In early 2008, advanced practice nurses and quality improvement staff at the Medical Center of the Rockies (MCR; see Figure 1) recognized that the CAUTI rate on the Surgical Intensive Care Unit (SICU; see Figure 2) was above the NDNQI® mean in the fourth quarter of 2007. This continued for the first two quarters of 2008. When the problem with CAUTI rates was identified, the organization’s process improvement methodology, the Plan-Do-Check-Act (PDCA) cycle, was activated. A PDCA team was formed consisting of staff RNs, a clinical nurse specialist (CNS), an infection prevention and control RN, the patient safety officer, an education nurse specialist, and a wound/ostomy nurse. Building on the existing quality monitoring program, the PDCA team investigated the specific causes of CAUTIs on the SICU, and then implemented evidence-based practice (EBP) changes that eliminated CAUTIs for 5 consecutive quarters.

RNs in the SICU are well informed about the quality of care they are providing. The nurse manager and CNS provide regular updates on patient outcomes through verbal communication and by posting NDNQI results on the unit for review. SICU staff nurses are active on both the Critical Care Standards of Care Committee (SOC) and the organizational Nursing Quality Committee. Nursing-sensitive indicators, including CAUTIs, are reviewed regularly at these committee meetings. When CAUTI rates increased above the NDNQI mean, the PDCA team began the Planning phase, setting goals and initiating in-depth review of each CAUTI case to identify contributing factors.

The PDCA team set the following goals: review 2007 CAUTI data at MCR, identify EBP processes for
urinary catheter care, identify areas for implementation of improvements, and provide recommendations for improvement to the EBP committee (a subcommittee of the Nursing Quality Committee). The team defined its success measure as a 75%-100% reduction of CAUTI rates by July 2008.

As the PDCA team investigated the 2007 CAUTI cases, it found the average age of the patient who developed a CAUTI was 73.3 years. The incidents were evenly split between males and females and the average time to infection for a patient in the SICU was approximately 4.5 days. Notably, patients who developed a CAUTI were most often those who were assessed to be a high fall risk. The team hypothesized that some of the infections were related to the prolonged use of the catheter to decrease the patient’s movement to the bathroom in an effort to reduce the likelihood of a fall.

Evidence-based practice recommendations stated that removal of the urinary catheter as early as possible is very effective in CAUTI prevention (Smith, 2003; Senese, Hendricks, Morrison, & Harris, 2005). Silver-coated catheters were also noted as an effective prevention measure (Rupp et al., 2005). No special perineal care techniques were recommended in the EBP literature. The perineal area should be cleaned with soap and water prior to sterile insertion of the
catheter (Wong & Hooton, 1981; Gray, 2004). Antimicrobial solutions are not necessary and only routine hygiene is required for patients who have a urinary catheter in place (Gray, 2004; Newman, 2007). Therefore, the PDCA team determined the primary change needed was to standardize ongoing review of whether the patient still needed a urinary catheter or it could be discontinued. The team also initiated use of silvercoated catheters in March 2008.