Reducing Foley Catheter Device Days in an Intensive Care Unit

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Reducing Foley Catheter Device Daysin an Intensive Care UnitUsing the Evidence to Change Practice

AACN Advanced Critical Care

Volume 17, Number 3, pp.272–283

© 2006, AACN

Laura Reilly, RN, BSN, CCRN

Patty Sullivan, RN, BAIS, CIC

Sharon Ninni, RN, BSN, CCRN

Denise Fochesto, RN, MSN, CCRN, APN-C

Karen Williams, BS, MT (ASCP) CIC

Brandee Fetherman, RN, BSN, CCRN

Catheter-associated urinary tract infections(UTIs) are the most common hospital-ac-

quired infection and can lead to increasedlength of stays, mortality rates, and ultimatelyhigher hospital costs. The length of time foleycatheters remain in situ is directly related to in-creases in UTIs. This article describes a step-by-step clinical quality initiative to reduce UTIs byreducing foley catheter device days in an inten-sive care unit (ICU). A multidisciplinary teamwas assembled, and staff was engaged to develop the plan. Criteria-based foley catheterguidelines, a decision-making algorithm, andan educational program were developed andimplemented. The strategy resulted in a signifi-

cant reduction in foley catheter device days anda decrease in catheter-associated UTIs. Thisproject supported an evidence-based qualityimprovement approach to change clinical prac-tice and improve patient outcomes.

Practice Problem: Incidence,Diagnosis, and Prevalence ofUrinary Tract InfectionsApproximately 30 million indwelling urinarycatheters are used in the United States each

The prolonged use of indwelling urinary

catheters can lead to many complications, the

most prevalent being urinary tract infections.

These hospital-acquired infections can in-

crease hospital costs, length of stay, and mor-

tality rates. Evidence-based guidelines for the

prevention of urinary tract infections are com-

pared and discussed. Minimizing indwelling

urinary catheter use is well-recognized in the

literature to reduce the risk of these infec-

tions. To decrease the incidence of catheter-

associated urinary tract infections, the staff of

a 22-bed, mixed medical, surgical, and

trauma intensive care unit focused on reduc-

ing the number of foley catheter device days.

A multidisciplinary team was convened to

create an evidence-based plan. Staff nurses

were engaged in the development and imple-

mentation of the plan. Criteria-based foley

catheter guidelines, a decision-making algo-

rithm, and a daily checklist were imple-

mented that led to a significant reduction in

foley catheter device days and a decrease in

catheter-associated urinary tract infections.

Keywords: critical care, urinary catheter,

urinary tract infections

A B S T R A C T

Laura Reilly is ICU Coordinator, Morristown Memorial

Hospital, 80 Turner Street, Dover, NJ, 07801 (e-mail: laura.

[email protected]).

VOLUME 17 • NUMBER 3 • JULY–SEPTEMBER 2006 FOLEY CATHETERS

273

year.1 This is estimated to be 15% to 25% ofall hospitalized patients.2 Urinary tract infec-tions are the most prevalent hospital-acquiredinfection and are directly associated with theuse of indwelling urinary catheters, or foleycatheters. The literature estimates that UTIsaccount for 40% of all hospital-acquired in-fections, and that 80% of these infections aresecondary to a foley catheter.2 There are 2routes that allow bacteria to enter into thecatheterized patient. Intralumenal migrationallows passage through the inside of thecatheter tubing. Extralumenal migration al-lows passage in the space between the urethralmucosa and outside of the catheter tubing.3

The National Nosocomial Infection Sur-veillance (NNIS) system is a national databasedeveloped by the Centers for Disease Controland Prevention (CDC) to benchmark infec-tion rates of similar hospitals. The CDC clas-sifies catheter-associated UTIs into 2 groups:symptomatic UTIs and asymptomatic bacteri-uria (Table 1). The term catheter-associatedmeans that the patient had a foley catheter atthe time or within 7 days of the onset of theinfection.4

NNIS criteria define the incidence ofcatheter-associated UTI by dividing the num-ber of UTIs by the number of foley catheterdays and multiplying by 1000 (UTIs/1000 fo-ley days). The NNIS benchmarks are pub-lished annually and are determined by calcu-lating the pooled mean infection rates forsimilar participating critical care units. Thereare over 300 participating hospitals in theNNIS database. The pooled mean for med-ical/surgical ICUs in major teaching hospitalsin 2004 was 3.9 UTIs/1000 foley days.5

The complication of a UTI can increase apatient’s hospital length of stay by 0.4 days foran asymptomatic UTI and 2.0 days for a sym-pomatic UTI.6 One recent cost analysis of UTIsestimated an additional expense ranging from$401 to $1,727 per UTI.7 Additional reportedestimates have been as high as $3,803 per infection.8

