Nurse Driven Indwelling Urinary Catheter Removal Protocol Starts Wednesday, March 13th!

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Hello everyone!

I’m reaching out with some very exciting news! This Wednesday, March 13, 2019 we are finally going live with a new protocol for RN driven removal of indwelling urinary catheters (IUC) in all adult inpatient units!! Some of you have already heard me talk about this in your staff meetings, or in other meetings, but for those of you who haven’t yet, I’ll give you a little background.

This protocol is part of a larger initiative here at UCSF to reduce our CAUTI rates. RN driven IUC removal is a strategy that is used in MANY other organizations with great success, and I am confident that we will find similar success here. We know that the biggest risk factor of developing a CAUTI is length of dwell time of the IUC, so prompt removal of IUC is critical. With this protocol, we are hoping to decrease the amount of time between the time the RN assesses the catheter is no longer required and the time the catheter is actually removed. The protocol has been approved and is supported by our physician colleagues who have also received information about this go-live.

This will be a big change in practice for all of us, so please review the practice update and algorithms that are attached to this email and reach out to me with any questions or concerns.

Thank you in advance!


Amy Larsen, MS, RN, CNS