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Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide

Appendix B. Urinary Catheterization – Sample Policy

Purpose

The purpose of urinary catheterization is to facilitate urinary drainage when medically necessary.  Urinary catheters should be evaluated every day for need and removed promptly when no longer necessary. 

Urinary catheters are deemed medically necessary for the following reasons:

  1. Urinary retention including obstruction and neurogenic bladder: The patient is unable to pass urine because of an enlarged prostate, blood clots, or an edematous scrotum/penis or unable to empty the bladder because of neurologic disease/medication effect.
  2. Short perioperative use in selected surgeries (less than 24 hours) and for urologic studies or surgery on contiguous structures.
  3. Need for accurate hourly output measurements to manage treatment in intensive care units.
  4. Assistance with healing of perineal and sacral wounds in incontinent patients to avoid further deterioration of wound and skin when alternative methods are ineffective.
  5. Required strict immobilization for trauma or surgery.
  6. Hospice/comfort care or palliative care, if requested by patient.

Background

Urinary catheterization is the aseptic process of inserting a sterile hollow pliable tube into the urethra to facilitate urine drainage into a closed bag system. The urinary tract is the most common site of hospital-acquired infections, accounting for approximately 40 percent of hospital infections. The intent of this policy is to not only give guidance for urinary catheter maintenance techniques, but also to assist in the prevention of catheter-associated urinary tract infections.

Policy

  1. General
  • 1.1 Urinary catheters should be inserted only when medically necessary and should be evaluated daily for need. Urinary catheters should not be used solely for the convenience of health care workers. Document attempts at and inadequacy of alternative methods for bladder elimination prior to insertion of the indwelling catheter. 
    • 1.1.1 Alternative methods include:
      • Programmed toileting, which consists of placing the patient on the bedpan or commode every 2-4 hours while awake.
      • Utilizing a bladder scan machine for suspected urinary retention (refer to the Bladder Scan Policy, Appendix C of the Implementation Guide, for guidelines).
  • 1.2 Urinary catheters should be placed only under the direction of a physician order. However, if the patient's nurse does not deem the urinary catheter meets the indications for placement, the patient's nurse should question the need.
  1. Insertion/Application
  • 2.1 Indwelling, straight, and suprapubic urinary catheters should be inserted using aseptic technique and sterile equipment.
    • 2.1.1 Sterile gloves, drape, and sponges; an appropriate antiseptic solution for periurethral cleaning and a single-use packet of lubricant jelly should be used for insertion.
  • 2.2 The smallest bore catheter possible should be utilized to minimize urethral trauma and irritation.
    • 2.2.1 Coude catheters may be placed by nursing staff based on urology orders.
  • 2.3 Indwelling catheters should be properly secured after insertion to prevent movement and urethral trauma.
  • 2.4 Patients who perform self-catheterization at home should be encouraged to continue performing this procedure while in the hospital.
    • 2.4.1 Patients performing self-catheterization should utilize clean technique.
    • 2.4.2 Nursing personnel should evaluate the patient's performance and reinforce positive behaviors.

  1. Maintenance   

  • 3.1 Standard Precautions: Use gloves when manipulating the catheter site and drainage system and practice hand hygiene before and after.
  • 3.2 A sterile, continuously closed drainage system should be maintained for indwelling and suprapubic catheter systems.   
  • 3.3 If there are breaks in aseptic technique, disconnection of tubing, or leakage from the bag, or if the catheter becomes contaminated, the catheter should be replaced. 
  • 3.4 Drainage bags should always be placed below the level of the patient's bladder to facilitate drainage and prevent stasis of urine.
  • 3.5 Urine in drainage bags should be emptied at least once each shift using a container designated for that patient only. Care must be taken to keep the outlet valve from becoming contaminated. Use gloves and practice hand hygiene before and after handling the drainage device. 
  • 3.6 Patients with urinary catheters will have intake and output recorded. However, urinary catheters are not to be inserted simply to monitor outputs with the exception of in intensive care units when accurate hourly output assessment is necessary for management. Make use of other means to monitor outputs in the incontinent patient, such as daily weights.
  1. Catheter Change
  • 4.1 Catheters of postop urology patients should only be changed or removed with urology's approval.
  • 4.2 Catheter change: The interval between catheter changes should be determined by the individual patient's needs. Indications for change may include mechanical dysfunction or blockage of the urinary catheter system, and contamination of the closed system.
  • 4.3 Indwelling catheters should not be changed at arbitrary fixed intervals.
  1. Meatal Care
  • 5.1 Meatal care: Cleansing the meatal surface during daily bathing is appropriate. The periurethral area should not be cleaned with antiseptics in patients with indwelling urinary catheters.
  1. Specimen Collection
  • 6.1 Small-volume urine specimens should be obtained by inserting a sterile needle/syringe into a disinfected sampling port and aspirating the urine. Generally, urine cultures should be obtained prior to starting antibiotics for patients with suspected urinary tract infections.
  • 6.2 Regular bacteriologic monitoring of catheterized patients is not recommended.
  • 6.3 The patient with an indwelling catheter should be monitored for signs of catheter-associated urinary tract infection such as fever, chills, or suprapubic pain.
  1. Responsible Persons
  • 7.1 Only persons (e.g., nursing staff, family members, or patients themselves) who know the correct technique of aseptic insertion and maintenance of the catheter should handle catheters. Health care workers and others who take care of catheters should be given periodic education and training, stressing the correct techniques and potential complications of urinary catheterization.

Bibliography

Gould CV, Umscheid CA, Agarwal RK, et al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 2009. Centers for Disease Control and Prevention. . Accessed April 24, 2015.

Maki DG, Tambyah PA. Engineering out the risk for infection with urinary catheters. Emerg Infect Dis. 2001 Mar-Apr;7(2):342-7. PMID: 11294737.

Meddings J, Saint S, Fowler KE, et al. The Ann Arbor Criteria for appropriate urinary catheter use in hospitalized medical patients: results obtained by using the RAND/UCLA appropriateness method. Ann Intern Med. 2015 May 5;162(9 Suppl):S1-34. PMID: 25938928.

Ortega R, Ng L, Sekhar P, et al. Female urethral catheterization. N Engl J Med. 2008 Apr 3;358(14):e15. PMID: 18385493.

Saint S, Kaufman SR, Rogers MA, et al. Condom versus indwelling urinary catheters: a randomized trial. J Am Geriatr Soc. 2006 Jul;54(7):1055-61. PMID: 16866675.

Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis. 2008;46:243-50. PMID: 18171256.

Thomsen TW, Setnik GS. Male urethral catheterization. N Engl J Med. 2006 May 25;354(21):e22. PMID: 16723610.

Page last reviewed October 2015
Page originally created October 2015

Internet Citation: Appendix B. Urinary Catheterization – Sample Policy. Content last reviewed October 2015. Agency for Healthcare Research and Quality, Rockville, MD.
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