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VUMC Urinary Catheter Guidelines

The VUMC guidelines provide standards for the insertion, management, and discontinuation of indwelling urinary catheters. Key points include: urinary catheters require an order and should only be used for approved clinical indications; patients are on a nurse-driven discontinuation protocol unless excluded by a provider; and the multidisciplinary team assesses daily whether continued catheter use is necessary while providers perform their own assessments. The guidelines aim to minimize catheter use and prevent catheter-associated urinary tract infections through best practices for insertion, maintenance, access and removal.

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100% found this document useful (1 vote)
333 views5 pages

VUMC Urinary Catheter Guidelines

The VUMC guidelines provide standards for the insertion, management, and discontinuation of indwelling urinary catheters. Key points include: urinary catheters require an order and should only be used for approved clinical indications; patients are on a nurse-driven discontinuation protocol unless excluded by a provider; and the multidisciplinary team assesses daily whether continued catheter use is necessary while providers perform their own assessments. The guidelines aim to minimize catheter use and prevent catheter-associated urinary tract infections through best practices for insertion, maintenance, access and removal.

Uploaded by

Nurul Uswatin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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VUMC Guidelines for Management of Indwelling Urinary Catheters

UC Insertion
Preparation & Procedure
Indications for insertion and continued use of indwelling urinary catheters include:
Urinary retention or obstruction
o An epidural catheter is not an absolute indication for continued use of a
urinary catheter. Patients with epidural catheters should be assessed for
urinary retention on an individual basis.
Incontinence in patient with open perineal or sacral wounds
Critical illness AND a need for accurate monitoring of urinary output
Terminal illness receiving comfort care or withdrawal of care
Perioperative use for selected surgical procedures
o Surgeries of the GU tract or contiguous structures
o Anticipated prolonged duration of surgery
o Anticipated to receive large volume fluids/diuretics during surgery
o Need for intraoperative monitoring of urinary output.

UC Access/
Maintenance

UC
Discontinuation

Perform hand hygiene before


handling or accessing UC.

Perform perineal/meatal care


gently with soap & water or bath
wipes at least every 12 hours, after
bowel movements, and as needed.

All patients are on the urinary catheter


discontinuation protocol unless a provider
order is given to exclude them.

Keep the catheter anchored with a


securement device at all times to
prevent catheter movement.

Keep drainage port clean and


securely clamped. Do not allow
drainage port to touch the
receiving container when emptying
the drainage device.
Small urine samples (urinalyses or
cultures) are obtained from the
access port closes to the patient.
Do not send urine from the
drainage bag or meter.
Scrub to disinfect access port with
antiseptic before aspirating a urine
sample.

The catheter is removed when the clinical


indications are no longer present.

Empty the collection bag q 6-8


hours and prior to transport to
overfilling and backflow.

Consider changing the catheter if the patient


has a confirmed UTI. Routine catheter
replacement is not recommended for
prevention of CAUTI.

An order is required for catheter


placement. When a catheter is placed
emergently, or when patients are
admitted with a catheter in place, an
order is obtained within 24 hours.

Perform hand hygiene prior to insertion.


Proceduralist(s) wears sterile gloves.
Other PPE is necessary only if indicated
by the patients condition or
comorbidities, and per Standard
Precautions.

Maintain unobstructed urine flow:


keep drainage systems free of
kinking, above floor level and
below bladder level for gravity
drainage.

After catheter removal, assess the patient to


determine ability to void, to empty the
bladder, & to maintain continence. If unable
to void, notify provider.

Educate Patient/Family about necessity


for catheter and about CAUTI
prevention.

Do not inflate the balloon prior to


insertion.
After placement, do not inflate the
balloon until urine flow is achieved.

Minimize UC access; keep


collection system connected unless
disruption is required for patient
care. (e.g., irrigation).

Use aseptic technique when


performing interventions, including
obtaining specimens, emptying
urine, and irrigation.

If patient is unable to void, consider I/O


catheterization x 2 before replacing indwelling
catheter.
Consider Urology consult for urinary retention
of unknown etiology.

If patient is at risk for difficult


placement, a second person may assist
with positioning and/or placement.
Consider a Urology consult for patients
with a history of difficult insertions or
surgery.

Aseptic technique is maintained during


insertion.
If the catheter is contaminated during an
unsuccessful attempt at placement,
discard it and obtain a new insertion kit.

Do not routinely replace drainage


systems. If bag becomes visibly
soiled or integrity is breached, use
aseptic technique to change.

Do not culture asymptomatic


patients (exceptions: patients who
are pregnant or undergoing GU
surgical procedures).

