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Quality Improvement Project

NURS362 - FALL2015
Elizabeth N., Charleen K., Young-Jin K., Tomi D.

Summary of the Problem

How are CAUTI caused?

germs can enter the urinary tract when the catheter is being placed or while the catheter
remains in the bladder.

CAUTI has been associated with increased morbidity, mortality, health care costs, & length of

CAUTI is one of five common Healthcare Associated Infections (HAIs)

HAI are infections patients can get while receiving care in a healthcare facility

Why patients get urinary catheters:

unable to urinate on their own

urine output needs be measured such as in intensive care units

doing and after some types of surgery such as orthopedic surgery

doing some tests of the kidneys and bladder

Types of catheters: indwelling, intermittent, external, & suprapubic

Key players involved include the healthcare team and the patient. The staff inserts the
catheter and follows up with catheter care. While the patient is the one with the catheter.

Comparing the problem

to national and state indicators

6 percent increase in CAUTI between

2009 and 2013
12% 2,781 U.S. hospitals had an SIR
significantly worse than the national
SIR of 1.06.
1 of 4 patients in the hospital will
have a urinary catheter during their
stay. 50% of which are unnecessarily
placed and increases length of stay if
CAUTI is present.

STATE: Hawaii
Hawaii : 38% decrease reported between 2012
and 2013
*When a urinary catheter is not put in correctly,
not kept clean, or left in a patient for too long,
germs can travel through the catheter and
infect the bladder and kidneys.*
0% Among the 13 hospitals in Hawaii with
enough data to calculate an SIR, 0% had an SIR
significantly worse than the national SIR of
*Still need to improve even with


QI tools for Failure Mode and Effects analysis

1. Select a process to analyze: to prevent residents from having CAUTI
2. Select people for the team: physicians, infection-related staff, nurses,
3. Describe the process:
Removal/postIndication/ insertion

What could go wrong during each step of the process


Untrained person
Inappropriate indications
(women, elderly, impaired
immunity, incontinence
maintenance, etc)
Violation of aseptic
technique (hand washing,

Disconnection or

Non-sterile to obtain
urine sample

Urine flow obstruction

(tube location lower than
bladder, kinked)

Placed longer
than necessary

QI tools for Failure Mode and Effects analysis

Pick which problems to work on eliminating and
(question about outcome, severity, and probability
using descriptive terms)
(ex. catheter use for more than prescribed # of days may have less
severe outcome than the violation of sterile technique when inserting, but
the probability may be much higher in the organization - priority)

Design and implement changes to reduce or prevent
Drill down the root cause of the problems utilizing Why? technique. (ex.
Why does our organization have such high incidence of overdue use of urinary
catheter? - Shortage of nursing staff)

QI tools for Failure Mode and Effects analysis


Design and implement changes to reduce or prevent problems

Core Measures
Insert catheter only for appropriate
Leave catheters in place only as
long as needed (staff training, a
display board, educational video at
Sterile techniques
Maintain a closed drainage
Maintain unobstructed urine flow


Supplemental Measures
Alternatives to
indwelling urinary
Portable ultrasound
devices to reduce
Antimicrobial/antisepticimpregnated catheter

Measure the success of process changes


The tool that the project leaders evaluate the plans

Goal - zero occurrence
Measure - # of CAUTI incidence divided by total # of hospitalization X 100
Time - one month

A small test & documentation - See if pts are aware how many days theyve had UC

Learned that most of pts dont know the length of their catheterizations

Implement pt education and place a board in pts room indicating the # of days of

Recommendations to eliminate or reduce the

risk of the problem
Reduce the absolute number of patients with urinary catheters by:
Minimize urinary catheter use and duration of use in all patients,
particularly those at higher risk for CAUTI or mortality from catheterization
such as women, the elderly, and patients with impaired immunity
Avoid use of urinary catheters in patients and nursing home residents for
management of incontinence.
Use urinary catheters in operative patients only as necessary, rather than
Proper hand hygiene immediately before and after insertion or with any
manipulation of the catheter device or site.
The addition of an antimicrobial drug in the coat of catheters is associated
with delayed bacterial colonisation.
(silver-alloy, nitrofural-impregnated, or standard polytetrafluoroethylene
urinary catheters)
Maintain a closed sterile drainage system with periodical bladder scans.
Electronic medical record system of alerts and reminders.
Review of skills: re-fresh skills course & specialized training team.

Data collection to evaluate success rate

Depending on accessibility: CAUTI prevention checklist activated
on electronic medical record for a selected hospital.
Faculty based risk assessment scores and monthly surveys
of necessary units.
Consider reporting/documenting both process and outcome
measures to senior Administrative, medical, and nursing
leadership and clinicians who care for patients at risk for CAUTI.
Catheter usage/supply unit count per year (decreased from
previous years)
Compare with nurse subtraction of IUC from omi-cell.
Room for error: wasted IUC sets

Centers for Disease Control. (2009). Guideline for Prevention of Catheter-Acquired Urinary Tract Infections 2009. Retrieved from:
Center for Disease Control and Prevention. (2015). Healthcare-associated infections progress report. Retrieved from:
FAQ's about Catheter-Associated Urinary Tract Infections. (2015, January 20). Retrieved from
Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009. (2009, December 29). Retrieved from
Leone, M. (2012). Prevention of CAUTI: simple and beautiful. The Lancet. Vol. 380, Issue 9857. Pg. 1891-1892. doi:10.1016/S01406736(12)61515-3
Oman, K., Makic, M., et. al. (2011). Nurse-directed interventions to reduce catheter associated urinary tract infection. American Journal of
Infection Control. Vol.40, Issue 6. Pg. 548-553. doi:10.1016/j.ajic.2011.07.018
Simon, M., Klaus, S. & Dunton, N. (2009). Using NDNQI data to manage CAUTI. Article in Nursing Management. Vol. 40, Issue 6. Pg. 16-18.
Meddings, J., Reichert, H., & McMahon, LF. (2014). Challenges and proposed improvements for reviewing symptoms and catheters. AM J
Infection Control. Vol.42 Issue10. Pg. s236-s241. doi: 10.1016/j.ajic.2014.05.024.