LWW/JNCQ JNCQ-D-13-00096 May 12, 2014 20:9

J Nurs Care Qual

Vol. 29, No. 3, pp. 245252
Copyright c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Implementation of a
Nurse-Driven Protocol
to Prevent Catheter-Associated
Urinary Tract Infections
Irene Alexaitis, DNP, RN, NEA-BC;
Barbara Broome, PhD, RN, FAAN
This article describes a quality improvement project to decrease catheter-associated urinary tract
infections (CAUTIs) at an academic medical center. A criteria-based, nurse-driven protocol for
discontinuation of indwelling catheters and use of bladder ultrasonography in conjunction with
intermittent catheterizations was the foundation for change. The CAUTI rate, the number of
CAUTIs, cost of medications and supplies associated with treating CAUTIs, catheter duration, and
intensive care unit length of stay decreased after protocol implementation. Key words: bladder
ultrasound, catheter-associated urinary tract infections, intermittent catheterization, nurse-
driven protocol, quality improvement, urinary tract infections

A LTHOUGH national guidelines have been

developed for the prevention of hospital-
acquired catheter-associated urinary tract in-
all hospital-acquired infections.1 CAUTIs are
responsible for 387 550 preventable hospital-
acquired infections per year.2 While the Cen-
fections (CAUTIs) and strategies to prevent ters for Disease Control reported a 7% de-
CAUTIs have been demonstrated through re- crease in CAUTIs between 2009 and 2011,
search, CAUTIs remain responsible for 40% of CAUTIs in intensive care units (ICUs) re-
mained essentially unchanged over the same
time period.3 CAUTIs are one of the most pre-
Author Affiliations: Nursing and Patient Services, ventable hospital-acquired infections in the
University of Florida (UF) Health Shands Hospital, United States4 yet remain the most preva-
Gainesville (Dr Alexaitis); and Community/Mental
Health, Department of Nursing, University of South lent hospital-acquired infection in acute care
Alabama, Mobile (Dr Broome). hospitals.5 They increase cost and length of
Dr Alexaitis received funding to purchase equipment stay (LOS), cause patient discomfort, and can
for the project from UF Health Shands Hospital and is result in death.6 The Centers for Medicare &
employed by UF Health Shands Hospital. For the other Medicaid deem CAUTIs preventable and no
author, none are declared.
longer reimburse hospitals for cost associated
Supplemental digital content is available for this article. with CAUTIs.1 In addition, The Joint Commis-
Direct URL citation appears in the printed text and is
provided in the HTML and PDF versions of this article sion added the prevention of CAUTIs to the
on the journals Web site (www.jncqjournal.com). National Patient Safety goals in January 2013.7
The authors declare no conflict of interest. Consequently, acute care organizations are
motivated to prevent CAUTIs from a quality,
Correspondence: Irene Alexaitis, DNP, RN, NEA-
BC, Nursing and Patient Services, UF Health Shands accreditation, and financial perspective.
Hospital, PO Box 100335, Gainesville, FL 32610
(alexai@shands.ufl.edu).
AREA FOR IMPROVEMENT
Accepted for publication: November 24, 2013
Published ahead of print: January 2, 2014 Guidelines for the prevention of CAUTIs
DOI: 10.1097/NCQ.0000000000000041 were previously implemented at an academic
245

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LWW/JNCQ JNCQ-D-13-00096 May 12, 2014 20:9

