Patients from Skilled Nursing Facilities (SNFs) require a fair amount of attention as most of them are often recovering from surgery, illness, or injury, with some having chronic medical conditions and in need of ongoing medical supervision and rehabilitation services. Catheter use in such medical environments is expected; however, research has shown its use is sometimes unnecessary. Unnecessary use of the catheter poses an issue due to Catheter-associated issues such as the commonly reports of catheter-associated urinary tract infections (CAUTIs), which are an important source of morbidity and mortality for patients in SNFs. Approximately 25% of SNF residents have an indwelling urinary catheter, and up to 50% may be unnecessary (Schiessler et al., 2018). Inappropriate use and slow removal of urinary catheters increase the risk of CAUTIs, which can lead to sepsis, longer hospital stays, and even death (Saint et al., 2009). CAUTI, therefore, becomes a good measure for appropriate catheter use in SNFs as the implementation of nurse-driven protocols (NDPs) for catheter insertion and removal has been shown to reduce CAUTIs in such hospital settings, which indicates the necessity of their use (Andreessen et al., 2012; Miranda et al., 2023). However, minimal research has examined the impact of NDPs on urinary catheter management in SNFs. The paper examines whether nursing-driven protocols for indwelling catheter use, compared to current practices for catheter insertion and removal, can be more effective over six months in skilled nursing facility patients, with the measure being a reduction of CAUTI rates by 25% in 6 months.
Objectives
A key objective is to develop an evidence-based nurse-driven protocol (NDP) for guiding urinary catheter insertion and timely removal in skilled nursing facility (SNF) patients. This NDP will establish clear criteria and standardized procedures for nurse-directed catheter placement and discontinuation decisions. Nurses will be empowered to insert and remove catheters based on protocol guidance without requiring physician orders. The primary outcome measure will be catheter-associated UTI (CAUTI) rates, calculated as the number of CAUTIs per 1,000 catheter days. The CAUTI rates will be tracked six months before NDP implementation and six months after implementation. This comparison of pre-and post-intervention rates will quantify the impact of the nurse-driven protocol. Secondary outcomes tracked will be total inappropriate catheter utilization days and catheter early removal rates, which can give further insights into the effectiveness of the empowered nursing discontinuation component. The SNF’s electronic medical record system will extract all outcome data. Prior research found that similar nurse-driven protocols achieved up to 28% reductions in CAUTI rates within pediatric ICU settings (Schiessler et al., 2019). Given the solid evidence base, a 25% CAUTI rate decrease within six months is a reasonable and achievable goal for our SNF patient population.
The nurse-driven protocol will launch as a pilot on two units within a large SNF chain, and all nurses working here will receive multi-modal education and training on the NDP components, including appropriate indications for urinary catheter use versus misuse, nurse-driven insertion and discontinuation protocols and proper catheter maintenance techniques. Adequate catheter supplies and IT support for workflow integration will be ensured on the pilot units. In terms of timeline, the nurse-driven protocol will be developed within the first month. The rollout of the two pilot units will occur over months two and three, including comprehensive nursing education. Outcomes will then be tracked for six months to allow sufficient time to assess the NDP’s efficacy on CAUTI and reduce inappropriate catheter utilization.
Strategies
A multi-disciplinary task force will be assembled to develop the nurse-driven protocol (NDP), including the Director of Nursing, nurse managers from the pilot units, frontline nurse representatives, the Medical Director, hospitalists, quality improvement consultants, and infection preventionists. This task force will extensively review current literature and evidence-based protocols on urinary catheter use in post-acute settings. They will construct draft NDP components aligned with recommendations that emphasize appropriate indications, nursing empowerment in device management, and utilization of alternative external devices over indwelling catheters where possible.
The protocol will establish diagnoses and clinical scenarios where nursing staff have autonomy to insert urinary catheters, such as acute urinary retention and the need for accurate intake/output monitoring in critically ill patients. This protocol empowers prompt catheter placement in medical necessity situations without awaiting physician orders. Nurses will be required to evaluate ongoing catheter needs during daily patient rounding, and clear criteria for removal will be integrated into the clinical workflow. For example, suppose a catheter was placed for acute retention, but the patient has now voided spontaneously. In that case, the nurse will be prompted to remove the unnecessary catheter without adding physician orders. External catheters and other alternatives will be recommended first-line for appropriate patients to avoid the risks of indwelling devices. The supply chain will ensure these alternatives are adequately stocked on the pilot units.
Standardized best practices for hygienic catheter insertion, perineal care, collection bag positioning, and removal will be provided to reinforce infection prevention. The task force will circulate the draft NDP to all physicians, nurse practitioners, charge nurses, staff nurses, and unit managers participating in the pilot. Their feedback on workflow integration and overall adoption feasibility will inform protocol revisions before finalization. Extensive nursing education on the NDP and its rationale will raise awareness of appropriate indications, nurse empowerment elements, and proper techniques. Training modalities will include skills fairs, eLearning modules, visual job aids, demonstrations, and simulations. Physicians and nurse practitioners will also receive training on the NDP components, emphasizing the clinical benefits and their oversight role. The NDP will integrate catheter necessity screening into admission and daily patient rounding documentation in the Electronic Medical Record to facilitate adoption. Relevant supplies like external catheters will be stocked on the units. During and after implementation, nurse managers and champions will conduct medical record audits with feedback on NDP compliance and techniques. Ongoing support through daily reinforcement, reminders, and peer coaching will promote sustained utilization.