The multidisciplinary team assesses continued


need for the catheter daily.
Patients are assessed by a nurse for clinical
indications for continued use:
Upon admission;
Every shift or with a change in caregiver;
With change in the level of care.

Monitor compliance with elements of insertion, care, access, and discontinuation.


Every member of the team is obligated to identify and correct any deviation or potential deviation of these standards.
CAUTI = Catheter-associated urinary tract infection; UC = urinary catheter

VUMC Policy CL 30-15.05 Indwelling Urinary Catheters: Insertion, Maintenance, Discontinuation

VUMC Standards for Non-emergent Insertion and Management of Central Venous Catheters (CVCs)
CVC Insertion
Preparation
Procedure

Insertion
Site Care

CVC
Access

CVC
Discontinuation

Educate Patient/Family about CLABSI


prevention and obtain informed
consent.

Prep site with chlorhexidine (CHG); allow


to dry before procedure starts.

Assess insertion site and


catheter each shift.

Minimize CVC access; bundle the


collection of multiple lab tests to
a single CVC access when
possible.

Remove CVC when no longer


medically necessary and when an
alternative IV access (e.g. peripheral
IV) can serve the patients needs.

Obtain all supplies.

Place sterile full body drape over patient.

Report abnormal findings to


physician or designee.

Perform hand hygiene before


accessing CVC.

Daily evaluation by primary care


team re: CVC necessity.

Perform hand hygiene before


procedure.

After insertion, a transparent CHGimpregnated dressing is placed,


maintaining sterility of the insertion site.

Daily evaluation by primary care


team re: CVC necessity.

Guidewire exchange of CVC follows


same procedures as CVC insertion.

Perform time-out.

Confirm CVC placement radiographically,


as appropriate.

Change dressings at regular


intervals (Q7d for transparent,
q24hrs if gauze).

Scrub to disinfect access port


with an alcohol or CHG prep pad
using a twisting motion 5 times
around the threads and
scrubbing 5 times across the
septum. Allow to dry before
accessing.

Proceduralist(s) wears cap, mask,


sterile gloves, sterile gown.

When adherence to aseptic technique


cannot be ensured (i.e., when catheters
are inserted during a medical
emergency), replace all catheters as soon
as possible and after no longer than 48
hours. Lines placed at outside facilities
are considered for replacement.

Change dressing if damp, soiled


or non-occlusive.

Only draw blood cultures from


CVC with physician order for
collection from CVC.

Routine CVC replacement is not


recommended for prevention of
CLABSI.

Perform dressing changes as a


sterile procedure.

Collect blood cultures from CVC


only to determine if CVC is
source of bacteremia.

Avoid guidewire exchange to replace


CVCs in patients suspected of having
catheter-related infection.

Nursing personnel is present in room;


wears cap and mask if not in contact
with sterile field.
Site selection is based on patient
needs and condition. Subclavian site
is preferred; femoral placement in
adults is avoided.

After 3 attempts at placement or before


changing sites, a second proceduralist is
consulted.

Ultrasound should be used for


guidance prior to or during IJ
placement, and may be useful to
evaluate other vessels prior to line
placement.

Trained providers discontinue CVCs.

Change soiled, leaking,


potentially contaminated hub
caps.
Change tubing, needleless
devices, and fluid as specified by
policy (CL 30-07.01).

Monitor compliance with elements of insertion, care, access, and discontinuation.


Any member of the team is obligated to identify and ensure correction of any deviation or potential deviation from these standards.
CLABSI = Central line-associated bloodstream infection; CVC = central venous catheter (includes temporary central lines, PICCs, tunneled catheters, etc)
For more detail see
CL 30-07.02
CVC Care and Maintenance
CL 30-07.11
CVC Insertion

CVC Insertion and Management

Approved MCMB 6 3 2010

UrinaryCatheterGuidelinesforProviders

AllProvidersShould:
BeAwareoftheVUMCIndicationsforUrinaryCatheters:

Urinaryretentionorobstruction
o Anepiduralcatheterisnotanabsoluteindicationforcontinueduseofaurinarycatheter.
Incontinenceinpatientwithopenperinealorsacralwounds
CriticalillnessANDaneedforaccuratemonitoringofurinaryoutput
Terminalillnessreceivingcomfortcareorwithdrawalofcare
Perioperativeuseforselectedsurgicalprocedures(involvingGUtractorcontiguousstructures)

BeAwareofRequirementforProviderOrdersforCatheters

Allurinarycathetersrequireanorder.
Everypatientisonthenursedrivendiscontinuationprotocolunlessspecificallyexcludedbya
providerorder.

