Hospital program leads to dramatic drop in CAUTIs

Four-fold focus includes removal protocol

Looking for a quality improvement (QI) project targeting catheter-associated urinary tract infections (CAUTIs)? Here's one that produced dramatic results, including a 68% decline in the CAUTI rate and a 20% reduction in the use of indwelling urinary catheters. Also, 90% of the nursing staff completed a nursing indwelling urinary catheter skills competency.

Overall, the hospital-acquired CAUTI rate decreased from 3.09 to 0.99/1000 IUC days.

"Our goal was to improve the safety at our facility and we did that in a pretty rapid manner," says Elaine Flynn, RN, MSN, CIC, Infection Preventionist for Moss Rehab, which is part of Albert Einstein Healthcare Network in Philadelphia, PA.

A catheter-associated UTI can extend a patient's hospital stay by one to two days and increase the cost of their care by some $750-$1500. In many cases, Medicare and other insurers regard CAUTIs as a preventable condition. CMS may not reimburse the hospital for the additional costs associated with treating the infection.

Flynn and colleagues compared their hospital's urinary catheter practices to those identified in the 2008 Compendium of Strategies to Prevent Healthcare-Associated Infections published by the Society for Healthcare Epidemiology of America (SHEA). The SHEA guidelines outline best practices to prevent catheter-associated urinary tract infections (CAUTI) in hospitals.1

The UTI Prevention team found areas where the hospital could improve its practices, so they decided to tackle the initiative as a multidisciplinary team project. A team of health care providers including physicians and nurses volunteered to participate on the CAUTI Prevention Team, adopting the Plan–Do–Study–Act quality model for the process.

Over an 18-month period the CAUTI Prevention team identified key evidence-based practices to prevent the infections. They broke the mission into four key areas, which were in turn targeted by four work groups:

1. Develop written guidelines for urinary catheter insertion and maintenance. Clinicians armed with guidelines or a checklist based on clinical indications often have better compliance and better outcomes, Flynn notes. The bladder management work group identified evidenced-based practices for insertion and maintenance of indwelling urinary catheters. These included performing hand hygiene before and after insertion, aseptic technique, using the smallest size urinary catheter that is appropriate, using a closed system catheter, securing the catheter and placing the drainage bag below the bladder.

Process measures to monitor catheter maintenance include:

  • Is there a written clinical indication for the catheter?
  • Is urinary catheter stabilized?
  • Is the urinary drainage system closed?
  • Is the urinary drainage bag below bladder?
  • On rounds, reassess clinical indication for the catheter.

2. Document guidelines and order sets. "We created an order set that physicians use to identify patients and the clinical indications," Flynn says. "There's a medical form used as a checklist to ensure patient safety."

If the patient comes in with an indwelling urinary catheter the history and physical must reflect that they have one and why. They have to list the clinical indication. The physician also has to order an indwelling urinary catheter on an order set. Nurses have to make a daily review and document the continued clinical indication for the urinary catheter.

"Our goal was to avoid unnecessary urinary catheter insertions," Flynn says. "Each day that a urinary catheter is in place there's an increased risk for a urinary tract infection."

The documentation guidelines/order set work group developed a nurse-driven protocol that will allow nurses to remove indwelling urinary catheters that are not indicated clinically. Also, there is a reminder embedded in the electronic medical record for catheter removal when it is no longer clinically indicated.

Nurses can refer to a catheter removal flow chart, which outlines the steps to take given different scenarios. (See diagram, below.)

Indwelling Urinary Catheter (IUC) Removal Protocol

Outcomes data, including number of HA-CAUTIs per 1,000 device days and catheterization utilization rates, are provided to the shared governance council, the physician group, and the nursing unit each month. The report explains the device utilization rate and the HA-CAUTI rate.

3. Provide urologic equipment. The hospital switched from having nurses collect four packages to create the urinary indwelling catheters to having all the pieces in one kit.

"We had urinary indwelling catheters that would be in one package, while another package had the bag, another one had the stabilization device, and still another the insertion tray," Flynn says.

In addition, the various packages often were not stored in the same area or available at the same time. This complex process increased the risk for contamination and infection, so the hospital switched to a closed urinary catheter system, which has the catheter pre-attached to the drainage bag with a stabilization device within it.

"So when nurses go into the clean utility room to get the catheter, they pull out one package with all of those products in it," Flynn says. "This means there is better compliance and less risk of contamination."

Plus it saves nurses time because they can pick up one box at one location, only needing to decide what size to select, she adds.

"It costs more, but the return on investment is reduced hospital-acquired infections, which is important for patient safety and provides better care," Flynn says.

Another equipment change was to have ultrasound bladder scanners added to each area. When patients no longer have clinical indications for catheters they are removed, and nurses monitor patients to make certain they could urinate. If there is no evidence of the patient urinating, nurses use the scanner to see if the bladder is empty. If so, no further catheterization is necessary.

"We did an assessment of how many bladder scanners were available and made a request to purchase additional ones to make certain every nurse had access to one," she adds.

4. Educate to ensure competency in all areas. Physician members of the CAUTI prevention team presented an education program to medical staff and residents in the various specialties, including departments of surgery, internal medicine, geriatrics, and others. The program focused on UTI prevention, implementation of the clinical indication for insertion and documentation requirement, and the daily documentation of the need for a catheter.

Nurses were trained on the procedure of inserting catheters and evidence-based practices to ensure prevention of UTIs. These were self-learning modules for both licensed nurses and non-licensed staff. Licensed staff were trained on all UTI prevention strategies, including utilization documentation and how to insert urinary catheters. Nonlicensed staff were trained on maintenance features, including hand hygiene and CAUTI prevention.

"We created an education group and education plan and competency for our nursing staff," Flynn says. "It was an education module with a test at the end."


  1. Lo E, Nicolle L, Classen D, et al. Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals. Infect Con Hosp Epi2008;29(supl 1):S41-S50.