Other complications associated with theuse of foley catheters include urethritis, ure-thral strictures, hematuria, bladder perfora-tion, catheter obstruction, and urosepsis.9

Urosepsis is a life-threatening infectious com-plication, and its associated risk increases withprolonged indwelling urinary catheter usage.Urosepsis mortality rates are reported as highas 25% to 60%.10

Table 1: CDC Criteria for Diagnosis ofSymptomatic Urinary Tract Infectionand Unsymptomatic Bacteriuria4

I. Symptomatic UTI must meet at least one of the

following criteria:

1. Positive urine culture with �105 cfu/mL urine

with 2 or less bacterial species and 1 of the

following symptoms with no other recognized

cause:

a. Fever (�38�C)

b. Frequency

c. Urgency

d. Dysuria or suprapubic pain at palpationa

positive urine culture

2. Two of the following symptoms with no other

recognized cause: fever (�38�C), frequency,

urgency, dysuria or suprapubic pain at

palpation and one of the following findings:

a. Evidence of leukocyte-esterase and/or nitrate

b. Pyuria (�10 leukocytes/mm3 or �3

leukocytes/high power field of

uncentrifuged urine)

c. Microscopic evidence of pathogen in Gram-

stain of uncentrifuged urine

d. Two urinary cultures with an identical

uropathogen �102 cfu/mL from correctly

obtained specimens

e. Pure culture with �105 cfu/mL after

appropriate antibiotic treatment

f. Physician diagnosis of a UTI

g. Physician institutes appropriate therapy for

a UTI

II. Asymptomatic bacteriuria must meet at least one

of the following criteria:

1. Patient has an indwelling urinary catheter

within 7 days before the culture and patient

has a positive urine culture, that is �105

cfu/mL with 2 or less bacterial species, andpatient has no fever (�38�C), urgency,

frequency, dysuria, or suprapubic tenderness.

2. Patient has not had an indwelling urinary

catheter within 7 days before the first positive

culture and patient has had at least 2 positive

urine cultures, that is, �105 cfu/mL with 2 or

less bacterial species and patient has no fever

(�38�C), urgency, frequency, dysuria, or

suprapublic tenderness.

UTI, urinary tract infection.

REILLY ET AL AACN Advanced Cri t ical Care

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Evidence-based Practice:Strategies to Decrease UrinaryTract InfectionsEvidence-based guidelines for the care andmaintenance of foley catheters are publishedby a number of different groups,6,9,10,11 includingthe CDC,11 Joanna Brigg’s Institute,9 and theAssociation of Practitioners in Infection Con-trol (APIC).6 Whereas these national guide-lines are very similar, there are some differ-ences in their recommendations (Table 2). Forexample, the CDC recommends properly se-curing the catheter to the leg, but JoannaBrigg’s Best Practice document does not ad-dress this issue. The CDC also recommendssterile technique during insertion, but JoannaBrigg’s states that sterile technique does not re-duce the risk of UTI.12

In an effort to base nursing practice on thebest supporting evidence at our institution,changes were implemented to decrease the in-cidence of catheter-associated UTIs. Productevaluation, practice issues, and education wereintegral to implementing change. There wereseveral studies that supported the use of silver-alloy catheters for the reduction of catheter-as-sociated UTIs13–16 and a meta-analysis of the re-search supported their use.17 Silver-alloycatheters were purchased and these cathetershave become the standard of care in this facil-ity. Studies have shown the benefit of a closeddrainage system.18–20 Catheter kits were imple-mented to provide a closed system. To furtherensure a closed system, a bladder scanner waspurchased to scan the bladder and confirmwhether a decrease in urine output is due tocatheter blockage or reduced urine in the bladder.21 This minimizes unnecessary irriga-tion that would require a break in the closedsystem. Once these changes were initiated, se-curement devices were addressed. CDC guide-lines strongly recommend the practice of prop-erly securing the foley catheter to the leg.11

Foley catheter leg-securing devices were usedto ensure an adequate securing system.

Education was the next focus. There is vari-ance regarding care practices of foleycatheters, and they are frequently not evi-dence-based.22,23 In one study,24 an estimated53.1% of patients with a catheter-associatedUTI had a “preventable mistake” in either theindications for or the management of thecatheter. Education regarding the care andmaintenance of foley catheters is recom-mended and has been shown to reduce

catheter-associated UTIs.25 An educationalprogram was developed by the ICU nurse educators in conjunction with the InfectionControl Department. A foley catheter educa-tional video tape was purchased and all ICUnurses viewed the tape and completed aposttest. The video tape was kept in the con-ference room where the nurses could view it attheir convenience. All new hires were also re-quired to view the tape.