246 JOURNAL OF NURSING CARE QUALITY/JULYSEPTEMBER 2014

medical center in Florida. However, 140 neurosurgical department. The NSICU nurse
CAUTIs were identified in 2012 at the aca- manager and clinical leaders championed the
demic medical center and goals for the pre- project. The chief nursing officer functioned
vention of CAUTIs had not been achieved as the project leader, and the clinical leaders
in all nursing units. The highest CAUTI rates and charge nurses in the NSICU facilitated the
and catheter utilization were in the ICUs. The practice change.
executive team at the medical center recog-
nized the need to improve the safety, effec-
LITERATURE REVIEW
tiveness, and efficiency of care for patients
with respect to urinary catheter management
A comprehensive review of the litera-
and developed a strategic goal to prevent
ture was conducted to find the best evi-
CAUTIs.
dence for urinary catheter management and
The neurosurgical intensive care unit
CAUTI prevention. The Nursing Reference
(NSICU) was selected for the quality improve-
Center, National Guideline Clearinghouse,
ment (QI) pilot project. Both CAUTI rates
Cochrane, PubMed, Cumulative Index to
and catheter utilization rates in the NSICU
Nursing and Allied Health Literature, and Dy-
exceeded National Health Safety Network
naMed were searched using prevention of
(NHSN) benchmarks in 2012. CAUTI rates
catheter-associated urinary tract infections as
in the NSICU were 4.4, 8.5, 3.6, and 2.8 per
the search term. The GRADE8 criteria were
1000 catheter-days per quarter, respectively,
used to evaluate the studies. Studies explored
in 2012 as compared with the NHSN 25th
alternatives to indwelling catheters, routine
percentile of 1.3. In addition, the catheter
catheter maintenance, protocols for catheter
utilization rate in the NSICU exceeded the
management, and reminders to physicians
NHSN 10th percentile benchmark of 58% for
and nurses to remove catheters.
all 4 quarters in 2012, 62.1%, 63.1%, 64.2%,
and 72%, respectively. In 2012, the NSICU
accounted for 22.2% of hospital-acquired Alternatives to indwelling catheters
CAUTIs. and routine catheter care
After reviewing the retrospective data, Insertion of indwelling catheters should
development and implementation of a nurse- be considered after assessing all other
driven protocol for urinary catheter manage- alternatives.9-12 Alternatives to indwelling
ment was undertaken to address the identified catheters include condom catheters and in-
issues. Eight goals were identified to improve termittent catheterization to avoid insertion
the safety, efficiency, and effectiveness of of indwelling catheters and bedside ultra-
care for patients with indwelling catheters in sound bladder scanners to limit needless
the NSICU. Goals were to reduce (1) monthly catheterizations.9-12 In a meta-analysis of 4
CAUTI rates, (2) catheter utilization, (3) num- studies, Palese and colleagues13 found uti-
ber of CAUTIs per month, (4) cost of supplies lization of bladder ultrasound procedures re-
and medications associated with CAUTI duced CAUTI risks by 73% when compared
treatment, and (5) LOS; (6) educate nurses with intermittent catheterizations and were
on routine catheter care, bladder scanning, effective in reducing needless intermittent
and a nurse-driven protocol; (7) achieve 95% catheterizations when urinary retention was
compliance with routine catheter care; and a concern after early removal of indwelling
(8) achieve 95% compliance with the nurse- catheters. Pratt and Pellowe9 and Gould and
driven protocol for management of urinary colleagues10 conducted systematic reviews of
catheters. existing guidelines for insertion and main-
Support for the project was obtained from tenance of indwelling catheters. Findings
the chief operating officer, chief medical offi- supported existing approaches for urinary
cer, chief quality officer, and the chair of the catheter insertion and maintenance.

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LWW/JNCQ JNCQ-D-13-00096 May 12, 2014 20:9

