Running head: SAY GOODBYE

Say Goodbye to Catheter Use

Lisa Morrill

SAY GOODBYE
Author Biography

Lisa Morrill is a Registered Nurse at Spectrum Health Ludington Hospital. She received her
Associates Degree in Nursing from West Shore Community College. Lisa graduated from Ferris
State University with her Bachelors of Science in Nursing in 2002. Most recently she completed
her Masters of Science in Nursing from Ferris State University. Lisa has been in the healthcare
field for 30 years. She currently is working as the Director of Medical-Surgical Nursing. Her
past experience includes, Emergency Nursing, Infection Control and several levels of nursing
management.
Her graduate school Capstone project was the development of a nurse driven catheter removal
process for the Critical Care Unit. This project included research and development of a process
which can be initiated within the electronic documentation platform and prompt nurses for
assessment of Foley catheter use, furthermore, the project includes steps to discontinue a Foley
catheter when evidence based criteria for use is no longer applicable.
Lisa Morrill lives in Ludington, Michigan. Lisa can be reached at morrilllisa@hotmail.com.

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Abstract
Nurses today are challenged to take a more accountable role and be more active toward
increasing quality and safety of the care they provide. The development, implementation, and
use of an evidence based Foley catheter assessment with a nurse driven removal process is one
way identified to help meet these challenges. Included are the steps taken toward
implementation, barriers encountered with physician staff as well as electronic documentation,

and overall outcomes of this project. Examples of documentation screens are included and initial
metrics are reviewed.

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Say Goodbye to Catheter Use
Since the Institute of Medicine (IOM) published report in 1999, To Err is Human,
healthcare organizations have been challenged to increase the quality and safety in the care they
provide. The IOM report (1999) indicated medical errors could be reduced, and set a goal for a
50% reduction in errors within five years. The Centers for Medicare and Medicaid Services
(CMS) as well as other private insurance companies took notice of the published goals and
developed reduced reimbursement rates for many healthcare associated conditions (HAC). In
2008, CMS developed new guidelines for reduced or nil reimbursement on certain hospital
associated conditions (Hartmann et al., 2012). One of the documented changes was
reimbursement for HACs, such as catheter associated urinary tract infections (CAUTIs) which
are not present on admission to an organization. CAUTI is the most often diagnosed healthcare
associated infection which suggests a need to reduce the use of urinary catheters in hospitalized

patients (Cromwell & Diaz, 2014). Targeting the highest rates of reimbursement, hospitals need
to find innovative ways to meet fiduciary guidelines for maximum compensation. The purpose
of this project was to identify a process to reduce the use of urinary catheters and lower CAUTI
rates, to help guarantee maximum insurance reimbursement.
Plotting and Planning
Primarily, the project plan was developed to assess and update the current urinary
catheter use bundle including policy, assessments, interventions, and metrics in a small Midwest
rural hospital. Evidence based research was used to outline, plan, and implement a best practice
process aimed at decreasing catheter use and lowering rates of CAUTIs. This project also
includes development, approval obtainment from all stakeholders, and initiation of a nurse driven
catheter removal process which will function within the existing electronic health record (EHR-

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Meditech). Initially a literature review was completed to identify best practice standards and to

use published evidence based practice guidelines for support during project development, during
creating buy in with staff and physicians, as well as collection of ideas toward HER
documentation.
Abbreviated Literature Review
Saint, Savel, & Matthay (2002) note that the use of catheters in critical patients has
shown an increase in healthcare associated infections. Healthcare governing bodies have
challenged providers to increase the levels of quality and safety they provide including
development of initiatives to reduce incidences of healthcare associated conditions. Roser,
Altpeter, Anderson, Dougherty, & Walton (2012) indicate catheter utilization rates and catheter
associated urinary tract infection rates decreased after implementation of a nurse driven catheter
removal protocol involving patients in the CCU and on inpatient nursing floors. Nurse driven
catheter removal protocols are decreasing the number of catheter days by promoting early
removal of urinary catheters in unnecessary catheter use. In another study published by Mori
(2014), after implementation of a nurse driven catheter removal protocol a reduction in catheter
rates, catheter dwell times, and catheter associated urinary tract infections were documented.
Using a collaborative nurse driven initiative to decrease hospital acquired urinary tract
infections, a research project was developed by Patrizzi, Fasnacht & Manno in 2009, this study
was aimed at decreasing the rate of catheter days in addition to decreasing the overall rate of
urinary tract infections. Lower catheter use rates, as well as reduced infection rates, were seen as
a result of a nurse driven catheter removal protocol (Patrizzi, Fasnacht & Manno, 2009).
Results of the research project by Partrizzi, Fasnacht, & Manno (2009), did show a decrease of
urinary catheters placed as well as a decrease of catheters at time of transfer to an inpatient unit.

