8 Catheter-Associated Urinary Tract Infections (CAUTI) Walden University Leadership Competencies in Nursing and Healthcare NURS-4220-5 Catheter-Associated Urinary Tract Infections (CAUTI) The healthcare system must provide safe and quality care to all patients. For years, hospitals nationwide have struggled with healthcare-associated infections (HAIs). Since HAIs are considered preventable events in a hospital setting the Centers for Medicare and Medicaid Services (CMS) established reimbursement changes and hospitals are focusing more on patient safety practices and improving processes to have better patient outcomes (Thornlow & Merwin, 2009). According to The Centers for Disease Control and Prevention (CDC, 2017), approximately seventy-five percent of hospital-acquired urinary tract infections are associated with a urinary catheter with a prolonged use being the most critical risk factor for developing a CAUTI. Also, CAUTIs can cause an overabundance of complications included but not limited to gram-negative bacteremia, sepsis, and mortality (Skanlon, 2017). In a long-term acute care hospital (LTACH), prolonged and unnecessary use of indwelling urinary catheters is interrelated with a higher risk of catheter-associated urinary tract infections (CAUTI) and extended lengths of stay (LOS) (Felix, 2016). The purpose of this paper is to reduce the usage of indwelling catheter days and decrease CAUTI rates from 2.48 to below the target rate of 1.71 by utilizing prevention practices in a 72-bed long-term acute care hospital emphasizing on the assurance of a continuous improvement process. This proposal consists of implementing alternatives before deciding to insert an indwelling catheter, utilizing maintenance bundles, and daily assessment of the necessity of the catheter. All these interventions are aiming at preventing and decreasing catheter-associated urinary tract infections (CAUTIs). The role of nurses in the prevention of CAUTIs is critical; we are the frontline of patient care and safety. Although, sometimes we encounter situations where a CAUTI occurs, the quality of care we provide to our patients reflects by the interventions we take to prevent our patients from getting an infection. Every action we make while providing care for a patient is an essential step in the quality of their care. Most patients admitted into long-term acute care have wounds or infections that require long-term antibiotics. These patients come in from acute care hospitals, and in the majority of the cases patients already have an indwelling urinary catheter, however, there are situations where the patient doesn’t come with an indwelling catheter, and nurses get orders to place one on admission. Finding alternatives to either discontinue or insert a foley is an essential part of the daily nursing assessment and on the hospitalization of these patients. Important factors to consider while assessing the patient are mobility, cognitive status, gender, and wounds. L ...

1. 8
Catheter-Associated Urinary Tract Infections (CAUTI)
Walden University
Leadership Competencies in Nursing and Healthcare
NURS-4220-5
Catheter-Associated Urinary Tract Infections (CAUTI)
The healthcare system must provide safe and quality care to all
patients. For years, hospitals nationwide have struggled with
healthcare-associated infections (HAIs). Since HAIs are
considered preventable events in a hospital setting the Centers
for Medicare and Medicaid Services (CMS) established
reimbursement changes and hospitals are focusing more on
patient safety practices and improving processes to have better
patient outcomes (Thornlow & Merwin, 2009). According to
The Centers for Disease Control and Prevention (CDC, 2017),
approximately seventy-five percent of hospital-acquired urinary
tract infections are associated with a urinary catheter with a
prolonged use being the most critical risk factor for developing
a CAUTI. Also, CAUTIs can cause an overabundance of
complications included but not limited to gram-negative
bacteremia, sepsis, and mortality (Skanlon, 2017). In a long-
term acute care hospital (LTACH), prolonged and unnecessary
use of indwelling urinary catheters is interrelated with a higher
risk of catheter-associated urinary tract infections (CAUTI) and
extended lengths of stay (LOS) (Felix, 2016). The purpose of
this paper is to reduce the usage of indwelling catheter days and
decrease CAUTI rates from 2.48 to below the target rate of 1.71
by utilizing prevention practices in a 72-bed long-term acute
care hospital emphasizing on the assurance of a continuous
improvement process. This proposal consists of implementing
alternatives before deciding to insert an indwelling catheter,