The accumulated results of these initiativesdecreased the incidence of catheter-associatedUTIs by approximately 50% from 1999 to2003. According to the NNIS,6 these ratesraised our unit to the top 50th percentile (thismeans that 50% of the hospitals reporting hadrates higher). Even though this was an accept-able improvement, further reductions in UTIincidence were desired. Recommendations inthe literature stress the importance of decreas-ing the unnecessary use of indwelling foleycatheters.6,11,26–28 Duration of catheterizationhas shown to be the major independent riskfactor for catheter-associated UTIs,29–30 andthere is some evidence that earlier removal ofurinary catheters is associated with a shorterlength of stay.31

The ratio of foley catheter days to patientdays is part of the required data submitted tothe NNIS; these data are collected and calcu-lated monthly. The NNIS comparative bench-mark was approximately 82% to 84% (foleycatheter device days/patient days) and themonthly average for this ICU was 92% to100%. Previous attempts to decrease foleycatheter days through education, charge nursesurveillance, and the use of a daily goals sheet32

in our ICU were unsuccessful. In an effort todecrease foley catheter-related complications(UTIs and urosepsis), our 22-bed, medical,surgical, and trauma ICU focused on reducingthe number of foley catheter device days in thecritical care setting.

Team Development to ChangePracticeA multidisciplinary team is imperative to thesuccess of any quality improvement or evi-dence-based change in practice. The multifac-eted complexity of a critically ill patient re-quires that all members caring for that patientenvision the same goals. All disciplines thatmay be affected by these practice changes mustbe consulted in the development phase, sothere is less resistance in the implementation


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Table 2: Comparison of Evidence-based Practice Guidelines to Decrease Urinary TractInfection Rates

Centers for Disease Control and Prevention11

and Association of Practitioners in Indicator Infection Control6 Guidelines* Joanna Briggs9 Guidelines*

Personnel

Catheter use

Catheter

insertion

Closed sterile

drainage

Irrigation

Specimen

collection

Spatial

separation

Urinary flow

Only trained professionals/personnel,

trained family members, trained patients

should handle the catheter (Category I);

Regular periodic inservices (Category II);

Effective hand washing before and after

handling (Category I).

Use only when necessary (Category I);

Consider other catheters such as condom

catheters, suprapubic, and intermittent

when appropriate (Category III);

No specific recommendation as to the

material used for catheter design.

Aseptic technique/sterile equipment

(Category I);

Smallest bore catheter possible (Category II);

Proper securement (Category I).

Sterile, continuously closed drainage

system (Category I);

If break in aseptic technique or

disconnection, the catheter should be

changed (Category III).

Intermittent irrigation should be avoided

unless obstruction (Category II);

Use aseptic technique to irrigate (Category I);

If frequent irrigation is needed, change

catheter (Category II).

Collect small volumes from port using

aseptic technique (Category I);

Collect larger volumes from drainage bag

using aseptic technique (Category I).

Infected and uninfected patients should not

share the same room (Category III).

Unobstructed flow should be maintained

*No kinks in tubing

*Empty regularly with separate container

(be sure spigot does not touch sides on

non-sterile container)

*Keep drainage bags below bladder at all

times (Category I)

No Level I or II evidence-supported

education; however, there were 3

studies that indicated that continuous

reinforcement through education may

reduce UTIs (Level III).

One study suggests intermittent

catheterization of postop patients

may reduce UTI, but further studies

needed to support this (Level II);

Silver impregnated catheters may

reduce UTI in certain patients, but

further research needed and cost

effectiveness is unclear (Level I).

Aseptic technique does not reduce UTI

(Level II);

No recommendation of catheter bore;

No recommendation for securement.

Sterile, continuously closed drainage

system recommended. but cost

should be considered (Level I).

Based on insufficient evidence, no

recommendation of irrigation could

be given.

No discussion.

No recommendation given.

No discussion

(continues)


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phase. A critical care nurse and infection con-trol nurse were chosen as project leads by thechief nursing officer, ICU manager, and infec-tion control manager, and the organization’sSix Sigma Department was consulted to guidethe project. Intensive care unit nurses, criticalcare physicians, nephrologists, urologists, in-fectious disease physicians, the ICU nursemanager, and representatives from the Infec-tion Control Department were consulted todevelop criteria for foley catheter use in thispatient population.

