1. Hand hygiene must be performed before and after handling of the catheter site or apparatus.
2. Gloves must be worn during any manipulation of the catheter or collecting system.
3. Routine catheter/perineal care is performed once a shift, as needed, or following any
episode of fecal incontinence. Periurethral use of antiseptics is to be avoided while
the catheter is in place.
4. Urinary catheters must be securely anchored to the upper anterior thigh to prevent excessive
tension on the catheter which can lead to urethral trauma and tears.
5. Indwelling urinary catheter stabilization device used to anchor catheters must be changed every 7
days and include the date of application and staff member’s initials on the anchor pad. Changing
the site location from one leg to another is recommended in order to prevent skin irritation.
6. Catheters and drainage bags are changed only when clinically necessary, for example with
specimen collection, infection, obstruction, or compromise of the closed system.
7. All indwelling catheters must be connected to a sterile, closed urinary drainage system. When
possible, a system with pre-connected and sealed catheter-tubing junctions should be used.
a. If any breaks in aseptic technique, disconnection, or leakage occur when a pre-connected,
tamper-proof catheter/collection system is used, the entire system (new insertion kit)
should be replaced using aseptic technique and sterile equipment (catheters placed by
urology may be exempt from this recommendation)
8. Exceptions to a pre-connected and sealed urinary drainage system are patients receiving frequent
urinary catheter irrigations as a result of clot clearance, continuous bladder irrigations, need for
bladder pressure monitoring, or patients who are undergoing leg bag teaching.
9. The urinary catheter drainage system must be maintained to allow unobstructed urine flow,
including:
a. Keeping the catheter and collection tubing free from kinking and dependent loops by
arranging the drainage tubing in a straight line, over the patient’s leg and securing the tubing
to the sheets with the attached green sheet clip
b. Positioning urinary drainage bags below the level of the bladder at all times to prevent reflux
of contaminated urine from the bag to the bladder. Bags must never rest on the floor, on top
of the patient, or on top of a bed or stretcher
c. Empty drainage bags frequently enough to maintain urine flow and prevent reflux, usually
when they are one- half to two-thirds full, and prior to patient transport
i. A separate clean collection container is used for each patient
ii. Care is taken to avoid splashing and to prevent contact between the drainage spigot and
the non-sterile collecting container
iii. The end of the bag spigot is wiped clean with an alcohol wipe after emptying
10. All new urinary drainage bags must be dated. The tamper–proof catheter collection systems
provide an orange square sticker for placement on the drainage bag to allow for the
documentation of the date, time, department and initials.
11. It is a recommendation that patients with a chronic indwelling urinary catheter in place upon
admission should have the catheter replaced prior to collecting urine specimens as ordered by the
provider. The information must be documented in the medical record.
12. Urine samples for laboratory testing (e.g. urinalysis or culture) must never be obtained from the
drainage bag – refer to “Obtaining Urine Specimens from Indwelling Urinary Catheters”
procedure below.