2. utilizing maintenance bundles, and daily assessment of the
necessity of the catheter. All these interventions are aiming at
preventing and decreasing catheter-associated urinary tract
infections (CAUTIs).
The role of nurses in the prevention of CAUTIs is critical; we
are the frontline of patient care and safety. Although, sometimes
we encounter situations where a CAUTI occurs, the quality of
care we provide to our patients reflects by the interventions we
take to prevent our patients from getting an infection. Every
action we make while providing care for a patient is an essential
step in the quality of their care. Most patients admitted into
long-term acute care have wounds or infections that require
long-term antibiotics. These patients come in from acute care
hospitals, and in the majority of the cases patients already have
an indwelling urinary catheter, however, there are situations
where the patient doesn’t come with an indwelling catheter, and
nurses get orders to place one on admission. Finding
alternatives to either discontinue or insert a foley is an essential
part of the daily nursing assessment and on the hospitalization
of these patients. Important factors to consider while assessing
the patient are mobility, cognitive status, gender, and wounds.
Literature review
In 2009, The Centers for Disease Control and Prevention
created guidelines for prevention of catheter-associated urinary
tract infections including recommendations to use external
catheters in cooperative male patients without urinary retention
or bladder outlet obstruction, intermittent catheterization in
patients with spinal cord injury and with bladder emptying
dysfunction. Although there is not much literature on any
alternative external devices to use with females, intermittent
catheterization, frequent perineal care for incontinent patients
and the use of bedpans are still adequate alternatives to an
indwelling catheter. The use of external continent devices
(ECD) in men such as condom catheters also known as Texas
catheters is an alternative to the insertion of indwelling
catheters for indications such as cognitive dysfunction due to

3. acute or chronic illness and men with neurogenic bladder
dysfunction (Gray, Skinner, & Kaler, 2016).
Implementation of catheter maintenance bundles is a
fundamental piece in the prevention of CAUTIs. Bundles are a
group of interventions. Unfortunately, many times staff are not
aware of the existence of bundles. Therefore, education on the
concept is a critical piece of implementation. A CAUTI bundle
includes interventions such as appropriate catheter use,
utilization of aseptic technique during catheter insertion, a
closed drainage system, and removal of the catheter as soon as
possible. (Meddings, Rogers, Krein, Fakih, Olmsted, & Saint,
2014). Appropriate indications for the use of an indwelling
catheter include relief for patients with acute urinary retention
or bladder outlet obstruction, accurate measurements of urinary
output in critically ill patients, preoperatively for select
surgeries, for incontinent patients with open sacral or perineal
wounds and to assist in wound healing, patients requiring
prolonged immobilization, and comfort for patients at end of
life care (CDC, 2016). Utilization of aseptic technique during
catheter insertion is a crucial step in preventing infection. In
most cases, a Registered Nurse of a Licensed Vocational Nurse
insert the catheter; consequently, policy and procedures, unit
guidelines, skill checks, nursing competencies, random audits,
and continuing education should be promoted (McNeill, 2017).
The maintenance of urinary catheters starts with the insertion of
the catheter. Staff must perform hand hygiene and use gloves
anytime the catheter or tubing is manipulated. Securement of
the catheter with a stat-lock to the patient’s leg helps prevent
pulling. A closed-draining system must be maintained to avoid
the entrance of germs. The bag should be below the patient’s
bladder and off the floor and emptied before it's three-quarters
full by using a container for patient use only and not allowing
the spigot touch the container. Daily meatal care is necessary to
reduce chances of infection (McNeill, 2017). Removing the
catheter as soon as possible is vital in the bundle to prevent
CAUTIs. The longer a catheter is in place, the higher risk for a

