ARTICLE IN PRESS

American Journal of Infection Control ■■ (2017) ■■-■■

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g

Major Article

Successful strategy to decrease indwelling catheter utilization rates in

an academic medical intensive care unit
Sushilkumar Satish Gupta MD a,*, Pavan Kumar Irukulla MBBS b,
Mangalore Amith Shenoy MBBS b, Vimbai Nyemba MD c,
Diana Yacoub RN, BSN, MPA, CIC d, Yizhak Kupfer MD e
a
Department of Pulmonary Medicine and Critical Care, Maimonides Medical Center, Brooklyn, NY
b
Department of Pulmonary Medicine and Critical Care, Maimonides Medical Center, Brooklyn, NY
c
Department of Infectious Diseases, University of Maryland, Baltimore, MD
d Infection Prevention, Long Island Jewish Forest Hills, Northwell Health, Forest Hills, NY
e Department of Pulmonary and Critical Care Medicine, Maimonides Medical Center, Brooklyn, NY

Key Words: Background: Duration of indwelling urinary catheterization is an important risk factor for urinary tract
Hospital-acquired infections infections. We devised a strategy to decrease the utilization of indwelling urinary catheters (IUCs). We
Catheter-associated urinary tract infections also highlight the challenges of managing critically ill patients without IUCs and demonstrate some of
(CAUTI)
the initiatives that we undertook to overcome these challenges.
Indwelling urinary catheter (IUC)
Methods: A retrospective observational outcomes review was performed in an adult medical intensive
utilization ratio
Incontinence associated dermatitis (IAD) care unit (ICU) between January 2012 and December 2016. This period included a baseline and series of
Quality improvement intervals, whereby different aspects of the strategies were implemented. IUC utilization ratio and catheter-
Intensive care unit associated urinary tract infection (CAUTI) rates were calculated.
Results: Our IUC utilization ratio had a statistically significant decrease from 0.92 (baseline) to 0.28 (after
3 interventions) (P < .0001). Similarly, CAUTI rates had a statistically significant decrease from 5.47 (base-
line) to 1.08 (after 3 intervention) (P = .0134). These rates sustained a statistically significant difference
over the 2-year follow-up period from the last intervention. Incontinence-associated dermatitis (IAD) was
identified as a potential complication of not using an IUC. There was no statistically significant change
in the IAD rates during 2013-2016.
Conclusions: Our interventions demonstrated that aggressive and comprehensive IUC restriction pro-
tocol and provider training can lead to a successful decrease in IUC use, leading to a lower IUC utilization
ratio and CAUTI rate in a large complex academic ICU setting.
© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

Health care–associated infections complicate the admissions of
one third to one fourth of patients admitted in adult intensive care
units (ICUs).1 ICU-acquired infections put patients at increased risk
of morbidity and mortality, delay hospital discharge, and increase
interventions, all the while resulting in increased hospital costs and
suffering to the patient.2
The Centers for Medicare & Medicaid Services, following a con-
gressional mandate, identified catheter-associated urinary tract
infections (CAUTIs) as 1 of 8 avoidable complications of hospital-
ization, and ceased reimbursing hospitals for the costs incurred
* Address correspondence to Sushilkumar Satish Gupta, MD, Department of
Medicine, 4802 10th Ave, Brooklyn, NY 11219.
E-mail address: sugupta@maimonidesmed.org (S.S. Gupta).
Conflicts of interest: None to report.
