Nurse-initiated removal protocol of unnecessary urinary catheters in non-intensive care units: A detailed protocol

In non-intensive care units the goal is to have the patient's bedside nurse, as part of the daily nursing assessment, note the urinary catheter's presence and evaluate whether or not the catheter is still indicated. Educating nurses about appropriate urinary catheter use during nursing rounds is central to success. The process includes a unit champion (usually a nurse) who rounds with nurses directly involved in patient care. During nursing rounds, the champion and nurses assess all patients for urinary catheter presence by asking: Does the patient have a urinary catheter? If so, what is the reason for use?

If the patient has a urinary catheter, the champion reviews reasons for use with the nurse caring for the patient. Appropriate indications are based on the 2009 Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines. If there are no valid indications for the urinary catheter, the unit champion asks the patient’s nurse to contact the physician to discontinue the urinary catheter. The nurse is coached to own the assessment of whether the catheter is indicated, and the ongoing need for the catheter.

The expected intermediate outcome is a reduction in inappropriate placement and continued use of urinary catheters. Reducing inappropriate placement and use will likely reduce the risk of hospital-acquired urinary tract infections. Additionally, reducing the use of the indwelling catheter will decrease the non-infectious complications of urinary catheter use.  

In this manual, you will find the detailed information necessary to implement this program.

Nurse-Initiated Removal of Unnecessary Urinary Catheters in Non-Intensive Care Units (manual) (PDF)

Nurse-initiated Removal of Unnecessary Urinary Catheters:  How to Implement the Program