Improving Catheter Care Practices at Toronto Grace Hospital

1
Improving Catheter Care Practices at Toronto
Grace Hospital
Toronto Grace Hospitals IC 5 Team Back row
Jane, Murray Carla Front row Janice Tamiza
Toronto Grace Hospital Soaring with Excellence,
Serving With Grace IC 5 Team Kathryn Catton,
Carla Curto-Correia, Murray Krock, Tamiza
Nazarali, Jane Sanders, Janice Sheppard Main
Contact Murray Krock mkrock_at_torontograce.org
or 416-925-2251
Conduct assessment of catheter use
Initiate Best Practices for catheter care
Yes
Best Practice for
Remove catheter

• Aim of Project
• To develop and implement a Urinary Continence
  Management Program that will maintain or improve
  continence while promoting quality of life and
  independence for patients in the Transitional
  Care Program within 12 months.
• Sub-aim Implement a new protocol for catheter
  care on the 5th floor (Pilot Unit for IC 5)

• The Changes Implemented
• Removal of foley catheters and the prevention of
  unnecessary catheterizations.
• Procedure for Foley Catheter Removal including
  actions for toileting, UI assessment and
  monitoring via 72 hr. voiding record and
  Intermittent Catheterization (IC).
• Revised 72 hr. Voiding Record to include bladder
  scan volumes.
• Acceptable Post Void Residual Volume (PVR) 150 mL
• Toilet and monitor output q. 4 hrs. post catheter
  removal
• Indication for IC if no void and retained urine gt
  250 mL. q. 4 hrs.
• Procedure for IC supporting the removal of foley
  catheters and for Scheduled IC in cases of
  overflow UI and urinary retention.
• Protocol for scheduled IC according to 24 hr.
  oral intake
• Indication for IC if PVR gt 150 mL
• Selection of appropriate foley and IC catheters
• Developed flow sheet for IC.

No
Catheter necessary?
Catheter Care
initiate assessment
Toilet q 3
-
4 hrs
Initiate Best Practices for catheter care
Monitor PVR

Manage contributing factors
No
IC if no void retained
urine gt 250 ml q 4h
Candidate for IC?
IC if PVR gt 150 ml post void
Yes
Urinary retention
PVR gt 150ml

?
Determine type of UI
No
No
Continue to toilet
Intractable UI
Continence
Monitor PVR
PVR lt 150ml?
Achieved?
Manage contributing factors

• Background/Introduction
• Toronto Grace Hospital is a 119 bed facility
  specializing in Complex Continuing Care (CCC) and
  Palliative Care (100 CCC beds and 19 Palliative
  beds).
• Given the high risk for urinary incontinence (UI)
  including occasional or frequent incontinence,
  there was a need to develop a urinary continence
  program including a formal assessment process and
  related tools to determine the type of UI and
  interventions. There was also the need to review
  the prevalence of indwelling catheters and
  urinary tract infections and to determine areas
  for improvement.
• IC5 provided the opportunity to share and learn
  best practices related to urinary continence
  while developing, implementing and evaluating
  practice changes framed in a model for quality
  improvement.

Yes
Yes
Monitor Assist with toilet
Urine Containment
Results

• Next Steps
• Incorporate identification and indicators for
  catheter removal into continence assessment
• for newly admitted patients
• Continue to avoid insertion of foley catheters
  and substitute with IC if necessary
• Formally introduce developed procedures to
  support catheter removal and scheduled IC
• Continue to monitor quality indicators (e.g., UI,
  UTIs, foley catheters)
• Continue to improve documentation on patient plan
  of care
• Work with industry to select best temporary,
  intermediate and long term catheters

• How the changes were implemented
• Literature review and consultation with IC5
  hospitals
• Review of MDS data and discussion with staff r/t
  prevalence of indwelling catheters and urinary
  tract infections
• Education to enhance knowledge and process
• Procedure for Foley Catheter Removal tested on 2
  patients
• 4 catheters removed 2 catheters reinserted for
  clinical reasons, 3 foley catheterizations
  prevented
• Procedure for Intermittent Catheterization tested
  on 4 patients 3 patients with overflow UI and
  retention and I catheter removal
• Clinical Nurse Specialist worked with patients
  and staff to provide education, assessment and
  monitoring

TORONTO GRACE HOSPITAL INTERMITTENT
CATHETERIZATION RECORD CODE
CATHETER TYPE SIZE Intake
Oral Fluids, Tube Feeds in mL Void
Voided Urine Volume in mL Incont.
Incontinent check mark (?) B.S.
Bladder Scan in mL (if being
used) I.C. Intermittent
Catheterization in mL
Change Implemented
Scheduled ICs Started
Quality is never an accident it is always the
result of intelligent efforts John Ruskin