treating a CAUTI that developed after admission.3 The Depart-
ment of Health and Human Services set a national goal to reduce
CAUTI rates in ICUs by 25%, and renewed this target for the year
2020.4 Consequently, this prompted a review of strategies used in
the ICU setting to reduce the risk of developing CAUTI in health care
settings, with the most effective approach involving a limited use
of urinary catheters.5-7
One of the primary ways to reduce CAUTI is to decrease the in-
dwelling urinary catheter (IUC) utilization ratio. Implementation,
which sounds like a simple concept, requires a significant cultural
change. A major risk factor for the development of urinary tract in-
fection (UTI) during ICU stay is the presence of an IUC.8 The duration
of catheter use has a linear correlation to the probability of devel-
oping a UTI. Furthermore, prolonged catheterization is the major
risk factor for developing CAUTI at a rate of 5% a day.9,10

0196-6553/© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2017.06.020
 ARTICLE IN PRESS
2 S.S. Gupta et al. / American Journal of Infection Control ■■ (2017) ■■-■■
In our project, the primary goal was to decrease the IUC utili-
zation ratio, and therefore reduce the CAUTI rates. Studies have
shown that a strict and restrictive IUC use policy along with inten-
sive education of health care providers can significantly decrease
the CAUTI rates in the non-ICU setting.11-13
Unfortunately, this strategy has not been shown to be effective
in the ICU setting, largely because of the physician and nursing at-
titudes toward the use of urinary catheterization in the critically
ill patient. Despite implementing a Comprehensive Unit-based Safety
Program, Saint et al were not able to reduce the incidence of CAUTI
rates in the ICU setting.14 We designed and implemented a suc-
cessful quality improvement (QI) ICU project that significantly
reduced our IUC utilization ratio and our ICU CAUTI rates. The
purpose of this article is to outline the strategies used by our multi-
interdisciplinary team, and to shed light on the consequences that
arose with the decrease in urinary catheter usage. We address some
of the challenges and our strategies to overcome them in the cause
of the project. We also describe in detail the strategies we used to
manage critically ill patients without urinary catheters and avoid
compromising quality of care.
MATERIALS AND METHODS
The data used in this QI project was a retrospective analysis of
the IUC utilization ratio and CAUTI rates of all patients admitted to
our 20-bed medical ICU (MICU) between January 2012 and De-
cember 2016. The national pooled mean CAUTI rate and IUC
utilization ratio benchmark defined by the Centers for Disease
Control and Prevention (CDC) were used as references for the study.
We used the CDC definitions of CAUTI and IUC utilization ratio.
Definitions of CAUTI and IUC utilization ratio were explained to the
health care providers in detail. As per the CDC, CAUTI is defined as
a UTI where an IUC was in place for >2 calendar days on the date
of event, with day of device placement being day 1 and an IUC was
in place on the date of event or the day before, whereas IUC utili-
zation ratio measures the proportion of total patient days in which
IUCs were used in a particular location.15 IUC utilization ratio gives
us a measure of how many urinary catheters are used on a given
unit.
CAUTI rates were calculated using the following formula: number
of CAUTI infections in a particular location/number of urinary cath-
eter days in a particular location × 1,000, whereas IUC utilization ratio
was calculated by dividing the number of urinary catheter days by
the number of patient days.15
Education of the health care providers
Many studies have shown that educating health care providers
can significantly decrease the CAUTI rate.12,13 We conducted monthly
in-service presentations along with the infection control depart-
ment to educate our core team members. In addition, posters
showing downtrending CAUTI rates and IUC utilization ratio were
posted on the unit for positive re-enforcement and improving staff
awareness. Finally, expectations were clearly delineated to all MICU
staff to decrease IUC days, maintain IUC utilization ratio below the
national rate, and therefore lower the CAUTI rate.
Stepwise interventions
We implemented a 3-step intervention to decrease the IUC uti-
lization ratio and CAUTI rates. A multidisciplinary team consisting
of the MICU medical director, MICU fellows, nurse managers, and
an infection control nurse were assembled to form a core team. The
baseline data from January 2012-March 2012 was obtained and
assessed. We implemented 1 protocol every year starting from April
2012, followed by January 2013 and January 2014.
As a part of the restrictive urinary catheter use policy, our first
intervention was to permit IUC use only in the following predeter-
mined indications: patients with acute urinary retention or bladder
outlet obstruction, patients with neurogenic bladder dysfunction
and urinary retention, to improve comfort for end of life care if
needed, patients planned for urologic procedures, patients with
trauma or surgery on contiguous structures, patients with stage 3-4
decubiti, patients with gross hematuria, and patients with strict input
and output monitoring.
Emphasis was placed on mandates regarding CAUTI and chang-
ing the mindset that urinary catheterization be used only in those
patients with the predetermined indications. Prior to the QI inter-
vention, patients who arrived in the ICU unit with urinary catheters
already in place could not be removed without a physician order.