4. patient to acquire an infection. Research has shown the risk of
developing bacteriuria on catheterized patients as high as 3% to
10% per day and close to 100% after the catheter has been in
place for 30 days (McNeill, 2017).
Daily assessment for the continuance of a catheter should be
nurse-driven and supported by charge nurses, physicians, and
infection control interventionists. In the United States, the
statistics are alarming, approximately five million catheters are
placed annually, and 50% of the patients do not meet
appropriate criteria, and 40% of physicians are unaware of their
patients have a urinary catheter in place (Mori, 2014).
Advocating for patient’s safety is vital, prevention is the key in
reducing CAUTIs, and this can be accomplished not only by
limiting foley catheter insertions but by early removal of such
devices (Yatim, Wong, Ling, Tan, Tan, & Hockenberry, 2016).
Daily ongoing catheter needs assessments, and reminder
protocols for early removal of catheters have proven
effectiveness in reducing CAUTIs (Mori, 2014).
Quality Improvement Process and PDSA
The quality improvement (QI) process occurs when performance
problems are identified. There is no standard definition of
quality; quality is a feature of a product or service (Spath,
2013). Because performance problems affect the quality of
service provided, actions must be taken to identify and resolve
the issue that is causing a decrease in performance (Spath,
2013). To improve a performance problem, an analysis of
measurable collected data needs to occur to find the gaps in
performance. Once the data is analyzed, a plan for necessary
changes develops, interventions are tested, implemented, and
measured again to check the effectiveness of the project.
Throughout the years, healthcare and other industries have used
different systematic performance improvement models that have
been created assisting in the delivery of a high-quality
performance level (Spath, 2013).
The process improvement model that will be used to reduce
catheter-associated urinary tract infection (CAUTI) is the Plan-

5. Do-Study-Act-Cycle. As described by Spath (2013), currently
the PDSA is the most recognized process improvement known.
The PDSA model guarantees continuous improvement by
repeating the cycle allowing the improvement team to learn
from failures and successes assisting them to plan for the next
process change. The long-term acute care hospital where I
currently work is a 72-bed facility of which eight beds are ICU.
Most of the patients admitted to this facility come in from acute
care hospitals to wean off the ventilator, long-term antibiotic
treatment, wound care, and hyperbaric oxygen treatments. Their
length of stay ranges from 25 to 28 days. Time is crucial in the
prevention of CAUTIs for these patients, the more days they
have a catheter in place the higher chances of them acquiring a
CAUTI.
References
Centers for Disease Control and Prevention. (2017). Catheter-
associated Urinary Tract Infections (CAUTI). Retrieved from
https://www.cdc.gov/hai/ca_uti/uti.html
Thornlow, D. K., & Merwin, E. (2009). Managing to improve
quality: The relationship between accreditation standards, safety
practices, and patient outcomes. Health Care Management
Review, 34(3), 262–272. doi: 10.1097/HMR.0b013e3181a16bce
Gray, M., Skinner, C., & Kaler, W. (2016). External Collection
Devices as an Alternative to the Indwelling Urinary Catheter.
Journal of Wound, Ostomy and Continence Nursing,43(4), 413.
doi:10.1097/won.0000000000000251
Scanlon, K. A. (2017). Saving Lives and Reducing Harm: A
CAUTI Reduction Program. Nursing Economic$, 35(3), 134-
141.
Centers for Disease Control and Prevention. (2016). Catheter-
Associated Urinary Tract Infections (CAUTI). Guideline for
Prevention of Catheter-Associated Urinary Tract Infections
(2009). Retrieved from
https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.ht
ml

6. Meddings, J., Rogers, M. A. M., Krein, S. L., Fakih, M. G.,
Olmsted, R. N., & Saint, S. (2014). Reducing unnecessary
urinary catheter use and other strategies to prevent catheter-
associated urinary tract infection: An integrative review. BMJ
Quality & Safety, 23(4), 277.
doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1136/bmjqs-
2012-001774
Corley, L. (2015). INSPIRING CHANGE. CAUTI awakenings.
Nursing, 45(1), 20-21.
doi:10.1097/01.NURSE.00004589373.65995.89
McNeill, L. (2017). Back to Basics: How Evidence-Based
Nursing Practice Can Prevent Catheter-Associated Urinary Tract
Infections. Urologic Nursing, 37(4), 204-206.
doi:10.7257/1053-816X.2017.37.4.204
`
Spath, P. (2013). Introduction to healthcare quality
management (2nd ed.). Chicago, IL: Health Administration
Press.
1
Week 6 Assignment: EBP Change Process form
ACE Star Model of Knowledge Transformation
Follow Nurse Daniel as your process mentor in the weekly
Illustration section of the lesson.
Name: __________Lishan Brown___________
Star Point 1: Discovery (Identify topic and practice issue)
Identify the topic and the nursing practice issue related to this
topic. (This MUST involve a nursing practice issue.)
The topic is hospital acquired infections. The nursing practice
issue is catheter associated urinary tract infections and the high
incidence on an acute rehabilitation unit.
Briefly describe your rationale for your topic selection. Include

