Nurse-driven protocols (NDPs) provide clinically approved methods for nursing to make autonomous care decisions. The objective of this project was to assess the impact of an Infection Prevention Specialist (IPS)-driven review process to determine the necessity of indwelling urinary catheters (IUC) and utilization of a hospital NDP for IUC removal by inpatient nurses.

An IUC justification review process was implemented from August 2021 through November 2021 at a 1315-bed academic hospital. Monday through Friday a list of patients with an IUC in place > 2 days was generated, including IUC indication. Intensive care units (ICU), women & infants’ units, and coronavirus disease 2019 (COVID-19) units were excluded. The indication for the IUC was reviewed in accordance with the hospital NDP. For any discrepancies a survey was completed, and an email was sent to unit leadership with the NDP. Discrepancies include improper documentation/charting of the indication, physician order that superseded the NDP, or missing IUC indication. Responses were tracked and categorized. Data was analyzed in Excel using a two-proportion Z-test.

IPS reviewed 1,887 IUCs during the study period (median 120 IUC/week; range 50-137). There were 672 (34.7%) discrepant with the NDP. The most common discrepancies were physician order (n=240, 35.7%), improperly documented hourly input and output (n=216, 32.1%) or lack of documented indication (n=117, 17.4%). Discrepant IUCs were more common in medicine, oncology, and surgery units. IUC removal was more common in cardiology (31.8%, p< 0.001), neurology (31.7%, p< 0.001), and surgery (29.7%, p< 0.001) than in medicine (10.8%). The same was true for cardiology (p< 0.01), neurology (p< 0.01), and surgery (p< 0.01) in comparison with oncology (15.7%).

34.7% of IUC in place >2 days were without proper justification. Only 44.9% of unit leadership followed NDP after prompting. Next steps include determining barriers to the nursing driven IUC removal process.