Purpose for the Program
The purpose of this initiative is to reduce the use of indwelling urinary catheters as a routine intervention for patients in labor who have had an epidural. This has been a common practice throughout a major southwestern hospital system. However, there is no evidence that this process improves patient care. Studies indicate that a patient's perception and satisfaction of labor are improved with less intervention. Likewise, there is no evidence to suggest that the use of an indwelling catheter will shorten labor. Therefore, the use of an indwelling urinary catheter should not be dependent upon a patient receiving an epidural during labor but rather upon her clinical need.
Clinical indications for the necessity of a urinary catheter may include Category III fetal heart rate tracing or arrest of labor, where an operative or cesarean birth is likely to occur; closer monitoring of intake and output, as in a patient receiving magnesium sulfate; or obese patients where bladder assessment is unobtainable. The greatest risk for urinary tract infections is via indwelling urinary catheters. This practice change will align labor and delivery units with national initiatives to decrease catheter-acquired urinary tract infections.
The proposed changes of this initiative are the following:
- To eliminate the use of indwelling catheters from labor order sets.
- Order an indwelling catheter for a patient in labor only when it is clinically appropriate.
- A patient should be encouraged to void prior to an epidural placement and subsequently every 2 to 4 hours.
- Nurses should assess the bladder and perform perinatal care every 2 hours for every patient in labor.
- If a patient is unable to void, proceed with straight catheterization, using sterile technique, and record volume.
Implementation, Outcomes, and Evaluation
This initiative was instituted in April 2011 at one facility. The clinical nurse specialist provided evidence-based information to the nursing staff and physicians to support the proposed change. In the first 3 months, indwelling catheter use decreased from 66% to 25%. These data were presented to the system's Clinical Consensus Group by the clinical nurse specialist and approved as an expected system practice. At the time of submission, the initiative was in the design phase of the project, with a projected roll-out date of October 2011.
Implications for Nursing Practice
Nurses will have the opportunity to improve patient care by assessing the evidence, considering patient preference, and using critical thinking skills to make sound clinical decisions. The clinical nurse specialist's role as a facilitator of change also is illustrated through the advancement of evidence-based practice.