PerformaDailyAssessmentofContinuedNeedfortheUrinaryCatheter

Patientswithurinarycathetersshouldbeassesseddailywhetherthecatheterisstillnecessary,
andunnecessarycathetersareremoved.

UnderstandtheVUMCUrinaryCatheterDiscontinuationProtocol

Nursingwillassesscatheternecessityandwillremovecathetersfrompatientswhonolonger
meettheindicationsforcontinuedneed(seeabove).
Ifpatientisunabletovoidaftercatheterremoval,theproviderwillbenotified.Unlessthereisa
knownobstruction,inandoutcatheterizationx2isrecommendedbeforetheindwelling
catheterisreplaced.

Education Highlights for Foley Policy Implementation


Insertion

Patients must have an order for a foley (even if device was present on admission).
The patient must have one or more of the following indications for a catheter:
o Urinary retention or obstruction. If the patient has a foley placed for this reason, a provider order is needed
to remove it.
o Incontinence in patient with open perineal or sacral wounds. (e.g., Stage 3 or 4 pressure ulcer, surgical
wound, wound vac)
o Critical illness AND a need for accurate monitoring of urinary output (does not apply outside the ICUs)
o Terminal illness receiving comfort care or withdrawal of care
o Perioperative use for selected surgical proceduresthese should be removed as soon as possible after
surgery
If the patient has a foley and no order, evaluate for indications. If the foley is indicated, contact the provider to
obtain an order. If not, remove the catheter.
Foleys are placed aseptically
o A second person assists when placement may be difficult (e.g., obese, limited mobility, etc.)
o If the first attempt fails, a new kit is obtained for the next attempt. Consider asking a second person to
attempt the placement.

Maintenance

While the foley is in, care is meticulous.


o BID and prn perineal / foley carebath wipes or soap and water are acceptable, depending on patient
needs
o Keep the catheter secured with Stat Lock
o Keep the bag below the bladder and off the floorthis means in transport, too.
Dont open the drainage system unless absolutely necessary. If you must open it, use aseptic technique.

The Discontinuation Protocol

Every patient with a catheter is on the discontinuation protocol unless the provider excludes the patient by order.
Remove the foley as soon as the patient no longer needs it (based on indications for use.) No order is needed to
remove the foley unless the provider has written an order specifying so.
If the order indicates a date and time for foley removal (4/1/14 @ 1400 or POD 2 at 0600), the patient is not on the
protocol, and the foley is removed as specified.
Once the catheter is removed, the patient is assessed at least every two hours for the need to urinate. Assistance is
offered for toileting. If the patient is unable to void within six hours, assess bladder volume with the bladder
scanner.
Notify provider for next steps if
o Patient has suprapubic pain or the urge to void but is unable to do so.
o A volume of greater than 300 ml is identified with the bladder scanner, and the patient is unable to void.
o The patient has not voided and does not have significant volume in the bladder 6 hours after catheter
removal.

For more information see VUMC Guidelines for Management of Urinary Catheters and VUMC Policy CL 30-15.05 Indwelling
Urinary Catheters: Insertion, Maintenance, Discontinuation

INDWELLING URINARY CATHETER


NURSING-DIRECTED DISCONTINUATION PROTOCOL
All patients with urinary catheters are placed on the protocol unless excluded by provider order.
Was the catheter placed
For urinary retention or obstruction?
In conjunction with GU surgery or
instrumentation?
By Urology?

Contact the ordering provider


for discontinuation
instructions / orders if not
already noted in chart.

YES

NO
Does the patient have one or more of the following
conditions?
Terminal illness receiving comfort care or
withdrawal of care;
Open perineal or sacral wounds;
Critical illness AND a need for accurate
monitoring of urinary output.

LEAVE
catheter in place
Reassess with change in shift,
caregiver, or level of care

YES

NO
Is the patient able to use one or more of
the following?
toilet
bedpan
urinal
bedside commode
adult protective garment

REMOVE

YES

catheter

Patient able to void within 4


hours following removal?

NO
NO

YES

LEAVE

Evaluate bladder using


bladder scanner

catheter in place
Reassess with change in shift,
caregiver, or level of care

NO

Scanned volume > 300 mL


AND / OR
Suprapubic pain

REPEAT BLADDER SCAN every 2 hours until:


(a) patient able to void OR
(b) patient meets criteria to notify provider

Continue to monitor
per unit standards.

YES

Notify Provider.
Consider I/O catheterization.

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