LWW/JNCQ
JNCQ-D-13-00096
May 12, 2014
20:9
J Nurs Care Qual Vol. 29, No. 3, pp. 245–252 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Implementation of a Nurse-Driven Protocol to Prevent Catheter-Associated Urinary Tract Infections Irene Alexaitis, DNP, RN, NEA-BC; Barbara Broome, PhD, RN, FAAN This article describes a quality improvement project to decrease catheter-associated urinary tract infections (CAUTIs) at an academic medical center. A criteria-based, nurse-driven protocol for discontinuation of indwelling catheters and use of bladder ultrasonography in conjunction with intermittent catheterizations was the foundation for change. The CAUTI rate, the number of CAUTIs, cost of medications and supplies associated with treating CAUTIs, catheter duration, and intensive care unit length of stay decreased after protocol implementation. Key words: bladder ultrasound, catheter-associated urinary tract infections, intermittent catheterization, nursedriven protocol, quality improvement, urinary tract infections
A
LTHOUGH national guidelines have been developed for the prevention of hospitalacquired catheter-associated urinary tract infections (CAUTIs) and strategies to prevent CAUTIs have been demonstrated through research, CAUTIs remain responsible for 40% of
Author Affiliations: Nursing and Patient Services, University of Florida (UF) Health Shands Hospital, Gainesville (Dr Alexaitis); and Community/Mental Health, Department of Nursing, University of South Alabama, Mobile (Dr Broome). Dr Alexaitis received funding to purchase equipment for the project from UF Health Shands Hospital and is employed by UF Health Shands Hospital. For the other author, none are declared. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). The authors declare no conflict of interest. Correspondence: Irene Alexaitis, DNP, RN, NEABC, Nursing and Patient Services, UF Health Shands Hospital, PO Box 100335, Gainesville, FL 32610 ([email protected]). Accepted for publication: November 24, 2013 Published ahead of print: January 2, 2014 DOI: 10.1097/NCQ.0000000000000041
all hospital-acquired infections.1 CAUTIs are responsible for 387 550 preventable hospitalacquired infections per year.2 While the Centers for Disease Control reported a 7% decrease in CAUTIs between 2009 and 2011, CAUTIs in intensive care units (ICUs) remained essentially unchanged over the same time period.3 CAUTIs are one of the most preventable hospital-acquired infections in the United States4 yet remain the most prevalent hospital-acquired infection in acute care hospitals.5 They increase cost and length of stay (LOS), cause patient discomfort, and can result in death.6 The Centers for Medicare & Medicaid deem CAUTIs preventable and no longer reimburse hospitals for cost associated with CAUTIs.1 In addition, The Joint Commission added the prevention of CAUTIs to the National Patient Safety goals in January 2013.7 Consequently, acute care organizations are motivated to prevent CAUTIs from a quality, accreditation, and financial perspective. AREA FOR IMPROVEMENT Guidelines for the prevention of CAUTIs were previously implemented at an academic 245
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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medical center in Florida. However, 140 CAUTIs were identified in 2012 at the academic medical center and goals for the prevention of CAUTIs had not been achieved in all nursing units. The highest CAUTI rates and catheter utilization were in the ICUs. The executive team at the medical center recognized the need to improve the safety, effectiveness, and efficiency of care for patients with respect to urinary catheter management and developed a strategic goal to prevent CAUTIs. The neurosurgical intensive care unit (NSICU) was selected for the quality improvement (QI) pilot project. Both CAUTI rates and catheter utilization rates in the NSICU exceeded National Health Safety Network (NHSN) benchmarks in 2012. CAUTI rates in the NSICU were 4.4, 8.5, 3.6, and 2.8 per 1000 catheter-days per quarter, respectively, in 2012 as compared with the NHSN 25th percentile of 1.3. In addition, the catheter utilization rate in the NSICU exceeded the NHSN 10th percentile benchmark of 58% for all 4 quarters in 2012, 62.1%, 63.1%, 64.2%, and 72%, respectively. In 2012, the NSICU accounted for 22.2% of hospital-acquired CAUTIs. After reviewing the retrospective data, development and implementation of a nursedriven protocol for urinary catheter management was undertaken to address the identified issues. Eight goals were