7. the scope of the issue/problem.
The nursing practice issue I would like to investigate is
healthcare associated infections (HAI), particularly catheter
associated urinary tract infection (CAUTI). CAUTI is very
important to investigate because I believe HAI’s can be
decreased, if not prevented. Being that nurses are educated on
the possible causes or symptoms of HAI’s, we can be more
proactive in our treatment plans. If a patient falls, that can be an
unpredictable event but HAI’s are more so predictable. With
CAUTI, making sure that the perineal area is cleaned on a
regular, consistent basis is important. Providing proper
interventions to not keep an indwelling catheter in longer than
necessary is also important.
Urinary tract infections are one of the most common hospital
acquired infections. At least 80% of urinary tract infections an
be attributed to an indwelling urinary catheter. There are
approximately 13,000 annual deaths associated with catheter
associated urinary tract infections (CAUTI). CAUTIs can
lengthen hospital stays, increase morbidity and mortality, and
raise healthcare costs.
Star Point 2: Summary (Evidence to support need for a change)
Describe the practice problem in your own words and formulate
your PICOT question.
The practice problem is members of the healthcare team are not
properly cleaning the perineal area of patients who have
indwelling catheters and indwelling catheters are placed for
unnecessary longer periods of time.
PICOT question- In (P) patients with an indwelling catheter on
an acute rehabilitation unit, does (I) cleansing the perineal area
every eight-hour period compared to (C) routine daily cleansing
of the perineal area (O) decrease the catheter associated urinary
tract infection with patients over a (T) six month period?
List the systematic review chosen from the Cochrane Database

8. of Systematic Reviews from the Chamberlain library. Type the
complete APA reference for the systematic review selected.
Interventions to improve professional adherence to guidelines
for prevention of device‐related infections.
Reference
Flodgren G, Conterno LO, Mayhew A, Omar O, Pereira CR,
Shepperd S. Interventions to improve professional adherence to
guidelines for prevention of device‐related infections. Cochrane
Database of Systematic Reviews 2013, Issue 3. Art. No.:
CD006559. DOI: 10.1002/14651858.CD006559.pub2.
List and briefly describe other sources used for data and
information. List any other optional scholarly source used as a
supplement to the systematic review in APA format.
In my search for evidence, I found an article about nurse-driven
CAUTI prevention. This evidence is relevant to my PICOT
because I would like to find a way to decrease or eliminate the
instances of CAUTI in a hospital setting. The article gives a
history of prevalence of CAUTI then goes into costs related to
CAUTI. The article also mentions ways of preventing CAUTI.
The article also discusses an algorithm used to decrease the
prevalence of CAUTI.
I also found an article about the causes of CAUTI and how to
properly clean the perineal area as an educational tool.
Reference
Russell, J. A., Leming-Lee, T. ‘Susie,’ & Watters, R. (2019).
Implementation of a Nurse-Driven CAUTI Prevention
Algorithm. Nursing Clinics of North America, 54(1), 81–96.
https://doi-
org.chamberlainuniversity.idm.oclc.org/10.1016/j.cnur.2018.11.
001
Memorial Sloan Kettering Cancer Center (2018). Caring for
Your Urinary (Foley®) Catheter. Retrieved from
https://www.mskcc.org/cancer-care/patient-education/caring-
your-urinary-foley-catheter
Briefly summarize the main findings (in your own words) from

