Implementing the Clinical Excellence Commission (CEC) criteria lead urinary catheter removal protocol in a major rural faciliity

Suzanne Lovell-smart 1

Orange Health Service, Orange, NSW, Australia


Orange Health Service was invited to be one of 8 NSW clinical units to participate in the pilot of the new protocol as the CEC had reviewed previous indwelling urinary catheter in elective hip/knee arthroplasty.

Unecessary use or prolonged catheterisation is a main cause of catheter associated urinary tract infections, over usage of antibiotics and reduction of early mobilisation. Many of the decisions are dependent on the patients’ medical officer who might not be available, unaware catheter remains insitu, does not write removal orders or writes removal on mobilisation.

The pilot period was over 5 months
Pre-implementation – data & survey collection
Implementation – Education & training
Post implementation – data collection, survey and review.

For the pilot to be a success it required team links, leadership, cultural and behaviour change in the clinical environment.

Auditing, reviews of change practice helps sustain change but also a cause for celebration of new beginnings. Empowerment of clinical staff to make informed decisions and actions regarding the early removal of IDCs, which led to a reduction of Hospital acquired CAUTI’s

The involvement in this pilot project led to the invitation to participate in the HETI eLearning Program: ‘Indwelling Urinary Catheter Insertion’

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