As part of the project, the nursing staff was permitted to discon-
tinue urinary catheters in patients admitted to the MICU without
a physician’s order. The aggressive removal of catheters became the
new standard of care. Physicians and nurses were required to dis-
continue urinary catheters in all patients on admission, unless
warranted. The admission order set in the electronic health record
also empowered the nurses to expediently remove the catheters.
The second intervention, which started in January 2013, was to
further narrow down the criteria for urinary catheter utilization to
urinary retention and genitourinary procedures only.
The third intervention, implemented in January 2014, was to use
sonographic bladder scanning to identify high-risk patients who may
need indwelling catheters in the near future.
As another part of the QI project, we interviewed the following
members of the multidisciplinary team: 5 medical ICU attend-
ing’s physicians, 8 critical care fellows, 12 medicine residents, 2
infection control nurses, 2 nursing managers, and 20 nursing staff
to identify potential barriers in implementing the protocol. The fol-
lowing questions were asked:
1. What were the challenges of managing a critically ill patient
without an IUC?
2. How did you overcome these challenges?
The objective of the interview process was to elucidate strate-
gies that were instrumental in the project success, and try to
formulate a policy that could be implemented throughout the hos-
pital to minimize the CAUTI rate. Both qualitative and quantitative
approaches were implemented to achieve maximal efficacy of the
intervention.
Statistical analysis
The data were obtained from the infection control department
and the clinical data manager team. We used PowerPoint presen-
tations (Microsoft, Redmond, WA) to educate our staff, and Excel
sheets (Microsoft) for charting the data. Graphs were created using
Excel sheets.
Statistical analysis, Student t test, mean, SD, and significant
P values <.05 were obtained by using the online SISA software
(http://www.quantitativeskills.com/sisa/index.htm; Dr. Daan
Uitenbroek PhD, Hilversum, The Netherlands) and Excel.
RESULTS
IUC utilization ratio and CAUTI
In 2011, the CDC set the CAUTI target rate at 2.6.16 We collect-
ed baseline data from January 2012-March 2012, before the strategies
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S.S. Gupta et al. / American Journal of Infection Control ■■ (2017) ■■-■■
were implemented in April 2012. The baseline IUC utilization ratio
and CAUTI rate were 0.92 and 5.47 respectively, significantly well
above the national benchmark. After the stepwise introduction of
the intervention strategies was implemented every year to curb in-
dwelling catheter use and decrease CAUTI rate from April 2012, we
started noticing a downtrend in the IUC utilization ratio and CAUTI
rates. The IUC utilization ratio declined to 0.66, and CAUTI rate de-
creased to 1.75, after the implementation of intervention 1, at the
end of December 2012. We assessed data at the end of every annual
year, which consistently showed a linear decline in the IUC utili-
zation ratio and CAUTI rate as shown in Figure 1 and Table 1.
Eventually, by the end of December 2016, the CAUTI rate and IUC
utilization ratio had decreased to 0.20 and 0.78, respectively (Fig 1
and Table 1).
There was a decline in the IUC utilization ratio from 0.92 in March
2012 to 0.20 in December 2016, compared with the CDC IUC uti-
lization ratio benchmark of 0.67 of 2013, which is 47% below the
national expected ratio. There was also a decline in CAUTIs from
5.47 in March 2012 to 0.78 in December 2016, compared with the
CDC CAUTI rate benchmark of 3.5 of 2013, which is 78% below the
national expected ratio.
Several t tests were performed between means of baseline and
different interventions, which are shown in Table 2. All interven-
tions show a statistically significant difference in means between
baseline and postintervention IUC utilization ratio. Further, the IUC
utilization ratio and CAUTI rates were sustained 2 years’
postinterventions. There was no statistical significant difference in
means between the third intervention and first year of continua-
tion of all 3 interventions, and between the first year continuation
of interventions and second year continuation of interventions, which
reflects the continued implementation of the program that we in-
stituted. The t tests of means between baseline and postintervention
CAUTI rates are all statistically significant except for baseline and
second intervention (2.97, P = .068); however, there was a statisti-
cally significant reduction in IUC utilization ratio rates (0.51, P <
.0001). The greatest decrease in the CAUTI rate was because of in-
tervention 1, which is education and strict adherence to the agreed
on indications of IUC insertion. The addition of bladder scan in par-
ticular did not further yield a statistically significant decrease in
CAUTI rate, but did decrease the IUC utilization ratio.