A thorough review of the literature regard-ing indications for the use of foley catheters inthe critical care setting and other patient popu-lations was conducted.33–35 After reviewing theliterature with various nurses and physicians,criteria for appropriate foley catheter use weredetermined (Table 3). These ICU nurses andphysicians were doubtful that many patients inthis population could tolerate the removal offoley catheters. They were convinced that allthe ICU patients would meet these indicationsfor appropriate catheter use. The team leadersagreed that the results of this project may con-firm these beliefs, but they persisted. The foleycatheter criteria were approved by the ICUCommittee and the Infection Control Commit-tee and presented at other appropriate meet-ings, such as the medical and surgical business

meetings and the ICU shared governance meet-ing. It was important to ensure that the goalswere communicated throughout the organiza-tion to reduce resistance during the pilot phase.

Determining the Baseline forFoley Catheter Device DaysIn the early stages of the project, the measure-ment unit of foley catheter device days was de-fined. A device day began when a patient wasadmitted to the ICU with an indwelling foleycatheter intact or one was inserted in the ICU.A device day ended when the foley catheterwas discontinued in the ICU or the patient wasdischarged from the ICU with the foleycatheter intact. After conducting a sample sizecalculation, it was determined that 123 patientcharts were needed for preintervention data. Arandomized, convenience sample of 124 pa-tient charts was gathered by the medicalrecord department. Exclusion criteria includedpatients who had expired in the ICU and pa-tients with no foley catheter. A fishbone dia-gram (Figure 1) was developed by nursing staffduring small, informal brainstorming sessionsto determine possible causes of prolongedcatheterization in the ICU. Data were collectedto determine baseline foley catheter devicedays and to determine possible causal factorsof prolonged catheterization.

Table 2: Comparison of Evidence-based Practice Guidelines to Decrease Urinary TractInfection Rates (Continued )

Centers for Disease Control and Prevention11

and Association of Practitioners in Indicator Infection Control6 Guidelines* Joanna Briggs9 Guidelines*

Meatal care

Catheter change

interval

*Centers for Disease Control and Prevention categories: Category 1: strongly recommended for adoption, Category 2: moderatelyrecommended for adoption, Category 3: weakly recommended for adoption; The Joanna Briggs Institute’s levels of evidence(recommendations are based only on randomized controlled trials): Level I: evidence obtained from a systematic review of all relevantrandomized controlled trials, Level II: evidence obtained from at leased one properly designed randomized controlled trial, Level III: (1)evidence obtained from well-designed controlled trials without randomization, (2) evidence obtained from well designed cohort or casecontrol analytic studies preferably from more than one center or research group, and (3) evidence obtained from multiple time series with orwithout the intervention. Dramatic results in uncontrolled experiments; Level IV: opinion of respected authorities, based on clinical experience,descriptive studies, or reports of expert committees.

Routine daily cleaning with povidone-

iodine solution or daily cleansing with

soap and water are not recommended

(Category II);

No further recommendations.

Do not change indwelling catheters at

arbitrary fixed intervals (Category II).

No specific recommendations other

than “good personal hygiene”;

Routine use of povidone-iodine,

neomycin polymixin, beta-bacitracin,

polyantibiotic products were not

recommended (Level I).

Routine monthly catheter changes

supported by one study (Level II);

No recommendation given.


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The data collection tool was created (Table 4)and evaluated by the team leaders to ensure thatthe measurement system was accurate. Therewere several problems encountered. The twodata collectors (the team leaders) were gather-ing the data from two different sources whichadded some variation to the data when com-pared. The infection control nurse was docu-menting the date and time of admission into theICU with the foley catheter by using the hospi-tal computer system and the critical care nursewas using the ICU flowsheet. This caused varia-tion in the data that could affect results. Afterthis was identified, consistency was established.There was also some variation when calculatingthe length-of-stay and device day measures. Inorder to obtain accuracy and consistency thedata collection tool was created in excel andformulas were used to provide accurate calcula-tions. It is crucial that the accuracy of the data

collection tool be determined and the process ofdata collection be defined by comparing andevaluating data collected on a small pilot sam-ple, in this case, 10 patient charts.

After adequacy of the measurement systemwas determined, the charts were reviewed ret-rospectively through a manual data extractionprocess by the team leaders. The preinterven-tion mean foley catheter device days was de-termined to be 4.72, with a standard deviation(SD) of 7.67 (n � 124). Foley catheter deviceday were similar to the average ICU length ofstay in our unit, indicating that the majority ofthe patients had the continued use of thecatheter for most of the ICU stay.

The next step was to analyze the multiplefactors that could contribute to the prolongeduse of foley catheters. During the baselinechart review, data was collected to determine:age of patient, physician service, delayedcatheter removal after a written physician’s or-der to discontinue, and length of time the pa-tient met the criteria for the foley catheter (ac-cording to the criteria developed by this unit).A regression analysis found that 71.9% (P � .05) (n � 124) of the process variationwas due to the fact that the catheters were notbeing removed once criteria for removal wasmet. This was the only significant factorshown to contribute to prolonged foleycatheterization and became the focus of our ef-forts to further reduce the incidence of UTIs.