9. the systematic review and the strength of the evidence.
The main findings from the systemic review were that there
weren’t sufficient evidence to properly corroborate the research.
The trials were too small and there was inadequate reporting of
information. Because the findings were too small, it was
difficult to determine which intervention would be optimal in
CAUTI care. The strength of the evidence was weak for the
change process.
Outline one or two evidence-based solutions you will consider
for the trial project.
An evidence-based solution would be the CAUTI Prevention
Tool by the American Nurses Association. This streamlined
evidence-based tool is used to reduce CAUTI by fewer catheters
being used, timely removal, and insertion, maintenance and post
removal care.
Reference
American Nurses Association (2009). Streamlined Evidence-
Based RN Tool: Catheter Associated Urinary Tract Infection
(CAUTI) Prevention. Retrieved from
https://www.nursingworld.org/~4aede8/globalassets/practiceand
policy/innovation--evidence/clinical-practice-material/cauti-
prevention-tool/anacautipreventiontool-final-19dec2014.pdf
Star Point 3: Translation (Action Plan)
Identify care standards, practice guidelines, or protocols that
may be in place to support your intervention planning (These
may come from your organization or from the other sources
listed in your Summary section in Star Point 2).
Care standards for urinary catheter care would be proper
education to staff and those in use of the indwelling catheter
(importance of infection prevention, symptoms of urinary tract
infection, proper care of an indwelling catheter).
Provide written criteria for the necessity of an indwelling
catheter by using the CAUTI Prevention tool.

10. Following procedures for the insertion and maintenance of an
indwelling catheter (proper handwashing, use of aseptic
techniques for insertion an removal of catheter, securing the
tubing and drainage bag, maintaining sterility, replacement of
supplies).
Having proper documentation of insertion, maintenance and
removal.
Reference
The Joint Commission (2017). Requirements for the Catheter-
Associated Urinary Tract Infections (CAUTI) National Patient
Safety Goal for Hospitals. Retrieved from
https://www.jointcommission.org/assets/1/6/R3_Cauti_HAP.pdf
List your stakeholders (by title and not names; include yourself)
and describe their roles and responsibilities in the change
process (no more than 5).
Nurse Leader- the person leading the trial, responsible for
ensuring the success of the project and day to day intricacies of
the project.
Nurse Manager- Person overseeing the trial to ensure the nurse
leader and provide assistance as necessary.
Unit Nurses- team members who are assisting in carrying out
the change process and day to day bedside care with patients
with indwelling catheters.
Patient- consents to a clinical trial and helping to identify
symptoms of CAUTI.
What specifically is your nursing role in the change process?
Other nursing roles?
My nursing role in the change process is to be at the forefront
of change process. As the nurse leader, I would want to ensure
that all supplies, education, proper documentation is in place
throughout the trial to ensure effectiveness. Unit nurses are
responsible the placement of an indwelling catheter, the daily
care management, and the removal of the indwelling catheter.
Nurses are also responsible for specimen collection. Nurses are

11. also the main person to diagnose a patient who is suspected of
CAUTI.
List your stakeholders by position titles (charge nurse,
pharmacist, etc.).-Why are the members chosen (stakeholders)
important to your project?
MD- Doctor of Medicine
DO- Doctor of Osteopathic Medicine
Nurse Educator
RN- Registered Nurse/ Unit Nurse
CNA- Certified Nursing Assistant
Nurse Manager
These members are important to the project because they are all
a part of the team who is essentially caring for a patient with an
indwelling urinary catheter. They are important in making
necessary changes to decrease the incidents of catheter
associated urinary tract infection. It all begins with proper
education right down to actually caring for the patient who has
an indwelling catheter. The MD/DO are responsible for ordering
the indwelling catheter for the patient. Unit nurses and CNA’s
are important in the day to day care of the indwelling catheter.
The nurse manager is important in making sure policies are
followed for the change process and provide additional
assistance if necessary.
What type of cost analysis will be needed prior to a trial? Who
needs to be involved with this?
The type of cost analysis which would be needed prior to a trial
would be a cost effectiveness analysis. A cost effectiveness
analysis is a method of analyzing the cost and health outcome of
an intervention. The finance department would need to be
involved in this portion of the change process. This is necessary
to see how much funds can be allocated to the project for
additional resources. It is also important to know the initial cost
to the hospital for CAUTI’s compared to after the completion of
the trial to see if there was an improvement. Having the quality

