Indwelling catheters can be uncomfortable and inhibit mobility. They can also lead to serious complications and infections. The
indwelling catheter quality measure
(QM) reports the percentage of residents who had an indwelling catheter at any time during the 7-day look-back period. The denominator of this QM includes all long-stay residents with a selected target assessment, except those with the following exclusions:
- Target assessment is an admission assessment or a Prospective Payment System (PPS), 5-day, or readmissions assessment.
- Assessment indicates indwelling catheter status is missing.
- Assessment shows resident has a diagnosis of neurogenic bladder and/or obstruction and these diagnoses are coded on the Minimum Data Set (MDS).
Performance Improvement Project (PIP)
teams should assess whether residents with catheters really require them based on specific diagnoses and conditions. PIP teams should work to improve their indwelling catheter QM and consider some of these questions to help their quality improvement efforts:
- Was the MDS coded per Resident Assessment Instrument requirements?
- Did the resident have a diagnosis of neurogenic bladder and/or obstruction and was this coded on the MDS?
- Is it possible to complete post-void residuals or straight catheterization to eliminate the use of the indwelling catheter?
Additionally, PIP teams must ensure their PIP goal to lower the use of indwelling catheters is clearly communicated and involves all staff members, residents, and families.
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