identified to improve the safety, efficiency, and effectiveness of care for patients with indwelling catheters in the NSICU. Goals were to reduce (1) monthly CAUTI rates, (2) catheter utilization, (3) number of CAUTIs per month, (4) cost of supplies and medications associated with CAUTI treatment, and (5) LOS; (6) educate nurses on routine catheter care, bladder scanning, and a nurse-driven protocol; (7) achieve 95% compliance with routine catheter care; and (8) achieve 95% compliance with the nursedriven protocol for management of urinary catheters. Support for the project was obtained from the chief operating officer, chief medical officer, chief quality officer, and the chair of the
neurosurgical department. The NSICU nurse manager and clinical leaders championed the project. The chief nursing officer functioned as the project leader, and the clinical leaders and charge nurses in the NSICU facilitated the practice change. LITERATURE REVIEW A comprehensive review of the literature was conducted to find the best evidence for urinary catheter management and CAUTI prevention. The Nursing Reference Center, National Guideline Clearinghouse, Cochrane, PubMed, Cumulative Index to Nursing and Allied Health Literature, and DynaMed were searched using “prevention of catheter-associated urinary tract infections” as the search term. The GRADE8 criteria were used to evaluate the studies. Studies explored alternatives to indwelling catheters, routine catheter maintenance, protocols for catheter management, and reminders to physicians and nurses to remove catheters. Alternatives to indwelling catheters and routine catheter care Insertion of indwelling catheters should be considered after assessing all other alternatives.9-12 Alternatives to indwelling catheters include condom catheters and intermittent catheterization to avoid insertion of indwelling catheters and bedside ultrasound bladder scanners to limit needless catheterizations.9-12 In a meta-analysis of 4 studies, Palese and colleagues13 found utilization of bladder ultrasound procedures reduced CAUTI risks by 73% when compared with intermittent catheterizations and were effective in reducing needless intermittent catheterizations when urinary retention was a concern after early removal of indwelling catheters. Pratt and Pellowe9 and Gould and colleagues10 conducted systematic reviews of existing guidelines for insertion and maintenance of indwelling catheters. Findings supported existing approaches for urinary catheter insertion and maintenance.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00096
May 12, 2014
20:9
A Nurse-Driven Protocol for CAUTI Prevention Nurse-driven protocols
247
METHODS
14
Gotelli et al conducted a QI project in an acute care hospital using a nurse-driven protocol with criteria for insertion and removal of catheters when indications for indwelling catheters were no longer met. The project demonstrated a 7% decrease in catheter utilization after 3 months. However, CAUTI rates remained unchanged. Topal et al15 conducted an observational, prospective, cohort study using a nurse-driven, criteria-based, independent protocol to allow nurses to discontinue catheters and use bladder scanners to monitor for urinary retention. Eighteen months postintervention results demonstrated a 65% reduction in catheter insertions, 79% reduction in catheter utilization, 73% reduction of inappropriate catheter use, and an 81% reduction in CAUTIs per 1000 catheter-days from baseline.
Physician and nurse reminders Meddings et al16 conducted a systematic review and meta-analysis of 14 studies and found that CAUTI rates decreased 56% with physician and nurse reminders and prewritten stop orders to discontinue catheters in 11 studies reviewed. Catheter duration decreased by 2.16 days, and CAUTI rates decreased by 41% with stop orders. Blodgett17 conducted a systematic review of the literature and found that face-to-face reminders during physician-nurse rounds, paper-based checklist reminders, and educational reminders during rounds with educators significantly reduced catheter duration and CAUTIs. In summary, several strategies were effective for CAUTI prevention and decreasing catheter-days. Implementing alternatives to indwelling catheters, such as the use of condom catheters, bladder ultrasonography, and intermittent catheterizations, reduced CAUTIs and catheter-days. Furthermore, implementing nurse-driven protocols, stop orders to remove catheters, and reminders for nurses and physicians to remove catheters demonstrated a reduction in CAUTIs.