Engaging the Staff to BrainstormSolutions Signs were posted in the ICU conference roomto invite staff to be a part of the solution to de-crease UTIs by participating in brainstormingsessions during several ICU luncheons. Staffcontinued to be doubtful that many of thecatheters in the ICU patients could be removedand they were concerned about the effects itmay have on their practice. Some of their con-cerns were patient focused, such as the poten-tial increase in decubiti and the inability to ac-curately determine intake and output; somewere staff focused, such as the resistance tochange the current standard of practice in theICU; and some were process focused, such asthe inability to physically manage patientswithout catheters due to the current challengesthat their workload requires and the complex-ity of patient assignments.

The team leaders promoted problem-solvingtechniques by working through these issues

Table 3: Criteria Indicating AppropriateFoley Catheter Use in a Medical/Surgical/Trauma Intensive Care Unit

Major Category

• 24-hour urine collection

• Epidural catheter

• Neurological head injury

• Skin breakdown in sacral area

• Spine X-rays not cleared

• Acute neurogenic bladder

• Clinical need for a foley, such as chemically

paralyzed and sedated

• Crush injury

• Pelvic fracture

Separate Category

• Hemodynamically unstable needing accurate

input and output monitoring

• Hourly intake and output monitoring

• Inability to void

• Strict input and output monitoring required and

patient incontinent

Surgical Category

• Gastric bypass surgery

• Renal surgery


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and allowing the nurses to discuss their con-cerns through continued brainstorming solu-tions. There were suggestions to have thecharge nurses, physicians, and/or residents con-duct surveillance for catheter removal but thatwas rejected by the nursing staff. The nurses in-sisted that they have control of surveillance forcatheter removal and requested a decision-making algorithm to help guide their practice.It was decided to implement nurse-driven sur-veillance of criteria-based foley catheter guide-lines through the use of a criteria-based foleycatheter checklist and a foley catheter decision-making algorithm. The checklist was createdby the nursing staff (Figure 2) and the algo-rithm was created by the team leaders with in-put from the multidisciplinary team (Figure 3).The nurses also suggested that an educationalprogram be developed and implemented. Theeducational program included complicationsrelated to prolonged catheterization and guide-lines for appropriate foley catheter use. Theplans for education and project implementationwere presented for approval at the ICU and Infection Control Committee meetings. Institu-tional Review Board (IRB) approval was obtained.

An educational binder was created and uti-lized to educate ICU staff including nurses,residents, and physicians. The education was

Figure 1: Fishbone diagram depicting possible causal factors for prolonged foley catheter device

days.

Table 4: Foley Catheter Data Collection Tool

• Medical record number

• Age

• Service

• Date/time of intensive care unit (ICU) admission

• Date/time of ICU discharge

• ICU length of stay (calculated from 2 prior variables)

• Presence of foley on admission

• Date/time patient came to ICU with a foley or

when foley inserted in the ICU

• Date/time of foley catheter removal or patient

transferred with foley in place

• Foley catheter device days

• Date/time patient met criteria for catheter removal

• Number of device days criteria met


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provided by the team leaders during multipleone-to-one in services for all shifts over a 2-week period. These in services were conve-niently located at the nurse’s station on a dailyinformal basis. A log was kept to ensure thatall staff completed the inservice. The educa-tion included risks associated with prolongedcatheterization such as UTIs, urosepsis, andmortality rates associated with urosepsis. Italso described appropriate indications for fo-ley catheter use in the ICU through the use ofthe criteria-based foley catheter guidelines,and explained how to use the foley catheterdecision-making algorithm which was placedin the bedside binders for easy referral.

The pilot was implemented upon comple-tion of the staff education. A daily checklistfor every ICU patient with a foley catheter wascompleted by the nurses. The checklist func-tioned as a trigger to determine the necessity ofthe catheter. If a patient did not fit the criteriathe nurse would contact the physician to rec-ommend catheter removal. The charge nursewas responsible for distribution and collectionof the daily checklist

Results and Patient OutcomesAfter implementation of the pilot, a conven-ience sample of 83 charts were reviewed in thesame manner as the preintervention study. The

FIGURE 2: Intensive care unit foley catheter checklist.

ICU Foley Catheter Checklist

Date: _______________ MR#:_________________

ICU room no.: ____________

Does your patient have a foley catheter? Y N

Is there an ICU order for the catheter? Y N

Which service is your patient on? Medical Surgical Trauma

Which criteria for appropriate use of foley catheters does your patient meet?