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Furthermore, it also showed a decrease in overall catheter use on an inpatient floor (Patrizzi,
Fasnacht & Manno, 2009). In another successful research project, results were documented
which also showed a decrease in urinary catheter use by using a nurse driven removal protocol
(Parry, Grant, & Sestovic, 2013). The research study concluded with metrics demonstrating
lower catheter use rates as well as reduced infection rates were seen as a result of a nurse driven
catheter removal protocol (Parry, Grant, & Sestovic, 2013).
The overall goal of this project is to decrease urinary catheter days by developing and
implementing interventions that will decrease inappropriate use of a urinary catheter and the
amount of dwell time of a catheter. Decreased use of catheters has shown correlation to a
decrease in urinary tract infections. Adams, Bucior, Day, & Rimmer (2012) conducted a study
that supported a concept of the nurse led protocol decreasing urinary catheter days as well as

documenting a decreased incidence of bacteria found in urine samples. Each of these studies has
shown promise of decreasing catheter days, catheter use, and urinary catheter associated
infections in a hospital inpatient.
In the Beginning
After completion of a literature review, time is spent updating the current policy and
procedure to reflect best practice. The next step is to obtain support from clinical staff as well as
our internal hospitalist group and surgeons. The Medical Director for the hospitalist program
readily accepted proposed changes; the surgeons approval required some process variations.
The plan is for nursing to assess catheter use and remove the catheter when criterion for use is no
longer being met. The surgeons and especially the Urologist struggled with allowing a nurse to
make the final determination on catheter removal. After reviewing some potential edits, it was
decided in place of the nurse removing the catheter when criteria was no longer met, prompts

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would be developed for the nurse to contact the physician when indications for use were no
longer applicable. The physician will then either give an order to remove the catheter or will
provide rationale for appropriate continuation of use. Once these changes were made,
presentations occurred at several Medical Staff meetings and the project was enthusiastically
accepted by those in attendance.
Charting the Course
A group was assembled to begin work on developing online nursing assessments and the
physician order entry documentation. Best practice standards were used to develop an
assessment of urinary catheter use and verbiage which prompts nurses to reflect on appropriate

use of a catheter. These prompts include direction to contact the attending physician when usage
criteria are not met.
See Appendix A
Appendix A includes a sample of screen shots that were developed within the current
EHR-Meditech system. The first screen is an example of the updated nursing documentation
screen. When documentation reflects a patient has a catheter, the completion of the catheter
indication section is mandatory. If catheter use does not meet criteria listed, nursing indicates
such in the criteria not met section. These actions will initiate a prompt for the physician to be
contacted. The second screen is a nursing assessment to be completed on removal of a catheter.
Edits were made to this screen to abstract catheter removal date and time. The final screen is the
physician order entry screen which demonstrates the physicians choices toward catheter criteria.
If appropriate criterion is not chosen the physician must document their reason for continuation
of catheter use.

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See Appendix B
Appendix B is a decision tree or process work flow which can be used separately from
the electronic documentation to determine steps toward catheter removal.
A power point was developed for staff education and training. The presentation was
placed in the Healthstream education platform and assigned to all inpatient nurses. Unit
presentations were scheduled and CCU staff was required to attend. Several superusers were

available on the unit to monitor the process and for help answering questions both from staff and
physician providers. Although this project was developed to be initiated in the CCU,
implementation will occur on the medical surgical units following a successful CCU go live
period.
The Number Crunch
Prior to the project development, metrics were collected on catheter days in the CCU.
The catheter use indicators were previously built in the nursing documentation; however, while
extracting data for the pre-project metrics, it was found staff was not completing the fields.
Using evidence based indicators; documentation was changed to reflect best practice criteria to
use for data mining on appropriate catheter uses. These fields were made mandatory for
completion. Metrics currently being collected include catheter days, indication for catheter use,
and a notification when prompts are initiated. Catheter days are recorded daily at 10am by the
CCU Monitor tech and placed in an online data base. A patient account number is identified
with the total count. Chart audits are performed on each patient to determine indications for
catheter use, staff, and physician responses. Audits continue with physician documentation if
catheter use criteria are no longer met. Manual follow up is done to assess use of proper process
and deviations from the process.