Background
CAUTIs account for 70-80% of all UTIs acquired in SNFs (Tsan et al., 2008), with risk factors including female gender, diabetes, improper catheter care, and prolonged use (Mody et al., 2010). Indwelling catheters are often overused in SNF patients for convenience or incontinence rather than appropriate indications like urinary retention or output monitoring, and this unnecessary use puts patients at increased risk of CAUTIs (Jain et al., 2015). NDPs have been shown to reduce inappropriate catheter use and CAUTI rates through nurse empowerment for early discontinuation (Alexaitis & Broome, 2014; Durant, 2017). A pediatric ICU implemented a similar NDP, reducing CAUTIs from 4.8 to 0.8 per 1,000 catheter days (Schiessler et al., 2019). Adaptation of these protocols to SNF patients could provide a mechanism to reduce avoidable catheter use and CAUTI risk.
CAUTI rates, measured as the number of catheter-associated urinary tract infections for 1,000 urinary catheter days, have been greatly employed as an outcome measure in prior studies examining interventions to reduce inappropriate catheter use (Laborde et al., 2021). The CAUTI rate controls for fluctuations in the actual catheter number, allowing reliable comparisons before and after implementing nurse-driven protocols or practice changes. Furthermore, since inappropriate catheter use has been directly linked to increased CAUTI risk, a reduction in CAUTI rates logically signals an intervention’s efficacy in optimizing catheter necessity evaluation and timely removal of unnecessary catheters. Tracking CAUTI rates for the six months before and after implementing the nurse-driven protocol for catheter management will efficiently quantify whether nursing-driven discontinuation and use protocols demonstrate improvement over the current standard SNF practices. A measurable reduction in CAUTIs would validate the benefit of implementing nurse-driven protocols over the preceding current state. Supplementary tracking process metrics like inappropriate catheter days can provide additional supporting evidence.
The widespread adoption of NDPs for catheter management has been limited in SNF settings (Schiessler et al., 2019). Barriers like provider resistance, lack of supplies, and nurse discomfort with autonomous discontinuation must be addressed through stakeholder engagement and education. Implementing and evaluating NDPs at select facilities would generate evidence and experience to drive broader adoption of protocols to reduce CAUTIs.
In conclusion,inappropriate indwelling urinary catheterization is highly prevalent in SNF populations, putting patients at risk of catheter-associated infections, sepsis, and death. Implementing and evaluating a nurse-driven protocol to facilitate the appropriate use and timely removal of catheters in this setting significantly reduces patient harm from CAUTIs. The 25% CAUTI reduction target within six months is attainable based on prior study results by Schiessler et al. (2019). If achieved, this NDP pilot could drive savings of health care dollars and lives through preventable infection prevention on a national scale. The protocol centered on daily nursing reassessment of catheter needs could become the new standard of excellent care.
References
Alexaitis, I., & Broome, B. (2014). Implementation of a nurse-driven protocol to prevent catheter-associated urinary tract infections. Journal of Nursing Care Quality, 29(3), 245–252.
Andreessen, L., Wilde, M. H., & Herendeen, P. (2012). Preventing catheter-associated urinary tract infections in acute care: the bundle approach. Journal of Nursing Care Quality, 27(3), 209-217.
Durant, D. J. (2017). Nurse-driven protocols and the prevention of catheter-associated urinary tract infections: a systematic review. American journal of infection control, 45(12), 1331-1341.
Jain, M., Dogra, V., Mishra, B., Thakur, A., & Loomba, P. S. (2015). Knowledge and attitude of doctors and nurses regarding indication for catheterization and prevention of catheter-associated urinary tract infection in a tertiary care hospital. Indian Journal of Critical Care Medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 19(2), 76.
Laborde, E., Hill, H., Dukovac, T. E., Carriere, S. P., Lata-Arias, K., Hebert, K., … & Gills, J. (2021). A nurse-driven protocol for Foley catheter utilization decreases the incidence of traumatic Foley catheterization. Ochsner Journal, 21(1), 41-62.
Miranda, M. E. D. Q., Rosa, M. R., Fontes, C. M. B., & Bocchi, S. C. M. (2023). Nursing protocols to reduce urinary tract infection caused by indwelling catheters: an integrative review. Revista Brasileira de Enfermagem, 76, e20220067.
Mody, L., Saint, S., Galecki, A., Chen, S., & Krein, S. L. (2010). Knowledge of evidence‐based urinary catheter care practice recommendations among healthcare workers in nursing homes. Journal of the American Geriatrics Society, 58(8), 1532-1537.
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Schiessler, M. M., Darwin, L. M., Phipps, A. R., Hegemann, L. R., Heybrock, B. S., & Macfadyen, A. J. (2019). Don’t have a doubt, get the catheter out: a nurse-driven CAUTI prevention protocol. Pediatric Quality & Safety, 4(4), e183.
Tsan, L., Davis, C., Langberg, R., Hojlo, C., Pierce, J., Miller, M., & Gibert, C. (2008). Prevalence of nursing home-associated infections in the Department of Veterans Affairs nursing home care units. American journal of infection control, 38(3), 173-179.
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