Incontinence-associated dermatitis
During the project, the nursing staff identified incontinence-
associated dermatitis (IAD) as a potential complication of not using
an IUC after the initiation of the project. The IAD rates data were
collected by the nurses who fill out the survey for each patient on
the unit, indicating on the sheet whether IAD is present or not. We
began collecting the data from the middle of 2013. The IAD rate in
the year 2013 (after 2 interventions were in place) was 10.81 and
in 2014 (after all 3 interventions were in place) was 13.51. Because
our team noticed a continuous absolute, but not a statistically sig-
nificant increasing trend in the IAD rates every year, we invited a
wound care specialist and nutritionist to develop a strategy to
prevent further IAD. The strategies included frequent examina-
tion, removal of irritants and contaminants, use of Braden risk
assessment tool, implementation of skin care bundles for patients
at risk of developing IAD, and use of barrier ointments (with or
without miconazole 2%).
After the strategy was implemented in 2015, we noticed a de-
crease in the IAD rates from 18.84 in 2015 to 8.33 in 2016. Although
it was a non-statistical decrease in the IAD rates, it reassured the
clinical team that IAD was not a significant clinical problem.
Figure 2 shows that IAD rates had a statistically nonsignificant
increase between 2013 and 2015 at the same time that the IUC
3
utilization ratio was decreasing. The IAD rates fell in 2016; however,
the IUC utilization ratio was significantly lower than baseline, which
could likely be because of the intervention we implemented in the
year 2015. IAD rates were independent of the IUC utilization ratio,
which suggests there could be other factors, such as patient base-
line clinical status, previous sacral infections, peripheral vascular
diseases, diabetes mellitus, poor nutritional status, and cerebro-
vascular accidents, which could play a role in the development of
IAD, and not using indwelling catheters may just increase the pos-
sibility of developing IAD.
Questionnaire response
Table 3 shows a compilation of the responses from 5 medical
ICU attendings physicians, 8 critical care fellows, 12 internal med-
icine residents, 2 infection control nurses, 2 nursing managers, and
20 nursing staff to identify and outline the major obstacles in imple-
menting the aforementioned intervention and possible solutions.
DISCUSSION
Saint et al found that it is difficult to decrease the CAUTI rate and
IUC utilization ratio in the ICU setting; however, they did find success
in a non-ICU setting.14 The major problem they identified is the cul-
tural practice of physicians in the ICU, where the general perception
is that sicker patients will need an IUC. In contrast, our study shows
the change in the culture and approach toward using IUCs in a large,
complex, and academic ICU setting to decrease the CAUTI rate and
IUC utilization ratio. The interventions implemented in our study
were unique and unlike prior ICU studies, and we were successful
in decreasing the IUC utilization ratio and CAUTI rates in a complex
ICU setting.
During the 4 years of the study we encountered numerous chal-
lenges. Each challenge was discussed in the core team meetings and
new formulations were designed. The major issue in the initial phase
was getting the ICU staff to buy in to the new IUC use paradigm. In
the past, it was standard practice to use an IUC in almost every
patient; bringing a change to this culture was the biggest chal-
lenge faced by our team. Updated guidelines, complications, mortality
statistics from the CDC, and the role of high value care were pre-
sented to the ICU staff to stress on the key elements of our project.
Nurses were empowered by the creation of a nursing protocol to
remove the IUC once the patient arrived in the ICU, if the IUC was
not warranted.
The concerns and questions were addressed accordingly for suc-
cessful implementation of the project as shown in Table 3. Based
on the acquired culture, this action led to a significant decrease in
catheter use; however, it raised concern among the nurses that it
would lead to an increased incidence of IAD. IAD is defined as an
inflammation of the skin, and it occurs as a result of repeated skin
exposure to urine or stool. It can result in formation of blisters,
leading to increased risk of pressure ulcers. To overcome this, we
followed the plan-do-study-act strategy. The objective was clear:
to reduce the incidence of IAD, and maintain low CAUTI rates in the
ICU.
A multidisciplinary team comprising of a nutritionist, a wound
care specialist, and a bedside critical care nurse was convened to
tackle IAD. The strategy included the following protocol:
1. Staff nurses were trained to identify patients at risk for IAD and
pressure ulcers using the Braden risk assessment tool.
