Frequently asked questions about the HOUDINI Protocol

Post-webconference Q&A with BJC nurse leaders

During a member spotlight webconference in April, a team of nurse leaders from BJC HealthCare shared their experience implementing a protocol enabling nurses to remove urinary catheters as soon as clinically appropriate. Nurses now remove urinary catheters without a direct physician order, as long as the patient does not meet one of seven criteria indicated by the acronym HOUDINI.

In a recent interview, I posed some frequently asked questions about the HOUDINI protocol to three of BJC's nurse leaders:

  • Dr. Mary Beck, VP, Patient Care Services, Boone Hospital Center

  • Jill Skyles, VP, Patient Care Services, CNO, Barnes-Jewish St. Peters Hospital and Progress West Healthcare
  • Deanna Vollmar, Nurse Manager, Barnes-Jewish St. Peters Hospital
  • While many organizations have implemented some nurse-driven protocols, few have thoroughly identified all areas appropriate for expanded nurse clinical decision making. For a starter list of nurse-driven protocols, including BJC’s HOUDINI Protocol, see our study, Achieving Top-of-License Nursing Practice.

What was nursing practice like before the HOUDINI Protocol was introduced?

Jill: When a nurse recognized a patient’s catheter should be removed, he or she had to ask the physician to write an order to remove it, which delayed removal.

Mary: We saw a lot of sticky notes on the front of patient charts asking physicians for orders to remove Foley catheters.

What does HOUDINI stand for?

Jill: HOUDINI is an acronym—each letter represents a different reason a nurse should not remove a Foley catheter. It’s an easy way to help nurses remember the protocol, and the clear criteria help ensure nurses only remove the catheter when appropriate. The protocol also helps physicians feel comfortable with the nurse-driven process. Here’s what the letters stand for:

  • Hematuria, gross
  • Obstruction, urinary
  • Urologic surgery
  • Decubitus ulcer—open sacral or perineal wound in incontinent patient
  • Input and output critical for patient management or hemodynamic instability
  • No code/comfort care/hospice care
  • Immobility due to physical constraints

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How did you develop the HOUDINI Protocol?

Jill: In 2010, the system-wide Preventable Harm Team for Hospital-Acquired Infections identified catheter-associated urinary tract infections (CAUTIs) as an area of opportunity. We knew reducing the prevalence of Foley catheters could help prevent CAUTIs.

The first step we took was educating ED staff about when patients did—and did not—require a urinary catheter. Our goal was to appropriately reduce the number of Foley catheters inserted in the first place. Next, the multidisciplinary Preventable Harm Team identified instances when a catheter should remain in place. These criteria formed the basis of the HOUDINI Protocol.

How did you confirm the protocol was within nursing scope of practice?

Jill: The Missouri State Board of Nursing gave us an algorithm to determine if the HOUDINI Protocol fell within nursing’s scope. The protocol met the algorithm’s requirements.

How did you roll out the HOUDINI Protocol?

Jill: The system-wide Preventable Harm Team introduced the protocol to BJC’s facility CNOs, who served as protocol champions at their respective institutions. We encouraged the CNOs to identify key stakeholders impacted by the protocol and anticipate their reactions to the change in practice.

The CNOs developed a common “elevator pitch” about the protocol so everyone—physicians and nurses—would hear the same message. Our talking points emphasized that following the protocol is within the scope of nursing practice and reduces the potential for urinary tract infections.

Download Talking Points

To help nurses learn the protocol, we gave them pocket cards spelling out the HOUDINI criteria.

How did you secure physician support for the protocol?

Jill: We involved physicians in the protocol’s development, which helped gain their support. Most physicians were comfortable with the protocol because it clearly specifies when catheters cannot be removed. In addition, physicians can always supersede the protocol with a written order to keep the catheter in.

Once physicians saw the benefits of the protocol—fewer interruptions to their workflow and more timely removal of catheters—they began looking for other elements of care nurses could deliver by following a protocol.

What were nurses’ reactions to the new protocol?

Jill: Interestingly, we generally faced more resistance to the protocol from nurses than from physicians. First, some seasoned nurses were so used to asking for permission to remove urinary catheters that they were initially uncomfortable with the protocol. Younger nurses seemed more open to using the protocol.

Some nurses were concerned that removing a Foley could lead to reinserting multiple straight catheters. They were afraid multiple straight catheters were worse than an indwelling Foley.