Setting The project was conducted at an academic medical center located in Florida. The QI project had institutional review board approval and was conducted in a 30-bed adult NSICU. Patients with neurosurgical and neurological conditions are admitted to the unit. Common diagnoses include aneurysms, arteriovenous malformations, central nervous system neoplasms, traumatic brain injuries, spinal cord injuries, hemorrhagic and ischemic strokes, and status epilepticus. Management of incontinence in the NSICU has been a challenge. Patients in the NSICU are neurologically impaired, comatose, and often ventilated causing a loss of bladder function. Furthermore, medications are frequently administered to induce diuresis in order to decrease cerebral edema caused by neurological injuries and neurosurgical procedures. Nurses are challenged to prevent skin breakdown and accurately monitor urine output without an indwelling catheter. An analysis of the NSICU revealed insufficient data regarding nurses’ knowledge of evidence-based practice guidelines for routine catheter maintenance, urinary catheter indications, bladder scanning, and intermittent catheterization. In addition, delays in removing catheters were occurring because nurses had to obtain a physician’s order before discontinuing urinary catheters when indications were no longer met, and compliance monitoring of evidence-based guidelines was inconsistent. Sample Patients in the NSICU with indwelling urinary catheters during the evaluation period (n = 183) were included in the sample. All registered nurses (n = 107) working in the NSICU were included. QI project The FADE18 QI methodology was used for the project. This methodology includes Focusing on the problem (CAUTIs); Analyzing
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
248
JNCQ-D-13-00096
May 12, 2014
20:9
JOURNAL OF NURSING CARE QUALITY/JULY–SEPTEMBER 2014
data (catheter utilization, CAUTIs, CAUTI rates, compliance with urinary catheter guidelines, and nurses’ knowledge of guidelines); Developing a plan to reduce CAUTIs; and Executing the plan and Evaluating results against targeted goals. Protocol development and implementation The team developed a QI plan that included an evidence-based, nurse-driven protocol for urinary catheter management to decrease CAUTIs. The plan addressed 6 objectives: protocol approval by NSICU stakeholders, education of nurses about alternatives to indwelling catheters and routine catheter care, education of nurses and physicians about the protocol, compliance monitoring to ensure adherence to the protocol and guidelines for routine catheter care, daily catheter rounds to assess the need for catheter continuation, and analysis of identified CAUTIs. The protocol was developed by the project leader on the basis of nurse-driven protocols and guidelines found in the literature, policies and procedures in the NSICU for urinary catheter management, and consultation with physicians and clinical nurse leaders in the NSICU and the chief of urology. Strategies identified in the literature to prevent CAUTIs and decrease catheter-days were incorporated into the nurse-driven protocol and included criteria-based discontinuation of catheters (stop orders), bladder ultrasonography to prevent needless catheterizations, and intermittent catheterizations to reduce indwelling catheter-days The protocol provided criteria for indwelling catheter use and directed nurses to discontinue indwelling catheters when criteria were no longer met. Indications for indwelling catheters included tissue plasminogen activator administration within 24 hours of catheter insertion, bladder outlet obstruction, acute urinary retention more than 48 hours, genitourinary or gynecological surgery, significant hematuria, a physician’s order to maintain a catheter for longer than the protocol, an unstable spinal fracture, a stage 2
or greater pressure ulcer, end-of-life/palliative care, hemodynamic instability more than 24 hours, and urine output of 250 mL or more per hour. Bladder ultrasonography and intermittent catheterizations Criteria for frequency of bladder ultrasound procedures and intermittent catheterizations were provided by the chief of urology and developed to minimize intermittent catheterizations and prevent damage to the bladder caused by urinary retention. The protocol was ordered by physicians on all NSICU admissions and enabled nurses to use intermittent catheterizations and insert and discontinue catheters on the basis of criteria. Nurses were directed to perform bedside bladder ultrasound procedures to monitor postvoid residuals to assess for urinary retention and perform intermittent catheterizations based on ultrasound readings. Bladder ultrasound procedures were required when a patient did not void in 4 hours, complained of bladder discomfort at any time, voided less than 250 mL, or was incontinent. Intermittent catheterizations were required when the postvoid residuals or bladder scan readings were greater than 250 mL. The goal of intermittent catheterizations was to restrict urine in the bladder to 250 mL or less; therefore, the frequency of intermittent catheterizations varied for each patient. Bladder ultrasound procedures and intermittent catheterizations were discontinued after 2 postvoid residual ultrasound readings of less than 100 mL for patients voiding 250 mL or more; however, nurses continued to monitor voiding every 2 to 4 hours for 24 hours. Nurses performed bladder ultrasound procedures and intermittent catheterizations and monitored urine output every hour for patients displaying indicators of incomplete bladder emptying (voiding