A Nurse-Driven Protocol for CAUTI Prevention 247

Nurse-driven protocols METHODS

14
Gotelli et al conducted a QI project in an
acute care hospital using a nurse-driven pro- Setting
tocol with criteria for insertion and removal The project was conducted at an academic
of catheters when indications for indwelling medical center located in Florida. The QI
catheters were no longer met. The project project had institutional review board ap-
demonstrated a 7% decrease in catheter uti- proval and was conducted in a 30-bed adult
lization after 3 months. However, CAUTI rates NSICU. Patients with neurosurgical and neu-
remained unchanged. Topal et al15 conducted rological conditions are admitted to the unit.
an observational, prospective, cohort study Common diagnoses include aneurysms, ar-
using a nurse-driven, criteria-based, indepen- teriovenous malformations, central nervous
dent protocol to allow nurses to discontinue system neoplasms, traumatic brain injuries,
catheters and use bladder scanners to mon- spinal cord injuries, hemorrhagic and is-
itor for urinary retention. Eighteen months chemic strokes, and status epilepticus. Man-
postintervention results demonstrated a 65% agement of incontinence in the NSICU has
reduction in catheter insertions, 79% reduc- been a challenge. Patients in the NSICU are
tion in catheter utilization, 73% reduction of neurologically impaired, comatose, and often
inappropriate catheter use, and an 81% reduc- ventilated causing a loss of bladder function.
tion in CAUTIs per 1000 catheter-days from Furthermore, medications are frequently ad-
baseline. ministered to induce diuresis in order to de-
crease cerebral edema caused by neurological
injuries and neurosurgical procedures. Nurses
Physician and nurse reminders are challenged to prevent skin breakdown and
accurately monitor urine output without an
Meddings et al16 conducted a systematic re- indwelling catheter.
view and meta-analysis of 14 studies and found An analysis of the NSICU revealed insuf-
that CAUTI rates decreased 56% with physi- ficient data regarding nurses knowledge of
cian and nurse reminders and prewritten stop evidence-based practice guidelines for rou-
orders to discontinue catheters in 11 stud- tine catheter maintenance, urinary catheter
ies reviewed. Catheter duration decreased by indications, bladder scanning, and intermit-
2.16 days, and CAUTI rates decreased by 41% tent catheterization. In addition, delays in
with stop orders. Blodgett17 conducted a sys- removing catheters were occurring because
tematic review of the literature and found that nurses had to obtain a physicians order be-
face-to-face reminders during physician-nurse fore discontinuing urinary catheters when in-
rounds, paper-based checklist reminders, and dications were no longer met, and compliance
educational reminders during rounds with ed- monitoring of evidence-based guidelines was
ucators significantly reduced catheter dura- inconsistent.
tion and CAUTIs.
In summary, several strategies were ef- Sample
fective for CAUTI prevention and decreas- Patients in the NSICU with indwelling uri-
ing catheter-days. Implementing alternatives nary catheters during the evaluation period
to indwelling catheters, such as the use of (n = 183) were included in the sample. All
condom catheters, bladder ultrasonography, registered nurses (n = 107) working in the
and intermittent catheterizations, reduced NSICU were included.
CAUTIs and catheter-days. Furthermore, im-
plementing nurse-driven protocols, stop or- QI project
ders to remove catheters, and reminders for The FADE18 QI methodology was used
nurses and physicians to remove catheters for the project. This methodology includes
demonstrated a reduction in CAUTIs. Focusing on the problem (CAUTIs); Analyzing

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LWW/JNCQ JNCQ-D-13-00096 May 12, 2014 20:9

248 JOURNAL OF NURSING CARE QUALITY/JULYSEPTEMBER 2014

data (catheter utilization, CAUTIs, CAUTI or greater pressure ulcer, end-of-life/palliative

rates, compliance with urinary catheter guide- care, hemodynamic instability more than 24
lines, and nurses knowledge of guidelines); hours, and urine output of 250 mL or more
Developing a plan to reduce CAUTIs; and per hour.
Executing the plan and Evaluating results
against targeted goals.
Bladder ultrasonography and
Protocol development and intermittent catheterizations
implementation Criteria for frequency of bladder ultrasound
The team developed a QI plan that included procedures and intermittent catheterizations
an evidence-based, nurse-driven protocol for were provided by the chief of urology and
urinary catheter management to decrease developed to minimize intermittent catheter-
CAUTIs. The plan addressed 6 objectives: pro- izations and prevent damage to the bladder
tocol approval by NSICU stakeholders, educa- caused by urinary retention. The protocol was
tion of nurses about alternatives to indwelling ordered by physicians on all NSICU admis-
catheters and routine catheter care, education sions and enabled nurses to use intermittent
of nurses and physicians about the protocol, catheterizations and insert and discontinue
compliance monitoring to ensure adherence catheters on the basis of criteria. Nurses were
to the protocol and guidelines for routine directed to perform bedside bladder ultra-
catheter care, daily catheter rounds to assess sound procedures to monitor postvoid resid-
the need for catheter continuation, and anal- uals to assess for urinary retention and per-
ysis of identified CAUTIs. form intermittent catheterizations based on
The protocol was developed by the project ultrasound readings. Bladder ultrasound pro-
leader on the basis of nurse-driven proto- cedures were required when a patient did not
cols and guidelines found in the literature, void in 4 hours, complained of bladder dis-
policies and procedures in the NSICU for comfort at any time, voided less than 250 mL,
urinary catheter management, and consulta- or was incontinent. Intermittent catheteriza-
tion with physicians and clinical nurse lead- tions were required when the postvoid residu-
ers in the NSICU and the chief of urology. als or bladder scan readings were greater than
Strategies identified in the literature to pre- 250 mL. The goal of intermittent catheteriza-
vent CAUTIs and decrease catheter-days were tions was to restrict urine in the bladder to
incorporated into the nurse-driven protocol 250 mL or less; therefore, the frequency of
and included criteria-based discontinuation of intermittent catheterizations varied for each
catheters (stop orders), bladder ultrasonog- patient.
raphy to prevent needless catheterizations, Bladder ultrasound procedures and inter-
and intermittent catheterizations to reduce in- mittent catheterizations were discontinued af-
dwelling catheter-days ter 2 postvoid residual ultrasound readings
The protocol provided criteria for in- of less than 100 mL for patients voiding
dwelling catheter use and directed nurses to 250 mL or more; however, nurses contin-
discontinue indwelling catheters when crite- ued to monitor voiding every 2 to 4 hours
ria were no longer met. Indications for in- for 24 hours. Nurses performed bladder ultra-
dwelling catheters included tissue plasmino- sound procedures and intermittent catheter-
gen activator administration within 24 hours izations and monitored urine output every
of catheter insertion, bladder outlet obstruc- hour for patients displaying indicators of in-
tion, acute urinary retention more than 48 complete bladder emptying (voiding <250
hours, genitourinary or gynecological surgery, mL in a 2- to 4-hour period or incontinence).
significant hematuria, a physicians order to Patients who did not spontaneously void in
maintain a catheter for longer than the pro- 4 hours or complained of bladder discom-
tocol, an unstable spinal fracture, a stage 2 fort at any time underwent bladder ultrasound