2. Staff performed initial skin and risk assessment to identify the
presence of IAD or pressure ulcers.
3. The plan of care includes implementation of the Maimonides
Medical Center skin care bundle for all patients at risk.
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Fig 1. (A) Decreasing MICU indwelling urinary catheter utilization ratio from January 2012-December 2016. (B) Decreasing MICU CAUTI rate from January 2012-December
2016. CAUTI, catheter-associated urinary tract infection; CDC, Centers for Disease Control and Prevention; MICU, medical intensive care unit.
 ARTICLE IN PRESS
S.S. Gupta et al. / American Journal of Infection Control ■■ (2017) ■■-■■ 5

Table 1 The ICU nursing staff was trained in using bladder ultrasound
Mean IUC utilization ratio and CAUTI rate with SDs every 6 hours in patients developing urinary retention. Patients with
IUC urine volume >500 mL were designated for intermittent catheter-
utilization ization, and were determined as watchers, who had a high
Timeline of interventions ratio CAUTI vulnerability of developing complications. Alternatively, strict moni-
Baseline (January 2012-March 2012) 0.92 ± .03 5.47 ± 1.49 toring of input and output was achieved by the use of a condom
After intervention 1 (April 2012-December 2012) 0.66 ± 0.1 1.75 ± 2.12
catheter in men, urine hat for women, and daily weights.
After interventions 1 and 2 (January 2013- 0.41 ± 0.18 2.5 ± 3.61
December 2013) UTIs are the fourth most common type of health care–associated
After interventions 1, 2, and 3 (January 2014- 0.28 ± .08 1.08 ± 1.99 infection, accounting for >12% of infections reported by acute care
December 2014) hospitals.17 It is estimated that approximately 12%-16% of adult hos-
Interventions continuation 1 (January 2015- 0.24 ± .05 0±0 pital inpatients will have an IUC at some time during their
December 2015)
Interventions continuation 2 (January 2016- 0.20 ± .05 0.78 ± 2.02
hospitalization, and each day the IUC remains, a patient has a 3%-
December 2016) 7% increased risk of acquiring a CAUTI.18,19
Currently, many efforts have been put forth to address the in-
CAUTI, catheter-associated urinary tract infection; IUC, indwelling urinary catheter.
appropriate use of urinary catheters, especially in long-term care
facilities and general medicine floors. However, there is a paucity
Table 2 of literature regarding practical strategies of how to address reduc-
Comparisons of IUC utilization ratios and CAUTI rates after every intervention and
ing CAUTIs in the ICU setting where urinary catheterization is usually
between each intervention
a vital component of patient care and the indication of catheter-
Mean IUC ization is appropriate. Our article enhances the understanding of
utilization Mean
the multilayered complexities involved in successfully reducing
Head to head comparisons ratio CAUTI
between interventions difference P value difference P value CAUTIs in the ICU setting. It offers a systematic and succinct ap-
Baseline vs after intervention 1 0.26 <.0001 3.72 .0208
proach that can be reproduced; this will in turn result in a substantial
Baseline vs after intervention 2 0.51 <.0001 2.97 .0688 decline in complications associated with CAUTI, particularly pro-
Baseline vs after intervention 3 0.65 <.0001 4.39 .0134 longed hospital stay and increased costs and mortality.
Baseline vs interventions 0.69 <.0001 5.47 <.0001 The most important risk factor for CAUTI is the duration of cath-
continuation 1
eterization. Unfortunately, at times, the IUC duration exceeds the
Baseline vs interventions 0.72 <.0001 4.69 .0112
continuation 2 indication for its placement because of the convenience, or simply
because it is easily forgotten. With an estimated 1 million CAUTIs
CAUTI, catheter-associated urinary tract infection; IUC, indwelling urinary catheter.
per year, associated with an additional cost of $676 per admission
(or $2,836 when complicated by bacteremia), it is not surprising that
CAUTIs were among the first hospital-acquired conditions se-
lected for nonpayment by Medicare as of October 2008,20 and have
been further targeted for complete elimination as a never event, with
a national goal to reduce CAUTIs by 25% and reduce urinary cath-
eter use by 50% by 2014.21 Complications associated with CAUTI
include discomfort to the patient, prolonged hospital stay, and in-
crease in health care cost and mortality.21 Each year, >13,000 deaths
are associated with UTIs.15
In this study, we showed how aggressive measures in our MICU
limit the use of urinary catheters, resulting in IUC utilization ratio
and CAUTI rates below the CDC benchmarks. From a quality care
perspective, avoidance of the potential for any nosocomial infec-
tion is the right thing to do because it is said sometimes doing less
is better.