_____ 24-hour urine collection_____ Epidural catheter_____ Head injury_____ Skin breakdown_____ Spine not clear_____ Acute neurogenic bladder_____ Clinical need, ie, chemically paralyzed and sedated_____ Crush injury_____ Pelvic fracture_____ Hemodynamically unstable needing accurate input and output (I&O)_____ Hourly I&O_____ Inability to void_____ Strict I&O and incontinent_____ Gastric bypass surgery_____ Renal/urology surgery_____ Colorectal surgery (questionable after 48-hour postop)_____ Abdominal/pelvic surgery (questionable after 48 hour postop)

If none of the above criteria are met, was an order for discontinuation of foley obtained? Y N


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postintervention mean foley catheter devicedays were 2.98, with a SD of 3.17 (n � 83).This was a decrease from preintervention foleycatheter device days of 4.72, with a SD of 7.67(n � 124).

A two-sample t-test was conducted on thepre- and postintervention means and a test forequal variance was completed for the pre- andpostintervention standard deviations. Thedata showed a statistically significant decrease

Figure 3: Decision-making algorithm to use for determining the appropriate use of a foley catheter.

Reprinted with permission from the Morristown Memorial Hospital Intensive Care Unit, Morristown, NJ.

D/C, discontinue.

Patients Without a Foley Catheter

1. Assess patient and consider the following every 2 hours or more frequently as needed.• Check for incontinence or offer bedpan.• Assess for bladder distention.• Turn and reposition and assess skin.• Use a protective moisture barrier.

2. If no voiding after 6 hours, utilize the bladder scanner to evaluate amount of urine inbladder:• If greater than 300 mL or patient complains of discomfort and/or bladder distension on

palpation, call physician for straight catheter order X1.• If less than 300 mL, reevaluate every 2 to 3 hours.

3. If unable to void a second time, call MD for an order to insert a foley catheter.4. Call physician if no voiding after 12 hours.5. Consider twice a day or daily intermittent catheterization for patients with low urine

output rather than a foley catheter.


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in the means (P � 0.38; t-value � –2.10; df �176; n � 83). There was a 59% reduction inthe pre- and postintervention standard devia-tion, but the test for equal variance did notprove a statistically significant difference.However, the improvement has a practicalclinical significance that should be considered.Another important clinical consideration wasthat at preintervention, only 6% of the foleycatheters were removed before the patient wastransferred out of the ICU, but at postinter-vention, 20% of the foley catheters were re-moved prior to transfer out of the ICU. Whena patient leaves the ICU without the foleycatheter, chances are the foley catheter will notbe reinserted on the general patient care unit,and it is likely that hospital-wide, catheter-associated UTIs have also been affected.

In the control phase of the project, a randomsample of 30 patient charts was reviewedmonthly to ensure that the improvement wassustained. This phase continued for 1 yearpostintervention. The monthly control data re-vealed intermittent months that the improve-ment was sustained and some months that theimprovement was not. Every month, the teamleader would post the results with either a con-gratulatory note for a job well done or a re-minder that the criteria needs to be followedand the guidelines enforced. Catheter-associatedUTI rates were also posted in the same manner.

One year postintervention, the catheter-as-sociated UTI rates in this unit decreased by33% and the device-day to patient-day ratiodecreased from an average of 96% to an aver-age of 86%, with a decrease of 408 foleycatheter device days. There was some concernthat lowering the device days may superficiallyinflate the UTI rate because it would lower the

denominator (the NNIS calculates UTI ratesby calculating UTIs/1000 foley days). A de-crease in device days could potentially makeeach UTI account for a higher NNIS rate. Wewere aware of the potential for this to occur, butfelt that the benefits of removing catheters out-weighed the risks of potentially inflating infec-tion rate percentages. It is also important to notethat the improvement achieved is even more im-pressive with this observation considered.

Implications of This ProjectAlthough a large percentage of the patientsmet the criteria for continued foley catheteruse, there was a subcategory that, prior to in-tervention, had a continued use of the foleycatheter when it was not warranted. Bothphysicians and nurses have an increasedawareness of what constitutes appropriate in-dications for foley catheters and the impor-tance of removing them when they are nolonger medically indicated. Similar resultshave been obtained by other studies. Onestudy36 implemented a written protocol for au-tomatic foley catheter removal by nursing staffin 3 intensive care units. In another study,37 anurse placed a daily reminder in the chart toremove the foley catheter after 5 days.