JNCQ-D-13-00096
May 12, 2014
20:9
J Nurs Care Qual Vol. 29, No. 3, pp. 245–252 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Implementation of a Nurse-Driven Protocol to Prevent Catheter-Associated Urinary Tract Infections Irene Alexaitis, DNP, RN, NEA-BC; Barbara Broome, PhD, RN, FAAN This article describes a quality improvement project to decrease catheter-associated urinary tract infections (CAUTIs) at an academic medical center. A criteria-based, nurse-driven protocol for discontinuation of indwelling catheters and use of bladder ultrasonography in conjunction with intermittent catheterizations was the foundation for change. The CAUTI rate, the number of CAUTIs, cost of medications and supplies associated with treating CAUTIs, catheter duration, and intensive care unit length of stay decreased after protocol implementation. Key words: bladder ultrasound, catheter-associated urinary tract infections, intermittent catheterization, nursedriven protocol, quality improvement, urinary tract infections
A
LTHOUGH national guidelines have been developed for the prevention of hospitalacquired catheter-associated urinary tract infections (CAUTIs) and strategies to prevent CAUTIs have been demonstrated through research, CAUTIs remain responsible for 40% of
Author Affiliations: Nursing and Patient Services, University of Florida (UF) Health Shands Hospital, Gainesville (Dr Alexaitis); and Community/Mental Health, Department of Nursing, University of South Alabama, Mobile (Dr Broome). Dr Alexaitis received funding to purchase equipment for the project from UF Health Shands Hospital and is employed by UF Health Shands Hospital. For the other author, none are declared. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). The authors declare no conflict of interest. Correspondence: Irene Alexaitis, DNP, RN, NEABC, Nursing and Patient Services, UF Health Shands Hospital, PO Box 100335, Gainesville, FL 32610 ([email protected]). Accepted for publication: November 24, 2013 Published ahead of print: January 2, 2014 DOI: 10.1097/NCQ.0000000000000041
all hospital-acquired infections.1 CAUTIs are responsible for 387 550 preventable hospitalacquired infections per year.2 While the Centers for Disease Control reported a 7% decrease in CAUTIs between 2009 and 2011, CAUTIs in intensive care units (ICUs) remained essentially unchanged over the same time period.3 CAUTIs are one of the most preventable hospital-acquired infections in the United States4 yet remain the most prevalent hospital-acquired infection in acute care hospitals.5 They increase cost and length of stay (LOS), cause patient discomfort, and can result in death.6 The Centers for Medicare & Medicaid deem CAUTIs preventable and no longer reimburse hospitals for cost associated with CAUTIs.1 In addition, The Joint Commission added the prevention of CAUTIs to the National Patient Safety goals in January 2013.7 Consequently, acute care organizations are motivated to prevent CAUTIs from a quality, accreditation, and financial perspective. AREA FOR IMPROVEMENT Guidelines for the prevention of CAUTIs were previously implemented at an academic 245
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
246
JNCQ-D-13-00096
May 12, 2014
20:9
JOURNAL OF NURSING CARE QUALITY/JULY–SEPTEMBER 2014
medical center in Florida. However, 140 CAUTIs were identified in 2012 at the academic medical center and goals for the prevention of CAUTIs had not been achieved in all nursing units. The highest CAUTI rates and catheter utilization were in the ICUs. The executive team at the medical center recognized the need to improve the safety, effectiveness, and efficiency of care for patients with respect to urinary catheter management and developed a strategic goal to prevent CAUTIs. The neurosurgical intensive care unit (NSICU) was selected for the quality improvement (QI) pilot project. Both CAUTI rates and catheter utilization rates in the NSICU exceeded National Health Safety Network (NHSN) benchmarks in 2012. CAUTI rates in the NSICU were 4.4, 8.5, 3.6, and 2.8 per 1000 catheter-days per quarter, respectively, in 2012 as compared with the NHSN 25th percentile of 1.3. In addition, the catheter utilization rate in the NSICU exceeded the