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Catheter associated urinary tract infection rates for the organization was 0% for quarter

one and two in 2014. Quarter three showed one instance of a CAUTI. Fourth quarter of 2014 is
CAUTI free to date. Due to delay in project go live limited amounts of metrics are available.
Continual data mining will be performed for a greater example of metric comparison and
trends prior to submission of article.
See Appendix C
This includes a table of pre and post project metrics. As described above, manual chart
audits were performed on each catheter day monitoring for appropriate catheter use and process
completion.
Summary
Patient safety and quality of care have taken a forefront in todays complex healthcare
environments. Healthcare associated conditions have been targeted by the media, consumers, and
insurance companies as types of medical errors which can be prevented. Initiatives have been
created challenging organizations to develop innovative processes to decrease these safety
threats our patients are exposed to during a care encounter. These initiatives have been directly
related to financial reimbursements. Providers must take an active role in attempt to eliminate
risks a patient may encounter. This article summarizes one effort to decrease chances of
developing an HAC, more specifically, a catheter associated urinary tract infection. Development
of an evidence based nurse driven catheter removal process is one way to address these threats.

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References
Adams, D., Bucior, H., Day, G., & Rimmer, J. (2012). HOUDINI: Make that urinary catheter
disappear nurse-led protocol. Journal of Infection Prevention, 13(2), 44-46. doi:
10.1177/1757177412436818
Cromwell, K. B., & Crespo-Diaz, J. (2014). Implementation and sustainment of hospital-wide
evidence based practice (EBP) bundles to prevent catheter associated urinary tract
infections (CAUTI). American Journal of Infection Control, 42, S21-22.
doi:10.1016/j.ajic.2014.03.068
Hartman, C. W., Hoff, T., Palmer, J. A., Wroe, P., Dutta-Linn, M. M., & Lee, G. (2012). The
Medicare policy of payment adjustment for health care-associated infections:

Perspectives on potential unintended consequences. Medical Care Research and Review,

69(1), 45-61. doi: 10.1177/1077558711413606
Institute of Medicine. (1999). To Err is Human. Washington, DC: The National Academies
Press.
Mori, C. (2014). A-voiding catastrophe: Implementing a nurse-driven protocol. MedSurg
Nursing, 23(1), 15-28.
Parry, M., Grant, B., & Sestovic, M. (2013). Successful reduction in catheter-associated urinary
tract infections: Focus on nurse-directed catheter removal. American Journal of Infection
Control, 41(12), 1178-1181. doi: 10.1016/j.ajic.2013.03.296

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Patrizzi, K., Fasnacht, A., & Manno, M. (2009). A collaborative, nurse driven initiative to reduce
hospital-acquired urinary tract infections. Journal of Emergency Nursing, 35, 536-539.
doi: 10.1016/j.jen.2009.04.017
Roser, L., Altpeter, T., Anderson, D., Dougherty, M., & Walton, J. (2012). A nurse driven Foley
catheter removal protocol proves clinically effective to reduce the incidents of catheter
related urinary tract infections. American Journal of Infection Control, 49(5), e92-e93.
doi: 10.1016/j.ajic.2012.04.161
Saint, S., Savel, R., & Matthay, M. (2002). Enhancing the safety of critically ill patients by
reducing urinary and central venous catheter-related infections. American Journal of
Respiratory and Critical Care Medicine, 165(11), 1475-1479.

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Appendix A

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Appendix B

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Appendix C
CCU catheter days
October-Total Days-18
October 1-5
3 days
October 6-12
2 days
October 13-19 0 days
October 20-26 12 days
October 27-31 1 days

CCU catheter days

November-Total Days-13
November 1-2
3 days
November 3-9
2 days
November 10-16
4 days
November 17-23
1 days
November 24-30
3 days