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LWW/JNCQ JNCQ-D-13-00096 May 12, 2014 20:9

A Nurse-Driven Protocol for CAUTI Prevention 249

procedures, intermittent catheterizations, and leader conducted a debriefing to analyze each

monitoring for spontaneous voiding every CAUTI and identify its root causes.
hour. If a patient did not spontaneously void in
Protocol revisions
48 hours, an indwelling catheter was inserted
and a follow-up appointment was scheduled After initial implementation of the proto-
in the urology clinic after discharge. col, modifications were made on the basis
A flowchart of the protocol was created of the nurses feedback and experience using
and presented to stakeholders including the the protocol. For example, after initial imple-
chair of neurosurgery, the NSICU medical mentation of the protocol, nurses recognized
director, and members of the NSICU interdis- the need to obtain a baseline bladder ultra-
ciplinary QI team. Approval of the protocol sonogram on admission to assess urinary sta-
was obtained and copies of the protocol tus for patients without indwelling catheters
were posted for easy reference. Supple- and determine when an intermittent catheter-
mental Digital Content Figure (available at ization might be required. Revisions to the
http://links.lww.com/JNCQ/A55) depicts a protocol were completed, and laminated pro-
flow diagram of the protocol. tocol flowcharts were distributed. The proto-
col was not incorporated into the electronic
Education and compliance monitoring medical record during the evaluation period
Computer-based education was developed because revisions were being made during the
by the project leader and provided to nurses study.
prior to protocol implementation. Didac-
tic education encompassed routine catheter RESULTS
maintenance, bedside bladder ultrasound in-
dications, and criteria in the nurse-driven pro- Education
tocol. Simulation education to assess profi- Three tests using didactic and simulation
ciency in using the bladder ultrasonography testing were administered to measure knowl-
was provided to nurses by the clinical lead- edge acquisition. Didactic tests focused on
ers and charge nurses. Knowledge acquisition principles of bladder ultrasound use and the
of education was measured using posttests protocol. Simulation testing was used to as-
and simulation checklists. Physician educa- sess competency in performing bladder ul-
tion was provided in meetings held by the trasound procedures. Average posteducation
chair of neurosurgery and the physician di- test scores were 90% or more on each test.
rector of quality for neurology. A 5-item, scenario-based, computerized
Laminated copies of the protocol flow di- test was administered to assess nurses knowl-
agram were provided and posted through- edge of the principles of conducting bladder
out the NSICU for easy reference. Monitoring ultrasound procedures and interpreting the
to evaluate compliance with routine catheter results. The test was completed by 102 nurses
care and the nurse-driven protocol was con- (92%), with an average test score of 91%.
ducted by the clinical leaders and the project A written 8-item, multiple-choice, scenario-
leader. During daily catheter rounds, the clin- based test was administered to measure
ical leaders discussed each patient with the knowledge acquisition of the protocol. The
primary nurse and reviewed the protocol to test was completed by 95 of the nurses (85%),
reinforce education. A checklist to monitor with an average test score of 95%. Finally, a
protocol compliance was developed by the 15-item checklist was used during simulation
project leader and used to review medical testing for bladder ultrasound competency
records of all patients with urinary catheters. assessment. Simulation testing was com-
Compliance data were shared with the clini- pleted by 96 nurses (86%). Proficiency in
cal leaders and the nurses. When CAUTIs were performing bladder ultrasound procedures
identified, the clinical leaders and the project during simulation testing was 100%.

