A Pennsylvania hospital is reporting good results from a quality improvement initiative aimed at reducing catheter-associated urinary tract infections (CAUTIs) in the ICU.1

The University of Pittsburgh Medical Center (UPMC) Williamsport uses a combination of education and practice-related interventions. The ICU reported no CAUTI events during the intervention period, and there also were improvements in the CAUTI incidence rate and documentation compliance.

The project began in 2018, when the hospital reported 13 CAUTIs, says Holly N. Shadle, DNP, CRNP, FNP-BC, nurse practitioner in the dermatology department at UPMC Susquehanna, also in Williamsport, PA. UPMC Williamsport and Susquehanna both are part of the UPMC Susquehanna health system.

The 13 CAUTIs were far above the hospital’s benchmark of four or fewer each year. Six of the 13 infections occurred in the ICU. Shadle and the rest of the quality improvement team targeted a 30% reduction in CAUTIs, a 20% reduction in urinary catheter days, and a 75% compliance rating in catheter-related documentation in the ICU.

“A lot of the issues came down to things that seemed simple. They weren’t always using sterile techniques the correct way, or they were collecting samples improperly or for the wrong reasons,” Shadle says. “I started to think that education was an issue. As I dived into the research, I found that in many cases, education was one of the biggest things that had to be addressed.”

The research also revealed clinical decision support from the electronic health record (EHR) played a role in reducing infections. Bundled interventions seemed to reduce rates, according to Shadle’s research, so she decided to take that approach.

“We had a removal protocol a long time ago, but it was really antiquated and wasn’t really even policy anymore. No one was really using it, and a lot of our new nurses didn’t even know that it existed,” she says. “We decided to focus on the checklist, the education, and the removal protocol. That’s how the bundle intervention was created.”

Focus on Education

Shadle created a didactic with a PowerPoint and checklists that addressed why catheters are used and the entire process of using them and removing them. After the didactic, staff would demonstrate their skills in inserting and removing catheters, how to obtain a specimen, and everything else they needed to know to properly use catheters and prevent CAUTIs.

The hospital also created an electronic daily checklist in the form of an Excel spreadsheet to monitor catheters. Previously, staff had used paper checklists, but Shadle says they often were not completed, and the hand tally left a lot of room for error.

The Excel spreadsheet made the catheter documentation more uniform, and supervisors could easily check to see what rooms had not entered information.

“We were in the process of getting a new EHR at the time, so we could not build it into the medical record. The Excel spreadsheet was a good second choice for us,” Shadle says. “Since then, we have been able to incorporate the documentation and the removal process in to the EHR, which makes it a lot easier for the whole hospital.”

The 30% reduction in CAUTIs, a 20% reduction in urinary catheter days, and a 75% compliance rating in catheter-related documentation in the ICU were good results.

Instructing nurses in the proper techniques for catheter insertion and removal was key to that success. Although the nurses were experienced and these techniques were not especially challenging, they still benefited from a refresher course.

“Teaching nurses how to put in catheters doesn’t seem like it’s that important, but when we went back and looked at how important the education was, we realized how much that kind of basic education has an impact on overall quality and CAUTI rates,” Shadle says. “Nurses in the ICU are very well equipped, but sometimes reminding them of how to do these very important foundational skills is such an important thing.”

One of the aims of the project was to reduce the total catheter days. However, during the study period, that number went up. Initially, Shadle was disappointed by that. When she and her team studied the utilization ratio and the census, they saw the census had been higher, which meant a higher acuity of patients.

“We had more catheter days, which means more opportunities for infections, but the infection rate actually went down. We thought that was very promising,” Shadle says.

The numbers from the ICU are holding steady, and the hospital continues to hold skill fairs for nurses to refresh their knowledge and techniques with catheters and other care that can result in infections.

“I think it’s changing how the whole hospital works,” Shadle says. “It’s going to be important for other things like ventilator-associated pneumonia. We can see big improvements throughout the hospital.” Shadle says the improved results came at little cost, and the education program was not challenging.

“One of the beauties of this project was how simple it was. We weren’t rewriting an entire program. We were just reminding people how to use the best procedures,” Shadle says. “There was not a lot in direct costs, and it was simple to implement. Sometimes, keeping things simple is important for an effort to have longevity.”


  1. Shadle HN, Sabol V, Smith A, et al. A bundle-based approach to prevent catheter-associated urinary tract infections in the intensive care unit. Crit Care Nurse 2021;41:62-71.


  • Holly N. Shadle, DNP, CRNP, FNP-BC, Nurse Practitioner, Dermatology, UPMC Susquehanna, Williamsport, PA. Email: hnshadle@gmail.com.