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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Delegation/Practice Protocols,Inpatient Delegation Protocols

Bladder Management – Medical/Surgical – Adult – Inpatient [26]

Bladder Management – Medical/Surgical – Adult – Inpatient [26] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols




Delegation Protocol Number: 26

Delegation Protocol Title:
Bladder Management - Medical/Surgical - Adult - Inpatient

Delegation Protocol Applies To:
UW Health Inpatients: Adult Medical and Surgical Inpatients. Does NOT apply to patients with:
• Primary surgical urological diagnosis
• Acute spinal cord injury
• Indwelling urinary catheters (IUC) placed by Urology
• Bladder outlet obstruction
• Chronic urinary retention
• Gross hematuria
• Complex pelvic reconstruction surgery
• Lumbar epidurals
• End of life care
• Home straight cath regimen

Target Patient Population:
Adult medical or surgical inpatients with exception of those listed above.

Delegation Protocol Champions:
Robert Hoffman, MD – Department of Medicine – Hospitalists
Nasia Safdar, MD – Department of Medicine – Infectious Disease
Dan Shirley, MD – Department of Medicine – Infectious Disease
Jeffrey Pothof, MD – Emergency Medicine
Dan Gralnek, MD – Department of Urology

Delegation Protocol Reviewers:
Jessica Viste MS, RN, ACNS-BC, CCTN – Department of Surgery – Transplant Surgery
Suzanne Purvis, DNP, RN CNS – Nursing-Practice Innovation - Geriatrics
Kelly Laishes, RN, MS ACNP – BC - Trauma Surgery
Ellie Burgenske, RN, CNS - Neurosurgery
Betsy Laessig-Stary, MS, RN-BC – Gynecology, Urology, Plastics & Otolaryngology
Kristen Stine, RN, CNS – Overnight Care, The American Center
Liz Godfrey, MS – Senior Business Intelligence Analyst
Linda Stevens, RN – Nursing Quality and Safety
Lori Williams, DNP, RN RNC-NIC, CCRN, NNP-BC – Pediatric Universal Care
Andrea Kyser, MS, RN, CPHQ – Nursing Informatics
Kelli Rogers, MPH – Infection Control
Tamara Zupanc, DNP, RN, CCRN-K – Nursing Education & Development

Responsible Department:
Department of Medicine – Hospitalists
Department of Surgery
Department of Medicine – Infectious Disease

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


Purpose Statement:
This protocol delegates authority from the attending physician or ordering provider to Registered
Nurses (RNs) to place orders for bladder management. The protocol will assist in reducing the risk of
complications including urinary tract infections, bladder over-distention and permanent detrusor
muscle damage.

Who May Carry Out This Delegation Protocol:
RNs trained in the use of this delegation protocol.

Guidelines for Implementation:
1. RN places the “Initiate Bladder Management Protocol” order with an ordering mode of
“Protocol without cosign” under the following situations:
a. Concern for urinary retention
b. Upon arrival from PACU or procedural areas without an IUC.
c. Patient has not voided in six hours.
d. Patient previously straight catheterized per bladder management protocol.
e. Directed to initiate it via the Indwelling Urinary Catheter Removal - Inpatient
− Adult Delegation Protocol [25].
2. RN will follow the Bladder Management Medical/Surgical Inpatient Adult Algorithm
3. If an IUC is placed per algorithm, the RN will place an “Insert and Maintain Urinary
Catheter” order.
4. If an IUC is placed per the Bladder Management – Inpatient Adult Delegation Protocol [26],
the RN will answer “NO” to the question “Initiate Urinary Catheter Removal Protocol?”
within the “Insert and Maintain Urinary Catheter” order.

Order Mode: Protocol/Policy, Without Cosign

References:
1. Brouwer, T.A., Rosier, P.F.W.M., Moons, K.G., Zuithoff, N.P.A., van Roon, E.N., Kalkman,
C.J. (2014). Postoperative bladder catheterization based on individual bladder capacity:
A randomized trial. Anesthesiology. 122 (1). 1-9.
2. Balderi, T., Mistraletti, G., D'angelo, E., & Carli, F. (2011). Incidence of postoperative urinary retention
(POUR) after joint arthroplasty and management using ultra-sound-guided bladder catheterization.
Minerva anestesiologica, 77(11), 1050.
3. Fink, R., Gilmartin, H., Richard, A., Capezuti, E., Boltz, M., & Wald, H. (2012). Indwelling urinary catheter
management and catheter-associated urinary tract infection prevention practices in Nurses Improving
Care for Healthsystem Elders hospitals. American journal of infection control, 40(8), 715-720.
4. Gil, M., Gomez, A., Vargas, D., Garcia, E., Daros, F., Tugas, E., et al. (2009). Factors associated
with delayed postsurgical voiding interval in ambulatory spinal anesthesia patients: a
prospective cohort study in 3 types of surgery. American Journal of Surgery, 23-6, 394-400.
5. Gould, C., Umscheid, C., Agarwal, R., Kuntz, G., Pegues, D. and the Healthcare Infection
Control Practices Advisory Committee (HICPAC) Guideline for Prevention of Catheter‐
Associated Urinary Tract Infections 2009
6. Joelsson-Alm, E., Nyman, C., Lindhol, C., Ulfvarson, J., Svensen, C. (2009).
Perioperative bladder distension: a prospective study. Scandinavian Journal of
Urology and Nephrology, 43, 58-62.
7. Krein,S.L., Kowalski, C.P., Harrod, M., Forman, J., Saint, S. (2013). Barriers to reducing
urinary catheter use. The Journal of American Medical Association. 173 (10). 881-886.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