We also endorse the use of the CAUTI care bundle in prevent-
ing infection. A CAUTI care bundle is a set of educational
Fig 2. Correlation between IAD rates and indwelling urinary catheter utilization ratio.
IAD, incontinence-associated dermatitis; IUC, indwelling urinary catheter.
interventions to improve appropriate use and clinical skill in cath-
eter placement. When followed consistently, they have been shown
to decrease the rate of infection and improve outcomes, provided
4. Interventions, such as specialty beds for immobile patients, nu- all the elements of the bundle are being applied.22 The CAUTI core
trition consults, and moisture management strategies, were in strategies, as per the CDC, include the following: insert catheters
place before the project was implemented. for appropriate indications only, leave catheters in place only as long
5. Our implementation plan included 3 main goals: removal of ir- as needed, ensure that only properly trained persons insert and
ritants, containment as appropriate, and early detection and maintain catheters, insert catheters using sterile technique and sterile
treatment of fungal infections. equipment (in acute care settings), after sterile insertion, main-
6. Maimonides Medical Center uses a no rinse cleansing agent and tain a closed drainage system, maintain unobstructed urine flow,
barrier ointments (with or without miconazole 2%) for preven- and practice hand hygiene and standard precautions (in addition
tion of IAD and treatment of fungal dermatitis. to other transmission-based precautions as appropriate) accord-
7. We initiated the use of disposable, breathable, incontinence briefs ing to Healthcare Infection Control Practices Advisory Committee
for use with patients who have urinary incontinence, receiv- guidelines.23
ing diuretics, and whose IUCs have been removed. During the study, we also emphasized the importance of inter-
8. Staff were reminded to use barrier ointments with the dispos- mittent catheterization. Multiple clinical trials have suggested that
able briefs and to keep the briefs open to prevent an increase intermittent or in-and-out catheterization, in conjunction with fre-
in fungal dermatitis. quent bladder scanning, is associated with a 50% drop in UTIs
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Table 3
Response to the questionnaire from the medical ICU staff
ICU team Challenges to indwelling urinary catheter removal
Critical care nurse • Increase in IAD
• Prolonged patient discomfort because of urinary retention
• Prolonged patient discomfort because of urinary incontinence
because delays occur in changing bed clothes for ICU patients who
are not able to verbalize discomfort and therefore rely on random
checks by a nurse
• Antagonistic relationship between the nurse and family because
of delays in changing the patient
• Delays in collecting urine samples for testing because patient
needed intermittent straight catheterization
Nursing manager • The biggest challenge was changing the culture of practice of
inserting indwelling urinary catheter in all ICU patients
• Increase in IAD
• Getting the nurses to buy into the intervention because it
increased work demands
• Expense incurred by use of diapers
• Overuse of diapers
ICU fellows • Inability to effectively monitor input and output
• Inability to assess objectively the effect of diuretics
• Late diagnosis of urinary retention because most ICU patients
sedated and unable to communicate discomfort
• Increased time demands on fellow to do a bedside bladder
ultrasound frequently to assess for retention
• Incontinence dermatitis
• Condom catheters usually fall off, therefore giving unreliable
estimates of urinary output
• No alternative collection tool for women
• Fear of over- or underdiuresing patients
ICU attending • Obtaining buy in by medical ICU staff that comprised the
physicians multidisciplinary team
• Possible transient rise in Cr secondary to urinary retention that
could be perceived as an acute kidney injury and lead to
unwarranted investigation
• Significant rise in cases of IAD and urinary retention with early
removal of urinary catheters
• Inability to monitor input and output
• Urinary retention contributing to increase in patient agitation,
leading to increase in sedation requirements in mechanically
vented patients
Infection control • Difficulty in obtaining nurses buy in because it required more
specialist initiative from them as the burden of the work fell on them
Cr, creatinine; IAD, incontinence-associated dermatitis; ICU, intensive care unit.
compared with continuous indwelling catheterization.24-26 Inter-
mittent catheterization allows greater mobility of patients and
therefore can help in accelerating the recovery of critically ill
patients.27,28 With the help of the aforementioned strategies, our ICU
was able to achieve zero incidence of CAUTI in the year 2015 and
maintain IUC utilization ratio and CAUTI rates well below the na-
tional benchmark during the study period, albeit it could also be
because of the revised CAUTI definition by the CDC in the year 2015.
