Policy Manual sample

MDT Home Health Care Agency, Inc. URINARY CATHETER POLICY (addressing patient care issues and prevention of infection(UTI)) Urinary instrumentation, especially by an indwelling bladder catheter, is the most common predisposing factor in urinary tract infections. Because of the scope and seriousness of the problem, the following principles are recommended to be confirmed by the individual physicians: 1. Indwelling urinary catheters should be avoided unless absolutely necessary for the medical well being of the patient. They should never be used as a matter of nursing convenience, and should be discontinued promptly when they are no longer absolutely necessary. 2. Insertion of an indwelling catheter should be done only by adequately trained personnel. 3. A closed drainage system with disposable clear plastic bag and connecting tubes should be used. 4. In the event the physician does not indicate the date for the catheter replacement, then the catheter and drainage system should be changed every thirty (30) days, or as necessary, but always the MD order must be obtained before any catheter change. 5. Catheters are irrigated only when absolutely necessary, as infrequently as possible. A sterile irrigation set must be used for each irrigation. If bladder irrigations are necessary, a 3-way Foley is to be used. Infection Prevention: The major predisposing factor for healthcare associated UTI is the presence of an indwelling urethral catheter. Purpose: To reduce the risk and incidence of urinary tract infections by following evidenced based guidelines. 1. Minimize urinary catheter use and duration of use in all patients, particularly those at higher risk for UTI or mortality from catheterization such as women, the elderly, and patients with impaired immunity. Avoid use of urinary catheters in patients in ALF for management of incontinence. 2. Use urinary catheters in operative patients only as necessary, rather than routinely. 3. Education and performance feedback regarding appropriate use, hand hygiene, and catheter care Home Health Agency - - Skilled Professional Services D-25