisms to the urinary catheter system. b. Sterile Water- the Catheter manufacturers recommend that only sterile water be used to inflate the catheter balloon. Other substances, such as normal saline, may cause the catheter balloon to become warped, which may be cause urethral trauma when the catheter is removed from the patient. c. Aseptic technique- Using aseptic technique with catheter insertion will prevent contamination of the urinary catheter system. When microorganisms are introduced into the urinary tract system or the catheter system, it can lead to a CAUTI. CAUTI can lead to many issues including sepsis and death. d. WTF (Why the Foley?)- Urinary catheters should only be used according to criteria. Always ensure catheters are being used appropriately. 1. ______a___ performance after providing perineal washing and before applying sterile gloves is an important process during the Foley insertion procedure.

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2. Do not use anything other than _____b____ for Foley catheter balloon inflation, because doing so may cause the balloon to deflate incorrectly, which may lead to urethral trauma. 3. Using ___c______during catheter insertion is important, because it may help prevent CAUTI and save lives! 4. Before inserting a Foley catheter, one should always ask themselves and the ordering physician _____d____?

True/False 5. Pre-testing the Foley catheter balloon, by prefilling it with sterile water, should be done prior to insertion, to ensure the balloon is intact.

a. True/False  Do not pre-test the balloon. Pre-inflating the balloon is not recommended by the manufacturer and may lead to an increased chance of urethral trauma

Part 4: Review of Protocol True/False 1. When A Foley Catheter order is placed in Meditech, via CPOE, the physician will be notified that the “Nurse Driven Catheter Removal Protocol” will be activated. The Protocol will remain active unless an order for “PROTOCOL DC, NUR FOLEY REMOVAL” is entered as well.

True/False Rationale: Per policy, the Nurse Driven Removal of Indwelling Foley Catheter Protocol is automatically implemented with each Foley catheter inpatient order, unless the ordering physician specifies otherwise. 2. If a telephone, verbal, or written order for a Foley catheter is received, then the nurse will remind the physician that the order set will be activated unless they want to discontinue it.

True/False Rationale: Whenever a “Foley Cather” order is placed in Meditech, the Nurse Driven Removal of Indwelling Foley Catheter Protocol is automatically implemented. A dc protocol order must be received if the protocol should not be used. Physicians will need to be reminded of this, because it is a new protocol.

3. When the “Nurse Driven Catheter Removal Protocol” is active, the nurse is responsible for assessing the patient every shift for the need for continued catheterization. If assessment reveals that the patient does not meet criteria for the catheter, then the nurse will discontinue the catheter promptly.

True/False

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Rationale: The nurse is responsible for monitoring and removing catheters when appropriate per the Nurse Driven Removal of Indwelling Foley Catheter Protocol.

4. After a Foley Catheter has been removed per the “Nurse Driven Catheter Removal Protocol”, the nurse must monitor the patient closely for urinary retention. If the patient is unable to void within four hours after the catheter is removed, the nurse will perform a bladder scan. The bladder scan results will determine the next action for the nurse to follow.

True/False Rationale: Per the Nurse Driven Removal of Indwelling Foley Catheter Protocol, nurses must monitor patients closely after a Foley is discontinued to prevent complications related to urinary retention.

5. If any complications occur while following the directions for the “Nurse Driven Catheter Removal Protocol”, the physician will be notified for further action.

Rationale: Per protocol and per the Board of Registered Nursing standardized procedures guidelines, any complications related to a standardized procedure must be reported to the attending physician.

True/False

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APPENDIX G

LEARNER PRE-ASESSMENT

1. A physician should determine when a Foley catheter is unnecessary? T/F 2. If a patient is receiving IV Lasix, they need a Foley catheter for correct intake and output measurement? T/F 3. If a patient is incontinent they should have a Foley catheter placed? T/F 4. Performing straight catheterizations on a patient increases the risk for an infection more than placing an indwelling Foley catheter. T/F 5. If a catheterized patient is receiving antibiotic treatment, they will not be at an increased risk for infection for catheter associated urinary tract infection?

5 level Likert: 1 never, 2. Almost never 3. Sometimes 4. Almost always 5. Always 1. I feel comfortable making independent clinical decisions which affect my patient’s care. 2. I feel like Foley catheters make patient care easier. 3. I feel like my department is well stocked with urinary elimination supplies, such as Foley catheters, condom catheters, straight catheters, bladder scanners and bedside commodes.