Limitations
Three important limitations of the study were identified. First,
in 2015, the CDC removed yeast and urinalysis as a component of
meeting the definition of CAUTI. The impact of these changes in the
definition likely decreased our CAUTI rate; however, it does not di-
rectly impact the IUC utilization rates, which continue to fall during
the phase of this project. Second, it was not a randomized trial, it
was a QI project to decrease the unacceptably high CAUTI rates. Third,
Tools to override challenge
• Use of moisture barrier creams to reduce IAD
• Increasing frequency of random checks
• Daily and more careful abdominal examination for bladder
distension
• Use of straight catheterization to obtain urinary samples for testing
• Increasing dialogue between family and nursing staff
• In-service training of use of bladder scans. A bladder scan was
performed 6 h after a urinary catheter was removed. If patients
were found to have <500 cc of urine retained, this would warrant a
repeat scan 2 h later. On the other hand, patients that were found to
retain >500 cc of urine would get straight catheterization without
permanent insertion of the urinary catheter.
• Straight catheterization was also used to obtain a urine sample for
testing
• Urine hats used for women
• Early involvement of bedside critical nurses in devising the protocol
and implementation
• Accountability
• Frequent feedback
• Empowering the nurses to have the authority to discontinue
unnecessary urinary catheters without a physician’s order
• Diaper use with protocol prophylaxis against IAD
• Condom catheters used as an alternative for men and urinary hats
for women
• Daily weighing to assess diuresis effectivity
• Nurse aide were asked to be more vigilant in charting urine output
• Bedside bladder sonography to assess for urinary retention by
nursing staff
• Extensive education and tutelage on appropriate urinary catheter
indications
• Mandating protocol for frequent bladder checks. A bladder scan was
performed every 6 h or more frequently when suspicion is high.
• Extensive education and tutelage on appropriate urinary catheter
indications
• Weekly feedback on progress via charts and graphs showcasing the
downtrends, which provided positive re-enforcement
sometimes floating nurses work in the ICU, who are not a member
of the core team and were not aware of the ongoing study, there-
fore appropriate protocols might not have been uniformly
implemented.
CONCLUSIONS
This study showed that a multidisciplinary approach, includ-
ing the stepwise interventions strategy and CAUTI bundle, can
significantly decrease the IUC utilization ratio and CAUTI rates in
a large academic ICU. IAD can be minimized by a multidisci-
plinary strategy, including nursing staff, nutritionists, and wound
care specialists. We were not only able to improve quality and safety
regimens in our ICU, but we were also able to create a durable cul-
tural change among the staff regarding the use of IUCs.
We think that our experience will be of value for other institu-
tions as well.
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Acknowledgments
We thank all the staff nurses, nursing managers, infection control
department, nursing aides, internal medicine residents, and fellows
who contributed to the success of this study. We also thank Dr.
Nomsa Musemwa MD, and Ms. Mary O’Keefe, senior director of the
infection control department, for their suggestions and inputs.
References
1. Eggimann P, Pittet D. Infection control in ICU. Chest 2001;120:2059-93.
2. Smith RL 2nd, Sawyer RG, Pruett TL. Hospital-acquired infections in the surgical
intensive care: epidemiology and prevention. Zentralbl Chir 2003;128:1047-61.
3. Wald HL, Kramer AM. Nonpayment for harms resulting from medical care:
catheter-associated urinary tract infections. JAMA 2007;298:2782-4.
4. Office of Disease Prevention and health Promotion. National action plan to
prevent health care—associated infections: road map to elimination. Available
from: http://www.health.gov/hcq/prevent_hai.asp#CAUTI. Accessed April 10,
2017.