8. Lo, E., Nicolle, L., Classen, D.,Coffin, S.. Gould, C., Maragakis, L., Meddings, J., et al (2014). Strategies to
prevent catheter-associated urinary tract infections in acute care hospitals: 2014 Update. Infection Control
and Hospital Epidemiology, 35(5), 464-479.
9. Meddings, J., Rogers, M. A., Krein, S. L., Fakih, M. G., Olmsted, R. N., & Saint, S. (2013). Reducing
unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract
infection: an integrative review. BMJ quality & safety, bmjqs-2012.
10. Newman, D.K., Willson, M.M. (2011). Review of intermittent catheterization and current
best practices. Urologic Nursing. 31 (1). 12-29.
11. Palese, A., Buchini, S., Deroma, L., Barbone, F. (2010) The effectiveness of the
ultrasound bladder scanner in reducing urinary tract infections: A meta-analysis. Journal
of Clinical Nursing. 19. 2970-2979.
12. Steggall, M., Treacy, C., & Jones, M. (2013). Post-operative urinary retention. Nursing Standard, 28(5), 43-
48.
13. Umer, A. F. F. A. N., Shapiro, D. S., Hughes, C. H. R. I. S., Ross-Richardson, C. Y. N. T. H. I. A., & Ellner, S. C.
O. T. T. (2016). The Use of an Indwelling Catheter Protocol to Reduce Rates of Postoperative Urinary Tract
Infections. Connecticut medicine, 80(4), 197-203.
14. UW Health Orthopedics and Rehabilitation (2009). Orthopedics and Rehabilitation
Programs. Retrieved March 6, 2009, from
http://www.uwhealth.org/orthopedicsurgeryrehab/ conditionsandtreatments/11181
15. Walker-Daniels, Kimberly. Creating and Implementing an Inpatient Bladder
Management Algorithm, Protocol and Procedure. University of Wisconsin –
Madison. 2009.

Collateral Documents/Tools:
Bladder Management Medical/Surgical Adult Inpatient Algorithm

Approved By:
UWHC CAUTI Workgroup: January 2015; *April 2017
UWHC Nursing Practice Council: February 2015; *June 2017
UW Health Center for Clinical Knowledge Management Council: February 2015; *April 2017
UWHC Medical Board: February 2015; *June 2017

Effective Date: June 2017

Scheduled for Review: June 2020
*Expedited approval








Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


Start
Do any of these indications apply:
• Concern for urinary retention
• Indwelling urinary catheter (IUC) discontinued
• On arrival from PACU or procedural areas without indwelling urinary catheter
• Patient previously straight catheterized per bladder management protocol
Does NOT apply for patients with:
• Primary surgical urological diagnosis
• Acute spinal cord injury
• Indwelling catheters placed by Urology
• Bladder outlet syndrome
• Chronic urinary retention
• Gross hematuria
• Complex pelvic reconstructive surgery
• Lumbar epidural
• End of life care
• Home straight cath regimen
Bladder scan for PVR
PVR <200 mL?
2
nd
void within 6
hours?
Yes
Yes
No
2
nd
PVR <200
mL?
Yes
End Algorithm
Discontinue “Initiate Bladder
Management Protocol” order
in Health Link
Yes
PVR <500 mL?
No
Bladder scan
No
Patient void
within 6 hours?
No
PVR >500 mL
OR
patient reports
bladder
discomfort?
Has patient been
*consistently
straight catheterized
for 24 hours?
Yes
No
Yes
No
No
Yes
*consistently = urine collected in last 24 hours
via straight catherization only
Bladder Management Medical/Surgical Inpatient Adult Algorithm
Start at beginning of
algorithm
1. Straight catheterize
2. Assess Risk Factors***
and discuss with provider
Bladder Scan every 2 hours
until >500 mL OR patient
reports bladder discomfort
Has patient had a
prior foley placed
per this algorithm?
***Risk Factors
BPH - Was patient on alpha-adrenergic blockers (Flomax) and/or
have a history of BPH prior to admission? If yes, discuss
restarting/starting medication with Primary Team. IUC should
stay in place for 3 days after initiating medication. Alpha blockers
have also been shown to help women with urinary retention.
Drugs with anticholinergic effects - Is patient on any of the
following medications? If yes, discuss temporarily stopping
medication(s) with Primary Team. Examples: Antimuscarinics,
Tricyclic antidepressants, Antipsychotics, Antihistamines, Anti-
Parkinson meds
Narcotics - Discuss with Primary Team about decreasing
epidural/opioid dosages.
Urological history/Chronic Urinary Retention - Discuss ordering
Urology consult with Primary Team.
High PVR – Consider if it is normal for patient to have a high PVR
if also voiding on own. If no bladder discomfort, a high residual
could be normal for the patient
Immobility
Chronic constipation
Yes
No
Insert IUC and place
order in HealthLink,
per protocol without
cosign. Notify
provider
Discuss clinical
considerations for trial
removal
Discuss with provider
next steps (i.e. straight
cath, IUC, urology
consult)

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org