Running head: QUALITY IMPROVEMENT PROCESS: CAUTIS

Quality Improvement Process: CAUTIs

Amy Lewis
Ferris State University

Catheter associated urinary tract infections (CAUTIs) represent a significant share of

hospital acquired infections (HAI) (Rabideaux, 2013). By reducing the frequency of CAUTIs
occurring in hospitalized patients, the opportunity exists to decrease length of stay and patient
discomfort, as well as reduce unnecessary costs of care. While there are many types of
infections that hospitalized patients can develop, this paper focuses on those infections
associated with the urinary tract following catheterization.
Clinical Need
Addressing the patient safety issue of hospital-acquired infections is a necessity as there
are an estimated two million patients each year who are diagnosed with these (Buchmann &
Stinnett, 2011). One way to tackle this issue is to implement best practice methods that will
decrease these acquired infections, such as CAUTIs.
According to the Centers for Disease Control (CDC), complications from CAUTIs
include cystitis, pyelonephritis, gram-negative bacteremia, prostatitis, urosepsis, and death

QUALITY IMPROVEMENT PROCESS: CAUTIS

(CDC, 2009). Considered a preventable complication by the Centers for Medicare and Medicaid
Services (CMS), there is no longer reimbursement within this system for the extra costs of a
patients treatment (CMS, 2010). The average cost of treating a CAUTI is $1,007 (Scott, 2009)
and this increases significantly if the patient develops secondary bacteremia.
While the knowledge and technology exists to help prevent CAUTIs, there is a need for
each organization to have both policies and procedures in place to promote prevention of these
types of HAIs. Following the best evidence based practice to improve patient outcomes by
preventing CAUTIs is within the scope of the nursing profession (American Nurses Association,
2010).
Interdisciplinary Team
By using an interdisciplinary team approach to tackle the problem of CAUTIs, which are
occurring because of urinary catheterization, input will be obtained from many aspects of a
patients care team. Committees must be formed, data collected through research,
implementation must occur and then evaluation follows this. Additionally, the hospital must be
open to revelation and change throughout the process.
Representatives from nursing, infection control, environmental services, equipment
management, physical therapy and physicians are all departments that may be included in the
task force (Finan, 2012). Eventually, there will also be the need for the Information Technology
department to be involved as they will be called upon to make some changes and prompts within
the computer system used.
The department of nursing will be instrumental in the implementation of the
recommendations made, as well as contributing their input during the formation of the process.
The nursing department will also complete research, and the hospital library databases will be
utilized for this. Nursing assistants will also be impacted, if they are utilized in the particular
hospital, as they will be having changes in their practice as well such as taking patients to the
bathroom more often if there are less urinary catheters in place. Both nurses and the nursing

QUALITY IMPROVEMENT PROCESS: CAUTIS

assistants will be instrumental in the additional duties of cleaning up incontinent patients, and
this will increase the workload of these individuals (Thomas, 2012).
The department of environmental services is also affected by making sure there is soap,
water and paper towels available, as well as alcohol based hand sanitizer in convenient locations,
as the role of improved hand washing will be stressed. Infection control nurses will also be of
assistance with these factors, as well as evaluating the data from different catheter kits, catheter
removal data, and urinary meatus cleansing routines are reviewed (Gotelli, Carr, Epperson,
Merryman, McElveen, & Bynum, 2008).
Physicians will be instrumental in the evaluation of the need for urinary catheters, and for
writing orders for the discontinuation of them when appropriate.
Data Collection Method
After the task group is formed, the data collection will begin regarding the current use of
urinary catheters, which patient populations they are being used in, and the current policy and
procedure guidelines regarding urinary catheters. The decision to evaluate and implement
change within the whole organization, or in one area should be made, and the data collection
should be done accordingly. Realistic goals will need to be set regarding the decreased use of
urinary catheters, and the subsequent desired decrease in CAUTIs.
Nurses will have the opportunity to conduct research, review available literature, which
will cite the most recent evidence based practice (American Nurses Association, 2010).
Collection and review of the research will help guide the data collection, and give the task group
guidelines about realistic changes to be made to the current practice. CINAHL and PubMed will
be excellent databases to search, as well as using the recommendations from the Institute of
Healthcare Improvement guide.
While there are many data tools available to use to analyze and present the data regarding
CAUTIs (Yoder-Wise, 2014), it is important to use an appropriate system that is concise and
easy to follow. As the use of urinary catheters is a multi-faceted intervention, the use of a