In addition to the nurse-driven, criteria-based foley catheter guidelines, a line has beenadded to the ICU Admission Order Set for thisunit. The additional line asks the “reason” forthe foley catheter, so that physicians will question the necessity of the catheter beforewriting the order. There is an evidence-basedinitiative underway to extend this project to thegeneral medical/surgical patient care units andto formulate hospital-wide, evidence-basedguidelines for foley catheter indications andcare. At present, this organization has no writ-ten policy for the care and indications for foleycatheters. Nursing practice is guided by CDCguidelines11 and Lippincott Procedure Manualguidelines,38 which recommends and refers tohospital-specific guidelines. The nursing care inthis organization is governed by a Shared Gov-ernance Model. This project has been presentedto the Shared Governance Practice Council andthe Advanced Practice Nurse Committee, andthe development of a hospital-wide foleycatheter initiative is in the beginning stages.

ConclusionsThe implementation of a set of evidence-basedpractice guidelines for foley catheter use and

Nurse: “While assessing my patient at 0730, Irealized she did not meet the criteria for thefoley catheter so I initiated a call to the physicianto recommend catheter removal. I discontinuedthe catheter by 0830 and the patient couldn’tthank me enough. She was diagnosed with con-gestive heart failure and was capable of using abathroom and/or a bedpan and couldn’t under-stand the necessity of the catheter. The patientsaid, ‘The catheter was very uncomfortable andit was a tremendous relief to have it removed.’She was very grateful.”

Box 1: PATIENT RESPONSE TO FOLEYREMOVAL


282

care resulted in a reduction in UTIs and foleycatheter device days in a 22-bed, medical/surgical ICU. The development of a set of criteria and an algorithm for appropriate foleycatheter use, as well as staff education, werefound to be effective strategies to changingpractice and improving patient outcomes.

AcknowledgmentsSpecial thanks to the following individuals forassistance with this project: Atlantic HealthSystem Six Sigma Department, especially Lou Gorga, Mark Jannone, Fran Schuster,RN, BSN, CCRN, CPHQ; Chief Nursing Officer Trish O’Keefe, RN, MSN, CNA; JohnSalaki, MD; Erwin Oei, MD; Louis DiFazio,MD; Rebecca Griffith, MD; Tony ForresterRN, PhD; and especially the nursing staff inthe ICU.

References

1. Infection Control Today Editors. Expert discusses strate-gies to prevent CAUTIs (interview with Dr RabihDarouiche). Infection Control Today. 2005;9(6):74–82.Available at: http://www.infectioncontroltoday.com/articles/561feat 2.html. Accessed June 23, 2006.

2. Goolsarran V, Katz T. Do not go with the flow, rememberindwelling catheters. J Am Geriatr Soc. 2002;50:1739–1740.

3. Wagenlehner F, Naber K. Hospital acquired urinary tractinfections. J Hosp Infect. 2000;463:171–81.

4. Horan TC, Gaynes RP. Surveillance of nosocomial infec-tions. In: Mayhall CG, ed. Hospital Epidemiology and In-fection Control, 3rd ed. Philadelphia: Lippincott Williams& Wilkins, 2004; 1659–1702.

5. National Nosocomial Infections Surveillance System.National nosocomial infections surveillance (NNIS) sys-tem report, data summary from January 1992 throughJune 2004. Am J Infecton Control. 2004;32:470–485.

6. Leithauser D. Urinary tract infections. Assoc Profession-als Infect Control Epidemiol. 2004;25:1–15.

7. Tambyah P, Knasinski V, Maki D. The direct costs ofnosocomial catheter associated urinary tract infection inthe era of managed care. Infect Control Hosp Epidemiol.2002;23;1:27–31.

8. McConnel, E. New catheters decrease nosocomial infec-tions. Nurs Manag. 2000;31(6):52,55.

9. Dunn S, Pretty L, Reid H, Evans D. Management of shortterm indwelling urethral catheters to prevent urinarytract infections: a systematic review. Joanna Briggs In-stitute. 2000;6:1–64.

10. Rosser C, Bare R, Meredith J. Urinary tract infections inthe critically ill patient with urinary catheter. Am J Surg.1999;177(4):287–290.

11. Wong ES, Hooten TM. Guidelines for prevention ofcatheter associated urinary tract infections. In: Guide-lines for the Prevention and Control of Nosocomial Infections. Atlanta: Centers for Disease Control and Prevention; 1982:1-50. Available at: http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html. Accessed June23, 2006.

12. Gray M. What nursing interventions reduce the risk ofsymptomatic urinary tract infection in the patient withan indwelling catheter? J Wound Ostomy ContinenceNurs. 2004;31(1):3–13.

13. Karchmer T, Giannetta E, Muto C, Strain B, Farr B. A ran-domized crossover study of silver-coated urinarycatheters in hospitalized patients. Arch Intern Med.2000;160(21):3294–3298.