NHSN 10th percentile benchmark of 58% for all 4 quarters in 2012, 62.1%, 63.1%, 64.2%, and 72%, respectively. In 2012, the NSICU accounted for 22.2% of hospital-acquired CAUTIs. After reviewing the retrospective data, development and implementation of a nursedriven protocol for urinary catheter management was undertaken to address the identified issues. Eight goals were identified to improve the safety, efficiency, and effectiveness of care for patients with indwelling catheters in the NSICU. Goals were to reduce (1) monthly CAUTI rates, (2) catheter utilization, (3) number of CAUTIs per month, (4) cost of supplies and medications associated with CAUTI treatment, and (5) LOS; (6) educate nurses on routine catheter care, bladder scanning, and a nurse-driven protocol; (7) achieve 95% compliance with routine catheter care; and (8) achieve 95% compliance with the nursedriven protocol for management of urinary catheters. Support for the project was obtained from the chief operating officer, chief medical officer, chief quality officer, and the chair of the
neurosurgical department. The NSICU nurse manager and clinical leaders championed the project. The chief nursing officer functioned as the project leader, and the clinical leaders and charge nurses in the NSICU facilitated the practice change. LITERATURE REVIEW A comprehensive review of the literature was conducted to find the best evidence for urinary catheter management and CAUTI prevention. The Nursing Reference Center, National Guideline Clearinghouse, Cochrane, PubMed, Cumulative Index to Nursing and Allied Health Literature, and DynaMed were searched using “prevention of catheter-associated urinary tract infections” as the search term. The GRADE8 criteria were used to evaluate the studies. Studies explored alternatives to indwelling catheters, routine catheter maintenance, protocols for catheter management, and reminders to physicians and nurses to remove catheters. Alternatives to indwelling catheters and routine catheter care Insertion of indwelling catheters should be considered after assessing all other alternatives.9-12 Alternatives to indwelling catheters include condom catheters and intermittent catheterization to avoid insertion of indwelling catheters and bedside ultrasound bladder scanners to limit needless catheterizations.9-12 In a meta-analysis of 4 studies, Palese and colleagues13 found utilization of bladder ultrasound procedures reduced CAUTI risks by 73% when compared with intermittent catheterizations and were effective in reducing needless intermittent catheterizations when urinary retention was a concern after early removal of indwelling catheters. Pratt and Pellowe9 and Gould and colleagues10 conducted systematic reviews of existing guidelines for insertion and maintenance of indwelling catheters. Findings supported existing approaches for urinary catheter insertion and maintenance.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00096
May 12, 2014
20:9
A Nurse-Driven Protocol for CAUTI Prevention Nurse-driven protocols
247
METHODS
14
Gotelli et al conducted a QI project in an acute care hospital using a nurse-driven protocol with criteria for insertion and removal of catheters when indications for indwelling catheters were no longer met. The project demonstrated a 7% decrease in catheter utilization after 3 months. However, CAUTI rates remained unchanged. Topal et al15 conducted an observational, prospective, cohort study using a nurse-driven, criteria-based, independent protocol to allow nurses to discontinue catheters and use bladder scanners to monitor for urinary retention. Eighteen months postintervention results demonstrated a 65% reduction in catheter insertions, 79% reduction in catheter utilization, 73% reduction of inappropriate catheter use, and an 81% reduction in CAUTIs per 1000 catheter-days from baseline.
Physician and nurse reminders Meddings et al16 conducted a systematic review and meta-analysis of 14 studies and found that CAUTI rates decreased 56% with physician and nurse reminders and prewritten stop orders to discontinue catheters in 11 studies reviewed. Catheter duration decreased by 2.16 days, and CAUTI rates decreased by 41% with stop orders. Blodgett17 conducted a systematic review of the literature and found that face-to-face reminders during physician-nurse rounds, paper-based checklist reminders, and educational reminders during rounds with educators significantly reduced catheter duration and CAUTIs. In summary, several strategies were effective for CAUTI prevention and decreasing catheter-days. Implementing alternatives to indwelling catheters, such as the use of condom catheters, bladder ultrasonography, and intermittent catheterizations, reduced CAUTIs and catheter-days. Furthermore, implementing nurse-driven protocols, stop orders to remove catheters, and reminders for nurses and physicians to remove catheters demonstrated a reduction in CAUTIs.
