Development of a Nurse-Driven Protocol to Remove Urinary Catheters

Background: Catheter-associated urinary tract infections (CAUTI) are the most common healthcare-acquired infection (HAI) in acute care hospitals.   Data show 12-15% of inpatients have a catheter placed during their hospital stay; 5% per catheter day will develop bacteruria and 10% of those will develop a UTI.  We extrapolated that annually, 20,354 BJC HealthCare patients (based on 2008 admissions to system hospitals), will have a catheter placed during hospitalization, 1,018 will develop bacteruria, and 102 patients per day (10% of 1,018) may develop a CAUTI.

Objective: The objectives of the intervention were to decrease CAUTI by reducing the number of urinary catheters in use; to implement a process to initiate an assessment for catheter need; and to develop communication with physicians about the process.

Methods: A team of nurses and Infection Prevention Specialists reviewed current literature and practices, then developed a standard procedure for assessing the need for a urinary catheter.  The team developed a list of indications for catheter retention including gross hematuria, urinary obstruction, urologic surgery, open sacral decubitus ulcers in incontinent patients, need for tracking “ins & outs” (I & O) for hemodynamic instability, “no code”/comfort care/hospice care, and immobility due to physical constraints (e.g., unstable fracture, IABP, epidural catheter, femoral nerve block).   The resulting acronym, HOUDINI was adopted to help staff remember appropriate indications and remind them to make the catheter “disappear” if no indications exist.  The algorithm was implemented as a nurse-driven protocol in 11 hospitals with proper communication to physicians via the patient’s printed or electronic medical record.  Data is available from 7 hospitals.  We evaluated urinary catheter utilization rates six months prior to and six months after implementation to assess the impact on catheter utilization.  Data were analyzed using chi-square & chi-square for trend. Successful implementation of the algorithm was set at a urinary catheter utilization decrease of 3% or more.

Results: Overall (7 hospitals), the catheter utilization ratio decreased by 1.78% from September 2009 to September 2010. Five hospitals showed a statistically significant (p <0.01, p <0.05) decrease in utilization, ranging from 2.8-7.5%.  Two hospitals had no improvement; pre-implementation urinary catheter implementation rates were low (about 20%) in these two facilities.  Investigation revealed that in one hospital, ward changes resulted in increased patient acuity and decreased number of patient days on monitored units.  An audit continues in hospital two.

Conclusions: Unit-level catheter utilization rate reductions were seen following implementation of the HOUDINI protocol.  A nurse driven protocol can be successful at decreasing urinary catheter utilization.