HFHS Orientation - Bladder Management PDF

## Policy This policy establishes procedures to reduce the risk of catheter-related UTI and follow CDC Guidelines by establishing a protocol for bladder management, removing unnecessary indwelling urinary catheters, and management of post urinary catheter removal urinary retention. The Center for D...

## Policy This policy establishes procedures to reduce the risk of catheter-related UTI and follow CDC Guidelines by establishing a protocol for bladder management, removing unnecessary indwelling urinary catheters, and management of post urinary catheter removal urinary retention. The Center for Disease Control (CDC) has recommended evidence-based criteria for the use and removal of indwelling urinary catheters as listed under the Procedure section below. The Bladder Management/Urinary Catheter Alleviation Navigation Protocol (UCANP) can be used in conjunction with the removal of an indwelling urinary catheter OR for urinary retention/inability to void (see Protocol below). ## Procedure ### Indwelling Urinary Catheter Management Initiate Indwelling Urinary Catheter Removal Guidelines for patients that do not meet CDC criteria CDC.GOV CAUTI Guidelines. #### Indications for urinary catheter: - Acute urinary retention (greater than 350 ml via bladder scan), bladder outlet obstruction, or neurogenic bladder. - Need for accurate measurement of output in critically ill patients. - Perioperative use for selected surgical procedures (e.g. urologic surgery, prolonged duration surgery, large volume infusion or diuretics during surgery, need for intraoperative monitoring of urinary output). - To assist healing of open sacral or perineal wounds (stage III, stage IV) in incontinent patients. - Prolonged immobilization (e.g. potentially unstable thoracic or lumbar spine, multiple traumatic injuries). - Hospice or Palliative care #### Inappropriate uses of indwelling catheters which have been identified by the CDC include: - Catheters used as a substitute for nursing care for a patient with incontinence. - Catheters used to obtain a urine specimen for culture of other diagnostic tests when the patient can voluntarily void - For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or continuous structures, prolonged effect of epidural anesthesia). #### Exclusions from the Catheter Removal Guidelines: Certain patients or groups of patients are considered appropriate for use of an indwelling urinary catheter as identified by the CDC Guidelines. These patients will be EXCLUDED from the Catheter Removal Guidelines: - Patients whose catheter was placed by urology service, including coude, council, hematuria catheters, or catheters placed via cystoscopy. - Patients with Epidural/Spinal catheters until the effects of the anesthesia have resolved. - Recent Renal transplant recipients - Recent pelvic, bladder or urethral surgery by Gynecology/Gynecology-Oncology or Urology - All patients under 15 years of age In limited cases, where providers think a patient will benefit from the use of an indwelling urinary catheter, but do not meet CDC criteria, they may write an order to continue the use of the catheter. ### Procedure #### Assessment - The RN will assess the patient to determine if the criteria for an indwelling urinary catheter are met. - If the patient meets the indwelling urinary catheter criteria, an ongoing assessment will be completed to assure that the criteria continue to be met, and the catheter will be discontinued as soon as possible. - If the patient DOES NOT MEET the indwelling urinary catheter criteria, the RN should assess for other potentially valid reasons to continue the catheter (long-term chronic indwelling catheter). - If the RN determines that there is no valid reason to continue use of the indwelling urinary catheter, the indwelling urinary catheter removal guidelines should be initiated. #### Management - The RN will discontinue the indwelling urinary catheter following the CDC Guidelines noted above. - The RN will place the EPIC order for "Bladder Management/UCANP", per protocol, no co-sign required. - The RN will monitor the patients voiding status after removal of catheter and follow the Bladder Management algorithm (UCANP): (See Attachment and steps outlined under bladder management/UCANP below). . The RN will document the PVR and interventions in the electronic health record. ### Bladder Management / UCANP The Bladder Management/Urinary Catheter Alleviation Navigation Protocol (UCANP) follows the following pathway: |No Void in 4 Hours|Bladder Scan |Pathway|Spontaneous Void|Bladder Scan for Post Void Residual (PVR)| |---|---|---|---|---| | | | | |Volume less than or equal to 400 mL| | | Volume greater than or equal to 400 mL | | |Volume greater than or equal to 400 mL| | | | | |PVR less than or equal to 100 mL - Pathway Stops - Monitor urine output per unit standard | | | | | |PVR 100 mL - 400 mL - Scan patient in 4 hours and restart pathway| | | | | |PVR greater than or equal to 400 mL - Initiate IC and restart pathway;| | | | | Spontaneous void | | | | | | | | | | | | | | | | | | | | | |Volume less than or equal to 400 mL | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | **Avoid indwelling catheter re-insertion unless it is medically necessary** #### A. Assess patient for signs of urinary retention or inability to void. * **Indications for bladder scan** - **Urinary Retention/Inability to Void** - If the patient is unable to void or when there are signs/symptoms of bladder distention present (i.e. discomfort, pain, feeling of fullness and/or palpable bladder). - Post indwelling urinary catheter removal to monitor for urinary retention. - **Post Void Residual (PVR)** - Must be checked within 20 minutes of void. * **Indication for Intermittent Catheterization (IC)** - **Urinary retention/inability to void with a PVR greater than or equal to 400 mL and/or** - **Signs/Symptoms of bladder discomfort, pain, feeling of fullness, and/or palpable bladder.** #### B. Follow Bladder Management pathway, as indicated. * **If at any time in the pathway, the patient becomes symptomatic (c/o suprapubic pain, tenderness, or discomfort), bladder scan and perform IC ASAP to avoid bladder injury.** #### 1. If a patient is unable to void, has urinary retention, or has had an indwelling catheter removed with no void within 4 hours. * **Bladder scan patient** - **Volume greater than or equal to 400 mL** - **Initiate IC and restart UCANP pathway.** - **Volume is less than 400 mL.** - **Bladder scan again in 4 hours and encourage spontaneous void.** - **If no void within 8 hours, bladder scan again in 4 hours and encourage spontaneous void (total of 12 hours)** - **If volume at 12 hours still less than or equal to 400 mL, notify provider.** #### 2. Spontaneous Void occurs * **Bladder Scan for PVR (within 20 minutes of void)** - **PVR less than 100 mL** - **Pathway stops, monitor urine output per unit standard.** - **PVR greater than 100 and less than 400 mL** - **Scan every 4 hours and restart pathway.** - **PVR greater than or equal to 400 mL.** - **Initiate IC and restart pathway.** #### C. Continued IC * **At Henry Ford Hospital (HFH) Detroit, HF West Bloomfield, HF Macomb, and HF Wyandotte, if continued IC is needed for greater than or equal to 48 hours, notify provider.** - **Consider initiating Clean Intermittent Catheterization (CIC) teaching if appropriate.** - **Assess patient's physical and cognitive ability and family support.** - **Collaborate with Providers /Case Manager for CIC supplies for home.** - **Collaborate with Provider for outpatient urology follow-up as applicable.** * **At HF Jackson ONLY** - **If patient requires continuous straight catheterization every 4 hours for 24 hours, notify provider.** - **Consult Urology if patient is unable to void after requiring straight catheterization for 24 hours.** - **Order Urology consult "per protocol, no cosign required."** - **Choose "consult and manage" for Urology consult.**