NURS 491 Week 5 Evidence-Based Practice Project: Part 1 Example

Out by Day Two: A Staff Teaching Presentation on Nurse-Driven Urinary Catheter Removal

Slide 1: Why We Are Here

• Last quarter: 31 patients with catheters past day 3
• 22 had no documented reason to keep them
• Two catheter-associated infections

Speaker notes: I want to start with our own numbers. In a review of last quarter's charts, 31 patients on our unit had an indwelling urinary catheter for more than three days, and for 22 of them, the chart gave no reason for keeping it. We also had two catheter-associated urinary tract infections. None of this happened because anyone was careless. It happened because our habit is to wait for the provider to order removal.

Slide 2: Every Day Counts

• Infection risk rises each catheter day
• Catheters also cause discomfort, falls and delirium
• The fix is simple: fewer catheter days

Speaker notes: The longer a catheter stays in, the greater the chance of infection, and catheters also tether patients to the bed, raise fall risk when patients try to get up and add to confusion in older adults. The single most effective step is removing catheters that are no longer needed.

Slide 3: What the Evidence Shows

• A Veterans Affairs hospital adopted a nurse-driven protocol
• CAUTI fell from 0.99 to 0.27 per 1,000 catheter days
• Catheter use fell from 14% to 12% of patient days

Speaker notes: Kamel et al. (2025) studied a nurse-driven removal protocol at a 160-bed Veterans Affairs hospital. After the protocol and a catheter dashboard were introduced, the infection rate fell from 0.99 to 0.27 per 1,000 catheter days, and the share of patient days with a catheter fell from 14% to 12%. The authors credit a multidisciplinary team and visible data.

Slide 4: The HOUDINI Checklist

• Hematuria, Obstruction, Urologic surgery
• Decubitus wound in an incontinent patient
• Input and output monitoring in critical illness
• Nursing comfort at end of life, Immobility

Speaker notes: HOUDINI is the checklist built into our protocol. If a patient has at least one of these reasons, the catheter stays and we document which one. If none applies, the catheter should come out. Kamel et al. (2025) used the same criteria. We will check HOUDINI every shift, not just when the provider rounds.

Slide 5: Our Protocol, Step 1

• Check HOUDINI at the start of every shift
• No indication: remove the catheter, no call needed
• Document the criteria checked and the time removed

Speaker notes: Our hospital approved a nurse-driven protocol two years ago, but our unit has rarely used it. Under the protocol, you do not need a new order to remove a catheter when no HOUDINI reason applies, unless the provider has written a specific order to keep it, such as after certain urologic surgery.

Slide 6: Step 2, After Removal

• Ask the patient to void within 6 hours
• Measure each void and record it
• No void in 6 hours or discomfort: bladder scan

Speaker notes: After removal, we watch for retention. Encourage the patient to void and measure every output. If six hours pass without urine, or the patient reports a full bladder, use the bladder scanner. Follow the protocol's thresholds for straight catheterization and notify the provider before any reinsertion.

Slide 7: Step 3, When to Call

• Bladder scan above the protocol threshold twice
• New hematuria, pain or fever
• Any question about whether removal is safe

Speaker notes: The protocol gives us authority, not isolation. Call the provider when retention persists, when the patient develops new symptoms or when you are unsure. Reynolds et al. (2022) found that across a large health system, about 6% of catheters removed under a nurse-driven protocol were reinserted within 48 hours, which reminds us that follow-up matters.

Slide 8: What Gets in the Way

• Workload and short staffing
• Waiting for providers out of habit
• Not knowing the protocol exists

Speaker notes: Huang et al. (2023) reviewed 34 studies of health care workers and catheter infection prevention. Barriers included heavy workload, understaffing, variation among physicians and poor documentation; facilitators included leadership, education, teamwork, support for nurse-driven protocols and removal reminders. Today is about the last two: knowing the protocol and having a reminder.

Slide 9: Reminders That Help

• HOUDINI prompt in the shift assessment
• Catheter days on the huddle board
• Charge nurse check at midday

Speaker notes: Starting next month, the shift assessment in the record will prompt you to check HOUDINI. The huddle board will list every patient with a catheter and the day count. The charge nurse will ask about catheters at the midday safety check.

Slide 10: One Change Is Not Enough

• Protocols work best with other steps
• Rounds, supplies and data together
• We are adding all three

Speaker notes: Wills et al. (2026) found that no single intervention meaningfully changed CAUTI rates at their hospital, but a combination of quality rounds, supply changes, a revised nurse-driven protocol and updated urine testing reduced infections significantly. Reynolds et al. (2022) also saw no drop in catheter use from a protocol alone. That is why we are pairing the protocol with reminders and monthly data.

Slide 11: How We Will Know

• Catheter days per month
• CAUTI rate per 1,000 catheter days
• Reinsertions within 48 hours

Speaker notes: Each month, I will post our catheter days, infection rate and reinsertions on the board. If reinsertions rise, we will review together whether we are removing catheters too early.

Slide 12: Your Part

• Check HOUDINI every shift
• Remove, monitor, document
• Report barriers to the charge nurse or manager

Speaker notes: Every catheter we remove a day sooner is one less day a patient carries a risk they do not need. Please tell me or your charge nurse what makes the protocol hard to use, so we can fix it rather than give up on it.

References

Huang, A., Hong, W., Zhao, B., Lin, J., Xi, R., & Wang, Y. (2023). Knowledge, attitudes and practices concerning catheter-associated urinary tract infection amongst healthcare workers: A mixed methods systematic review. Nursing Open, 10(3), 1281-1304. https://doi.org/10.1002/nop2.1384

Kamel, M., Harris, N., Berry, A., Warsavage, T., Bessesen, M. T., & Kon, S. E. (2025). Implementation of a nurse-driven protocol for indwelling urinary catheter removal and novel utilization dashboard: A pre/postintervention observational study. Therapeutic Advances in Infectious Disease, 12, 20499361251317900. https://doi.org/10.1177/20499361251317900

Reynolds, S. S., Lozano, H., Fleurant, M., & Bhandari, K. (2022). Using statistical process control charts to measure changes from a nurse-driven protocol to remove urinary catheters. American Journal of Infection Control, 50(12), 1355-1359. https://doi.org/10.1016/j.ajic.2022.03.005

Wills, W., Rosever, K., Bugajski, A., Gallo, A., Hinds, P., & Morata, L. (2026). Assessing the effectiveness of multidisciplinary interventions in reducing catheter-associated urinary tract infection: An interrupted time series modeling approach. Journal of Nursing Care Quality, 41(4), 321-329. https://doi.org/10.1097/NCQ.0000000000000956