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LWW/JNCQ JNCQ-D-13-00096 May 12, 2014 20:9

250 JOURNAL OF NURSING CARE QUALITY/JULYSEPTEMBER 2014

Compliance monitoring Hospital LOS for patients with a diagnosis of

Medical records of 183 patients with in- CAUTIs during the study period ranged from
dwelling catheters were reviewed during the 10 to 106 days, with a mean of 42.5 days and
evaluation period. The project leader and a a median of 27 days as compared with an
trained nurse who did not work in the NSICU average LOS of 8.05 days for patients without
reviewed daily documentation for each pa- CAUTIs. Average hospital LOS for patients
tient with an indwelling catheter. The data with a diagnosis of CAUTIs increased 8.14%
collected tool included date of catheter in- (from 39.3 to 42.5; P = .775) postprotocol
sertion and discontinuation, catheter size, in- implementation.
dication for the catheter, catheter mainte-
nance, patient/family education about pre- DISCUSSION
vention of infections when catheters are in
place, daily meatal hygiene, and performance The nurse-driven protocol for urinary
of bladder ultrasound procedures and inter- catheter management was successful in
mittent catheterizations as indicated in the improving 3 of 5 patient outcome goals,
protocol. Overall compliance with the proto- although statistical significance was not
col improved from 85.9% to 90.1% during the demonstrated. The CAUTI rate, average
evaluation period, and compliance with number of CAUTIs per month, and cost of
documentation of routine maintenance of medications and supplies associated with
catheters improved from 89.3% to 98%. Daily treating CAUTIs decreased during the eval-
monitoring and weekly feedback of findings uation period. However, catheter utilization
from the medical record review were success- rates and hospital LOS increased. The project
ful in improving protocol and documentation did not support findings by Gotelli et al14
compliance. and Topal et al,15 demonstrating decreased
catheter utilization after implementation of
a nurse-driven protocol. However, the study
Outcomes did support findings by Topal et al,15 demon-
Catheter utilization, CAUTI rates, number strating a reduction in CAUTI rates after
of CAUTIs per month, LOS, and cost asso- implementation of a nurse-driven protocol.
ciated with treating CAUTIs were collected Education and validation of knowledge ac-
on 322 patients during the study period and quisition using didactic, scenario-based, and
compared with data from 497 patients prior simulation testing of nurses about routine
to protocol implementation. Average catheter catheter maintenance and the protocol en-
duration decreased by 2.5 days, whereas aver- sured that nurses possessed the knowledge
age catheter utilization increased from 74.14% required prior to project implementation. Im-
to 76.2% (P = .791) postprotocol implemen- provement in CAUTI rates, catheter duration,
tation. The average CAUTI rate decreased by and the average number of CAUTIs per month
20.5% (from 3.85 to 3.06 per 1000 catheter- despite increased catheter utilization during
days; P = .296), and the average number of the evaluation period is attributed to daily
CAUTIs per month also decreased for the catheter rounds conducted by the clinical
same time period by 14.1% (from 2.33 to leaders and charge nurses to reinforce ed-
2.0 per month; P = .495). The average cost ucation and monitor protocol compliance.
of medications and supplies associated with Study findings supported the Blodgett17 study,
treating CAUTIs decreased 40.7% (from $334 demonstrating that rounds with educators re-
to $198 per patient; P = .514) after protocol duced catheter duration. Protocol implemen-
implementation. tation did not decrease overall hospital LOS or
All patients with a diagnosis of CAUTIs in catheter utilization as expected. Project eval-
the NSICU experienced significantly longer uation occurred for 2 months postprotocol
hospital stays than patients without CAUTIs. implementation and may have contributed to

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LWW/JNCQ JNCQ-D-13-00096 May 12, 2014 20:9

A Nurse-Driven Protocol for CAUTI Prevention 251

these results and the lack of statistically signif- Stakeholder involvement, education
icant findings. of nurses, compliance monitoring, and
Limitations of the study include the ho- continuous feedback to clinical leaders
mogeneous population, small sample size in and nurses from medical records reviews
one unit at a single acute care hospital. Plans were critical in decreasing CAUTI rates and
are underway to continue the study in the catheter duration. Involving stakeholders
NSICU and implement the protocol through- in development of the nurse-driven pro-
out the hospital. Although preliminary results tocol created buy-in and commitment for
of the project are promising, additional data the project. Feedback between the nurses
are required to determine statistical signifi- and the project team fostered communica-
cance and sustainability of the nurse-driven tion, collaboration, and improved protocol
protocol for urinary catheter management. compliance.

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