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detailed flowchart will be beneficial in this instance. This will be a way for the patient-care
process to be diagrammed, showing all of the steps in a sequence, and may reveal opportunities
for improvement (Yoder-Wise, 2014).
Outcomes
While urinary tract infections account for 30% of all HAIs (CDC, 2009), and
approximately 25% of all hospitalized patients in the United States have an indwelling urinary
catheter in place, it is necessary to determine the changes to be made to decrease both of these
numbers. Of the patients with a urinary catheter in place, 21% have no medical indication for
needing the catheter (Gotelli, Carr, Epperson, Merryman, MeElveen, & Bynum, 2008).
Due to the fact that the incidence of CAUTIs is believed to be reasonably preventable,
this is one area that change is needed to improve patient outcomes as well as to decrease the
financial impact on the healthcare system. With the 2008 CMS change in reimbursement for
these complications no longer being reimbursable, there is added incentive for hospitals to make
changes in the use of indwelling urinary catheters and also the care of those patients with
catheters (Finan, 2012).
Implementation Strategies
By reviewing the research regarding best practice, it has been shown that the use of
urinary catheters can be reduced in several ways, including the use of a computer reminder
system (Meddings, Rogers, Macy, & Saint, 2010). By setting a prompt to appear on the patients
chart daily, the necessity of the urinary catheter is evaluated by both nursing and physicians on a
daily basis.
The guidelines for necessitating the use of a urinary catheter should be evaluated by the
hospital, and should be reviewed regularly. Patients who are critically ill and need frequent
monitoring of urinary output, select urological surgeries, and those patients with large sacral
ulcers that need to heal and can not have incontinent urine in the area are those patients who have
a need for an indwelling catheter. Prompt and early removal of indwelling urinary catheters is a

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necessary step in decreasing CAUTIs, as well as the proper care and cleaning of the patient who
has a catheter in place (Saint, Olmsted, Fakih, Kowalski, Watson, Sales, et al., 2009).
Once new guidelines of practice have been determined, it will be necessary to educate the
staff on the new plan. Having unit inservices, online education, crucial coaching and enthusiastic
leadership are ways to get the staff onboard with the new changes (Rabideaux, 2013). Educating
and explaining the rationale for these changes will be crucial factors in getting the staff excited
about the changes, while also acknowledging the fact that there will be more work for the
bedside staff.
Evaluation
As part of the goals set by the task group, there will be a starting point that will be the
frequency of CAUTIs prior to the implementation of the new initiative. There will be set points
that will be used to evaluate the decrease in both urinary catheter use and CAUTIs. These will
be presented to staff regularly, in staff meetings and in posters around the unit to show the
progress, as well as opportunities for improvement.
Keeping in mind that this initiative will be a work in progress will help the staff to stay
motivated to find new and innovative ways to continue towards the goal of decreasing CAUTIs.
Being open to both the positive input and also the frustrations from the bedside staff will help to
reach the goals set by this quality improvement initiative.
Conclusion
While it is necessary for some patients to have a urinary catheter in place during their
hospitalization, some patients have them in without a distinct need. Patients often end up with a
urinary tract infection, which could have been avoided with more judicious use of catheters, or
with more attention paid to the hygiene and cleansing practices associated with catheters in
place. Evaluating the need for the urinary catheter initially, restricting the use of catheters for a
distinct population of patients, and having a plan in place for having daily evaluations of the
need for continued catheter use are ways to decrease CAUTIs in hospitalized patients.

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By having a quality improvement process in place to help guide the bedside nurses,
physicians, and other disciplines has proved to decrease the incidence of CAUTIs (Meddings,
Rogers, Macy & Saint, 2010). The use of daily reminder systems has been one key factor in
earlier removal of urinary catheters, and helps to keep all caregivers accountable for evaluating
the need daily.
While avoiding infections and complications associated with urinary catheters is in the
best interest of the patient, there are also financial benefits or implications for the hospital to
decrease the incidence of CAUTIs. The reimbursement from Medicare and Medicaid is
impacted greatly when a hospitalized patient has a CAUTI, and this data is tracked by CMS.
Both the adverse outcomes for patients and the increased cost to the organizations are incentives
to implement practice changes to decrease and eradicate CAUTIs (Finan, 2012).

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