Setting The project was conducted at an academic medical center located in Florida. The QI project had institutional review board approval and was conducted in a 30-bed adult NSICU. Patients with neurosurgical and neurological conditions are admitted to the unit. Common diagnoses include aneurysms, arteriovenous malformations, central nervous system neoplasms, traumatic brain injuries, spinal cord injuries, hemorrhagic and ischemic strokes, and status epilepticus. Management of incontinence in the NSICU has been a challenge. Patients in the NSICU are neurologically impaired, comatose, and often ventilated causing a loss of bladder function. Furthermore, medications are frequently administered to induce diuresis in order to decrease cerebral edema caused by neurological injuries and neurosurgical procedures. Nurses are challenged to prevent skin breakdown and accurately monitor urine output without an indwelling catheter. An analysis of the NSICU revealed insufficient data regarding nurses’ knowledge of evidence-based practice guidelines for routine catheter maintenance, urinary catheter indications, bladder scanning, and intermittent catheterization. In addition, delays in removing catheters were occurring because nurses had to obtain a physician’s order before discontinuing urinary catheters when indications were no longer met, and compliance monitoring of evidence-based guidelines was inconsistent. Sample Patients in the NSICU with indwelling urinary catheters during the evaluation period (n = 183) were included in the sample. All registered nurses (n = 107) working in the NSICU were included. QI project The FADE18 QI methodology was used for the project. This methodology includes Focusing on the problem (CAUTIs); Analyzing
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
248
JNCQ-D-13-00096
May 12, 2014
20:9
JOURNAL OF NURSING CARE QUALITY/JULY–SEPTEMBER 2014
data (catheter utilization, CAUTIs, CAUTI rates, compliance with urinary catheter guidelines, and nurses’ knowledge of guidelines); Developing a plan to reduce CAUTIs; and Executing the plan and Evaluating results against targeted goals. Protocol development and implementation The team developed a QI plan that included an evidence-based, nurse-driven protocol for urinary catheter management to decrease CAUTIs. The plan addressed 6 objectives: protocol approval by NSICU stakeholders, education of nurses about alternatives to indwelling catheters and routine catheter care, education of nurses and physicians about the protocol, compliance monitoring to ensure adherence to the protocol and guidelines for routine catheter care, daily catheter rounds to assess the need for catheter continuation, and analysis of identified CAUTIs. The protocol was developed by the project leader on the basis of nurse-driven protocols and guidelines found in the literature, policies and procedures in the NSICU for urinary catheter management, and consultation with physicians and clinical nurse leaders in the NSICU and the chief of urology. Strategies identified in the literature to prevent CAUTIs and decrease catheter-days were incorporated into the nurse-driven protocol and included criteria-based discontinuation of catheters (stop orders), bladder ultrasonography to prevent needless catheterizations, and intermittent catheterizations to reduce indwelling catheter-days The protocol provided criteria for indwelling catheter use and directed nurses to discontinue indwelling catheters when criteria were no longer met. Indications for indwelling catheters included tissue plasminogen activator administration within 24 hours of catheter insertion, bladder outlet obstruction, acute urinary retention more than 48 hours, genitourinary or gynecological surgery, significant hematuria, a physician’s order to maintain a catheter for longer than the protocol, an unstable spinal fracture, a stage 2
or greater pressure ulcer, end-of-life/palliative care, hemodynamic instability more than 24 hours, and urine output of 250 mL or more per hour. Bladder ultrasonography and intermittent catheterizations Criteria for frequency of bladder ultrasound procedures and intermittent catheterizations were provided by the chief of urology and developed to minimize intermittent catheterizations and prevent damage to the bladder caused by urinary retention. The protocol was ordered by physicians on all NSICU admissions and enabled nurses to use intermittent catheterizations and insert and discontinue catheters on the basis of criteria. Nurses were directed to perform bedside bladder ultrasound procedures to monitor postvoid residuals to assess for urinary retention and perform intermittent catheterizations based on ultrasound readings. Bladder ultrasound procedures were required when a patient did not void in 4 hours, complained of bladder discomfort at any time, voided less than 250 mL, or was incontinent. Intermittent catheterizations were required when the postvoid residuals or bladder scan readings were greater than 250 mL. The goal of intermittent catheterizations was to restrict urine in the bladder to 250 mL or less; therefore, the frequency of intermittent catheterizations varied for each patient. Bladder ultrasound procedures and intermittent catheterizations were discontinued after 2 postvoid residual ultrasound readings of less than 100 mL for patients voiding 250 mL or more; however, nurses continued to monitor voiding every 2 to 4 hours for 24 hours. Nurses performed bladder ultrasound procedures and intermittent catheterizations and monitored urine output every hour for patients displaying indicators of incomplete bladder emptying (voiding
