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

Indwelling Urinary Catheter Removal – Adult – Inpatient [25]

Indwelling Urinary Catheter Removal – Adult – Inpatient [25] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols





Delegation Protocol Number: 25

Delegation Protocol Title:
Indwelling Urinary Catheter Removal - Adult - Inpatient

Delegation Protocol Applies To:
UW Health Inpatients: UW Health Adult Medical and Surgical Inpatients. This protocol does not apply to
patients with:
• Primary surgical urological diagnosis
• Acute spinal cord injury
• Indwelling urinary catheters (IUC) placed by Urology
• Complex pelvic reconstructive surgery
• Lumbar epidurals
• End of life care
• Renal transplant during this admission
Target Patient Population:
Adult medical or surgical inpatients - except those listed above - that have an IUC.

Delegation Protocol Champions:
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:
Linda Stevens, DNP, RN-BC, CPHQ, CSPHP – Nursing Quality and Safety
Geeta Sharma, MSN, RN – Nursing Quality and Safety
Jessica Viste MS, RN, ACNS-BC, CCTN – Abdominal Transplant
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
Kristine Stine, RN, CNS – Overnight Care, The American Center
Liz Godfrey, MS – Senior Business Intelligence Analyst
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 Departments:
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 ordering provider to the Registered Nurse (RN) to
place orders for removal of indwelling urinary catheter (IUC). The delegated act will facilitate
timely removal and reduce the risk of catheter associated urinary tract infections.

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

Guidelines for Implementation:
1. The “Insert and Maintain Urinary Catheter” order will include a question asking
“Initiate Urinary Catheter Removal Protocol?”
a. If the order is placed by an ordering provider and the answer to the question is
“No,” the IUC cannot be removed without the ordering provider discontinuing the
“Insert and Maintain Urinary Catheter” order.
b. If the order is placed by an ordering provider and the answer to the question is
“Yes,” the attached Indwelling Urinary Catheter Removal - Inpatient - Adult
Algorithm will be followed.
2. If an IUC is removed via the algorithm, the RN will place the Discontinue Urinary
Catheter order and sign it with an ordering mode of “Protocol/Policy, Without Cosign”.
3. After discontinuation of the order, the RN will be presented with a BPA on the
Patient’s Story Page to enter the “Initiate Bladder Management Protocol” order which
will be signed with an ordering mode of “Protocol/Policy, Without Cosign”.

Order Mode: Protocol/Policy, Without Cosign

References:
1. 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.
2. Steggall, M., Treacy, C., & Jones, M. (2013). Post-operative urinary retention. Nursing Standard, 28(5),
43-48.
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 Health system Elders hospitals. American journal of infection control, 40(8), 715-720.
4. 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.
5. 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.
6. Association for Professionals in Infection Control and Epidemiology (2014). Guide to
preventing catheter-associated urinary tract infections. Washington, D.C.
7. 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.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

8. 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
9. Hinman, F. (1976). Postoperative overdistention of the bladder. Surgery,
Gynecology, & Obstetrics, 142, 901-2.
10. 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.
11. 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.
12. UW Health Orthopedics and Rehabilitation (2009). Orthopedics and
Rehabilitation Programs. Retrieved March 6, 2009, from
http://www.uwhealth.org/orthopedicsurgeryrehab/
conditionsandtreatments/11181
13. Voss, A. (2009) Incidence and duration of urinary catheters in hospitalized older adults:
Before and after implementing a geriatric protocol. Journal of Gerontological Nursing.
35 (6). 35-41
14. Walker-Daniels, Kimberly. Creating and Implementing an Inpatient Bladder
Management Algorithm, Protocol and Procedure. University of Wisconsin –
Madison. 2009.
15. Wilson, M., Wilde, M., Webb, M., Thompson, D., Parker, D., et al (2009). Nursing
interventions to reduce the risk of catheter-associated urinary tract infection: Part 2:
Staff education, monitoring, and care techniques. Journal of Wound Ostomy
Continence Nursing. 36(2). 137-154

Collateral Documents/Tools:
Indwelling Urinary Catheter Removal – Adult – Inpatient Algorithm

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

Effective Date: June 2017

Scheduled for Review: June 2020
*Expedited Review Process

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