Finally, some nurses recognized that removing a Foley catheter would mean more work toileting the patient, so they were hesitant to remove it.

How did you address nurse resistance to adopting the protocol?

Deanna: The first thing we did was reinforce that nurses had the expertise to follow the protocol. I did a lot of on-the-spot coaching to help nurses think critically about whether patients really needed a Foley catheter. Charge nurses helped with this, too. During rounds, they walked nurses through the protocol to double-check whether patients met the criteria to keep the catheter in.

To address nurses’ concerns about inserting multiple straight catheters, I worked with infection prevention to educate nurses about the drawbacks of indwelling Foley catheters.

We shared a review explaining how chronic urinary catheterization can result in a biofilm on the catheter, ultimately leading to infection (Trautner BW and Darouiche RO, “Role of biofilm in catheter-associated urinary tract infection,” American Journal of Infection Control 32 (2004): 177–183). The same article noted that studies suggest 21% to 38% of initial urinary catheters are unjustified and one-third to one-half of continued catheterization days are unjustified.

I also set a goal for the unit to appropriately remove one to two catheters per day following the HOUDINI Protocol. I publicly tracked progress toward the goal on our Key Performance Indicator (KPI) board. Nurses wrote their initials on the board when they removed a Foley catheter and used a Pareto chart to document why a catheter couldn’t be removed (which HOUDINI criterion the patient met). At staff meetings, I shared the total number of Foley catheters we had appropriately removed as a team.

Jill: Deanna’s staff were so excited about their progress—I received emails even on the weekend from staff celebrating that they had just used the protocol to appropriately remove a Foley catheter.

Do nurses use a bladder scanner to assess for urinary retention when removing Foley catheters?

Mary: A nurse first removes the catheter following the protocol. If the patient is unable to void within six hours of catheter removal, the nurse uses a bladder scanner to assess urinary retention. If the scan shows a volume greater than 300 cc’s, the nurse inserts a straight catheter. If the scan shows a volume of less than 150 cc’s, the nurse shares the report with the physician.

What results have you seen from implementing the HOUDINI Protocol?

Deanna: On my cardiology-telemetry unit, the number of catheter days decreased 18% from 1,257 in 2010 to 1,028 in 2011. There was one CAUTI on the unit in 2011.

We saw qualitative benefits, too. After eight months, I removed the HOUDINI Protocol goal from the KPI board because we’d made so much progress. The protocol was engrained in nursing practice, and nurses were coaching each other about when to remove Foley catheters.

Mary: At Boone Hospital Center, the ICU’s rate of catheter days per patient days has decreased from about 0.8 in February 2012 to about 0.7 in February 2013.

What other nurse-driven protocols have you implemented?

Mary: We have several nurse-driven protocols in place at Boone Hospital Center. For example, our Pediatric Asthma/Reactive Airway Management Protocol enables a respiratory therapist and the nurse caring for a patient experiencing respiratory distress to adjust the frequency of inhaled medication.

The protocol is based on respiratory distress scoring guidelines and is used for patients experiencing distress from asthma or reactive airway disease. If the patient is not making progress after the respiratory therapist and nurse adjust the frequency of medication, they call the physician for guidance.

Our experience implementing another nurse-driven protocol highlights the importance of enabling protocols to evolve over time in response to clinician feedback. In 2011, we implemented the Pneumococcal/Influenza Vaccine Assessment and Administration Protocol. This protocol allows nurses to screen patients to determine eligibility for influenza and pneumococcal vaccinations. Initially, nurses administered the vaccines (if appropriate) at admission.

However, after a few months, several physicians were concerned that they could not determine the cause of fevers in newly admitted patients—was the fever due to the patient’s illness or to the vaccine? To address this concern, we changed the protocol and nurses now deliver the appropriate vaccines on the anticipated discharge date.

What advice would you give to nurse leaders looking for ways to appropriately expand nurse clinical decision making with nurse-driven protocols?

Jill: Challenge yourself to ask when nurses really need a physician’s order versus when nurses have traditionally obtained a physician’s order. Nursing has the education and skills to follow protocols, but we sometimes rely too heavily on physician orders.

Be careful not to overestimate physician resistance to potential nurse-driven protocols. In our experience, physicians were more open to the protocol than we might have expected.

Mary: In fact, now physicians are coming to us asking if we can implement more nurse-driven protocols.


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