Discussion

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How Your Practices Differ From Best Practice (describe the practice problem you have identified for this improvement process)

Best Practice Strategies (what a review of the literature indicates is a best practice approach that you could implement to address the problem)

Barriers to Best Practice Implementation (this could be actual or anticipated/potential barriers)

Will Implement Best Practice (considering the barriers you identified – discuss your thoughts about the identified best practices being implemented

Best Practice #1: Use clear clinical indications and consider alternatives before insertion

A potential gap is catheter insertion for convenience rather than clinical need. Prolonged use is the most important CAUTI risk factor (Centers for Disease Control and Prevention [CDC], 2025).

Require a recognized indication, such as acute urinary retention or bladder outlet obstruction; incontinence alone is insufficient (CDC, 2024). Take into account assisted toileting, urinals, commodes, appropriate external devices, or intermittent catheterization when clinically appropriate (Patel et al., 2023).

Busy admissions and familiar ordering habits may encourage unnecessary insertion. These habits can be reinforced by limited toileting support and lack of available alternatives.

I would begin here to prevent unnecessary catheter use. Agreed indications and available alternatives would make adoption feasible.

The goal is to use a catheter only when a recognized indication outweighs its risks and to consider suitable alternatives first (CDC, 2024).

Include an essential indication field and a short alternatives prompt in the electronic health record (EHR). Bladder scanning should be used by trained staff when necessary. Communicate the choices in a manner that honors the mobility, communication and privacy of each patient.

The change of the order needs the support of information technology and consensus between the nursing, hospital medicine, and referring teams. Bladder scanners and appropriate collection devices should also be available to staff.

Pilot on one unit, urgent drainage with subsequent documentation. The teacher would train the personnel with short clinical cases.

A four-week audit would compare each new catheter order with the patient's clinical findings. Classifying insertions as appropriate, inappropriate, or unclear would help distinguish missing documentation from care that was genuinely unnecessary.

External devices collect urine but do not relieve retention. Uncertain or complex drainage decisions should be referred to the responsible clinician. Patient preferences should inform discussions without replacing a clinical assessment of whether catheterization is needed.

Some patients may prefer a catheter. Electronic restrictions could also delay urgent drainage. Completing an order field alone is not proof that insertion was appropriate.

Review uncertain indications weekly. Target 95% documented appropriate indications within 90 days; this is a proposed local goal.

  Best Practice #2: Use aseptic insertion and consistent daily catheter care

A second gap to assess is variation in insertion technique and daily care. A completed checklist does not necessarily show that asepsis, securement, bag positioning, and hygiene were maintained.

Use trained staff, hand hygiene, aseptic technique, and sterile equipment for insertion. Secure the catheter, keep the drainage system closed, prevent kinking, and keep the bag below the bladder and off the floor. Provide routine meatal hygiene; avoid routine antimicrobial irrigation or fixed-interval changes solely to prevent infection (CDC, 2024).

Interruptions, inconsistent kits, missing securement supplies, and differences in float-staff preparation may make care less reliable. Staffing pressures can also leave little time for training.

I would implement this alongside appropriate use. Reliable supplies, protected training time, and supportive supervision are essential.

Every necessary catheter should receive the same insertion and maintenance safeguards, regardless of the shift or staff member providing care (CDC, 2024).

Use a shared insertion checklist and a brief maintenance check each shift. Ask staff to demonstrate the required skills and correct unsafe practices immediately. This links documentation to bedside care rather than treating a completed form as the end goal.

Staff may see observation as criticism rather than support. Auditing only during the day could also miss problems on nights or weekends.

The educator would train permanent and float staff; supply staff would standardize kits, and unit champions would coach at the bedside.

The educator would observe insertions where feasible and review maintenance across shifts. Comparing observations with records, checking supplies, and identifying missed steps would show whether problems involve skills, resources, or documentation.

Li et al. (2025) reported improved outcomes after a nursing initiative in a medical intensive care unit. Because several changes were introduced together in a different setting, the study supports a coordinated approach but does not establish the benefit of each element on a general ward.

The team needs protected teaching time and a shared definition of full compliance. A completed checklist should not substitute for demonstrated skill or observation of safe care.

Track encounters meeting every required element as a percentage of all observations. Review missed steps weekly, not just average scores.

  Best Practice #3: Review catheter need daily and use an approved nurse-driven removal protocol

A catheter may remain after its indication resolves because reassessment responsibilities are unclear or removal awaits another order. Handoffs may mention the device without discussing whether it is still needed.

Review catheter necessity during daily multidisciplinary rounds. Use an approved nurse-driven removal protocol, with clinician review for exceptions such as postoperative urologic care or specialist-assisted placement (Patel et al., 2023).

Nurses may hesitate to remove catheters, while prescribers may disagree about authority or indications. Incomplete handoffs and an unclear removal plan can delay action.

I would support a supervised pilot after nursing and medical leaders approve the protocol, clarify authority, and confirm staff readiness.

The desired practice is a documented daily reason for continued use and a clear removal decision. Eligible catheters should be removed promptly when the indication ends (Patel et al., 2023).

The bedside nurse would document continued need and follow the approved removal protocol. The care plan should cover voiding after removal, bladder scanning when indicated, and escalation to a clinician when retention is suspected.

Kamel et al. (2025) reported staff distrust of the protocol, nursing hesitancy, and documentation difficulties. These concerns should be addressed before expecting consistent use.

Medical, nursing, and urology leads would agree on exceptions and follow-up care. The charge nurse would review unresolved cases daily.

Audit daily reviews and the time between resolution of the indication and removal. Separate justified exceptions and uncertain cases from avoidable delays instead of assuming that every additional catheter-day was unnecessary.

Kamel et al. (2025) reported CAUTI rates of 0.99 before and 0.27 after implementation per 1,000 catheter-days. However, infections numbered only three before and one afterward, and catheter utilization did not change significantly. The nonrandomized study combined several changes, so it cannot establish the removal protocol's independent effect or guarantee similar local results.

Fear of retention or difficult reinsertion can delay removal. Removal targets could also encourage premature action. Clear exceptions, bladder assessment, toileting support, and clinician review are essential.

Review necessity checks, removal delays, retention, and reinsertion within 24 hours weekly. Address adverse events before expansion without compromising necessary drainage.