12. control department involved ensures policy and procedures are
being followed as well.
Reference
Jamison DT, Breman JG, Measham AR, et al., editors. Priorities
in Health. Washington (DC): The International Bank for
Reconstruction and Development / The World Bank; 2006.
Chapter 3, Cost-Effectiveness Analysis. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK10253/
Star Point 4: (Implementation)
Describe the process for gaining permission to plan and begin a
trial. Is there a specific group, committee, or nurse leaders
involved?
The process of gaining permission to plan and begin a trial first
begins with management of the hospital. One cannot perform a
trial without the permission of management. There also needs to
be the onboarding of the finance department to see how much
resources can be allocated to the project. Quality assurance is
important for ensuring policy and procedures are being
followed. There also needs to be permission from other nurses
on the unit for their cooperation. Having signed permission
from patients are also important to begin the trial. Patients need
to be aware of what they are getting into and if they would
cooperate or not.
Describe the plan for educating the staff about the change
process trial and how they will be impacted or asked to
participate.
First, coordination with a nurse educator is important in order
for them to educate staff members on the change process. Nurse
educators can educate staff members of the proper way of
preventing CAUTI and an ongoing refresher course throughout
the trial period. Educators could be available for all shifts
throughout the day in order for convenience to the staff.
Educators can come to the unit to educate for added

13. convenience. Online educational learning exercises would be an
also added benefit.
Outline the implementation timeline for the change process
(start time/end time, what steps are to occur along the timeline).
The implementation timeline for the change process would be
over a six-month period. This would include the education of
staff members on proper catheter care and documentation. Also
included in this timeline would be the trial of patients who have
consented to be a part of the change process.
List the measurable outcomes based on the PICOT. How will
these be measured?
The measurable outcomes based on the PICOT would be the
number of CAUTI incidents over a six-month period. This can
be measured by the incident reports for CAUTI, the necessary
medications needed to treat CAUTI and also the number of
indwelling catheterizations utilized on the unit.
What forms, if any, might be used for recording purposes during
the pilot change process. Describe.
Forms that may be used for recording purposes would be
documentation of education and refresher for staff members.
Consent forms from patients detailing the intention of the trial
would be important. Staff would be required to document each
time perineal care was given or any catheter care to the patient.
Staff would also be given a self-assessment on their readiness
and understanding of catheter care in order to effectively care
for the population of patients with indwelling catheters.
What resources are available to staff (include yourself) during
the change pilot?
Resources that would be available to staff during the pilot
would be extra catheter care supplies, such as Foley catheter
bags, tubing, stat locks, perineal soap, etc. Educational
resources for staff and patients on recognizing CAUTI, ways of
preventing CAUTI and general care for an indwelling catheter.

14. Will there be meetings of certain stakeholders throughout the
trial? If so, who and when will they meet?
Meetings throughout the trial will be held with stakeholders on
the progress of the trial and if any necessary changes need to be
made. Meetings will be held weekly during the first month and
twice per month for the remainder of the trial. All stakeholders
would be invited to the meetings to get a progress of is
happening during the trial. Opinions can be shared on what
could be effective or changes that can be made to make the trial
a success.
Star Point 5: (Evaluation)
How will you report the outcomes of the trial?
Reporting of the outcomes will be posted throughout the staff
rooms on the unit in the form of a data report. A meeting at the
end of the trial will also be held to discuss how effective the
trial was or wasn’t. The data from the report can then be given
to management to consider further implementation or
recommendations.
What would be the next steps for the use of the change process
information?
Using the information from the trial, ongoing changes can
continue to be made regarding CAUTI using the takeaway from
the trial. After seeing what worked and what didn’t, staff can
adapt what was successful and build on that information and
make progress in decreasing the incidents of CAUTI on the unit.
2.2019 Update. DLP