Hospitals in pursuit of excellence

Nurse-driven Protocol for Urinary Catheter Removal

A nurse-driven protocol was implemented to increase the staff’s awareness on the appropriate indications of an indwelling urinary catheter to reduce the  use of indwelling urinary catheters and catheter-associated urinary tract infections (CAUTI).

After receiving education, nursing staff was charged with completing the review of need forms daily for each patient with a urinary catheter. According to the protocol, if the patient does not meet the requirement for a urinary catheter, it is discontinued without a physician order.

Although the hospital did not decrease the prevalence rate for urinary catheter days, the use of urinary catheters was appropriate and the rate of CAUTI had decreased.

This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state. These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Award recipients achieve measurable and meaningful progress in providing care that is:

• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered

(The Institute of Medicine's six aims for improvement.)