14. Lai K, Fontecchio S. Use of silver-hydro gel urinarycatheters on the incidence of catheter-associated uri-nary tract infections in hospitalized patients. Infect Con-trol. 2002;30:221–225.

15. Plowman R, Graves N, Esquivel J, Roberts J. An eco-nomic model to assess the cost and benefits of the rou-tine use of silver alloy coated urinary catheters to reducethe risk of urinary tract infections in catheterized pa-tients. J Hosp Infect. 2001;48(1):33–42.

16. Reiche T, Lisby G, Jorgensen S, Christensen A, NordlingJ. A prospective controlled randomized study of the ef-fect of a slow release silver device on the frequency ofurinary tract infection in newly catheterized patients.BJU Int. 2000;85(1):54–59.

17. Brosnahan J, Jull A, Tracy C. (with Cochrane Inconti-nence Group). Types of urethral catheters for manage-ment of short-term voiding problems in hospitalizedadults. Cochrane Database Syst Rev. 2005; Volume 1:[Data File]. Sidney, Australia.

18. Gillepsie W, Lennon G, Linton K, et al. Prevention of uri-nary tract infection by means of a closed drainage into asterile plastic bag. BMJ. 1967;3:90–92.

19. Kunin, C, McCormack R. Prevention of catheter-inducedurinary-tract infections by sterile closed drainage. NEngl J Med. 1966;274:1155–1161.

20. Thorton G, Andriole V. Bacteriuria during indwellingcatheter drainage-II: effect of a closed sterile drainagesystem. JAMA. 1970;214:339–342.

21. Sulzbach-Hoke L, Schanne L. Using a portable ultra-sound bladder scanner in the cardiac care unit. Crit CareNurse. 1999;19(6):35–39.

22. Smith J. Indwelling catheter management from habit-based to evidence-based practice. Ostomy Wound Man-age. 2003;49(12):34–35.

23. Penfold P. UTI in patients with urethral catheters; an au-dit tool. Br J Nurs. 1999;8(6):362,364,366,368.

24. Bouza E, San Juan R, Munoz P, Voss A, Kluytmans J. AEuropean perspective on nosocomial urinary tract infections II: report on incidence, clinical characteristicsand outcome. Clin Microbiol Infect. 2001;7(10):532–542.

25. Rosenthal V, Guzman S, Safdar N. Effect of education andperformance feedback on rates of catheter associated uri-nary tract infection in intensive care units in Argentina. In-fect Control Hosp Epidemiol. 2004;25(1):47–50.

26. Cassidy M. Catheter care and the prevention of UTIs.World Irish Nurs. 2001;9(4):26.

27. Johnson J. Nosocomial and catheter-associated urinarytract infections. Assoc Pract Infect Control; Clin Syn-dromes. 2002;92:1–10.

28. Nicolle L. Catheter related urinary tract infection. DrugsAging. 2005;22(8):627–639.

29. Tissot E, Limat S, Cornette C. Risk factors for catheter-associated bacteriuria in a medical intensive care unit.Clin Microbiol Infect. 2001;20(4):260–262.

30. Melekos, M., & Naber, K. Complicated urinary tract infections. Int J Antimicrob Agents. 2000;15:2247–2256.

31. Griffiths R, Fernandez R. Policies for the removal ofshort-term indwelling urethral catheters. CochraneDatabase Syst Rev. 2005;1:[Data File].

32. Pronovost P, Berenholtz S, Dorman T, Lipsett P, Sim-monds T, Haraden C. Improving communication in theICU using daily goals. J Crit Care. 2003;18(2):71–75.

33. Cravens D, Zweig S. Urinary catheter management. AmFam Physician. 2000;61(2):369– 376.

34. Gokula R, Hickner J, Smith M. Inappropriate use of uri-nary catheters in elderly patients at a midwestern com-munity teaching hospital. Am J Infect Control. 2004;32(4):196–199.


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35. Marklew A. Urinary catheter care in the intensive careunit. British Association of Critical Care, Nursing in Criti-cal Care. 2004;9(1):21–27.

36. Dumigan D, Kohan C, Reed C, Jekel J, Fikrig M. Utilizingnational nosocomial infection surveillance system datato improve urinary tract infection rates in three intensivecare units. Clinical Performance and Quality Healthcare.1998;6(4):172–178.

37. Huang W, Wann S, Lin S, Kunin C, Kung M, Lin C, et al.Catheter-associated urinary tract infections in intensivecare units can be reduced by prompting physicians toremove unnecessary catheters. Infect Control Hosp Epidemiol. 2004;25(11):974–978.

38. Schilling, J. Nursing Procedures and Protocols.Philedelphia, PA: Lippincott, Williams, & Wilkins;2003:495–503.

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