5. Huang W-C, Wann S-R, Lin S-L, Kunin CM, Kung M-H, Lin C-H, et al. Catheter-
associated urinary tract infections in intensive care units can be reduced by
prompting physicians to remove unnecessary catheters. Infect Control Hosp
Epidemiol 2004;25:974-8.
6. Meddings J, Rogers MA, Macy M, Saint S. Systematic review and meta-analysis:
reminder systems to reduce catheter-associated urinary tract infections and
urinary catheter use in hospitalized patients. Clin Infect Dis 2010;51:550-60.
7. Dumigan DG, Kohan CA, Reed CR, Jekel JF, Fikrig MK. Utilizing national
nosocomial infection surveillance system data to improve urinary tract infection
rates in three intensive-care units. Clin Perform Qual Health Care 1998;6:172-8.
8. Alberti C, Brun-Buisson C, Burchardi H, Martin C, Goodman S, Artigas A, et al.
Epidemiology of sepsis and infection in ICU patients from an international
multicentre cohort study. Intensive Care Med 2002;28:108-21.
9. Tissot E, Limat S, Cornette C, Capellier G. Risk factors for catheter-associated
bacteriuria in a medical intensive care unit. Eur J Clin Microbiol Infect Dis
2001;20:260-2.
10. Maki DG, Tambyah PA. Engineering out the risk for infection with urinary
catheters. Emerg Infect Dis 2001;7:342-7.
11. Shimoni Z, Rodrig J, Kamma N, Froom P. Will more restrictive indications decrease
rates of urinary catheterization? an historical comparative study. BMJ Open
2012;2:e000473.
12. Fakih MG, Watson SR, Greene MT, Kennedy EH, Olmsted RN, Krein SL, et al.
Reducing inappropriate urinary catheter use: a statewide effort. Arch Intern Med
2012;172:255-60.
13. Marigliano A, Barbadoro P, Pennacchietti L, D’Errico MM, Prospero E. Active
training and surveillance: 2 good friends to reduce urinary catheterization rate.
Am J Infect Control 2012;40:692-5.
7
14. Saint S, Greene MT, Krein SL, Rogers MA, Ratz D, Fowler KE, et al. A program to
prevent catheter-associated urinary tract infection in acute care. N Engl J Med
2016;374:2111-9.
15. Centers for Disease Control and Prevention. NHSN patient safety component
key terms. Available from: https://www.cdc.gov/nhsn/pdfs/pscmanual/
7psccauticurrent.pdf.
16. Dudeck MA, Horan TC, Peterson KD, Allen-Bridson K, Morrell G, Anttila A, et al;
Centers for Disease Control and Prevention. National Healthcare Safety Network
(NHSN) Report, Data Summary for 2011, Device-associated Module. Available
from: https://www.cdc.gov/nhsn/PDFs/dataStat/NHSN-Report-2011-Data
-Summary.pdf.
17. Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, et al.
Multistate point-prevalence survey of health care- associated infections, 2011.
N Engl J Med 2014;370:1198-208.
18. McGuckin M. The patient survival guide: 8 simple solutions to prevent hospital
and healthcare-associated infections. New York (NY): Demos Medical Publishing;
2012.
19. Lo E, Nicolle LE, Coffin SE, Gould C, Maragakis LL, Meddings J, et al. Strategies
to prevent catheter-associated urinary tract infections in acute care hospitals:
2014 update. Infect Control Hosp Epidemiol 2014;35:464-79.
20. (a) Centers for Disease Control and Prevention. Guideline for prevention of
catheter-associated urinary tract infections. 2009. Available from: http://
www.cdc.gov/hicpac/cauti/02_cauti2009_abbrev.html. Accessed March 15, 2017
21. Meddings J, Krein SL, Fakih MG, Olmsted RN, Saint S. Chapter 9: reducing
unnecessary urinary catheter use and other strategies to prevent catheter-
associated urinary tract infections: brief update review. In: Making health
care safer II: an updated critical analysis of the evidence for patient safety
practices. Rockville (MD): Agency for Healthcare Research and Quality (US);
2013. pp. 73-87.
22. Robb E, Jarman B, Suntharalingam G, Higgens C, Tennant R, Elcock K. Using
care bundles to reduce in-hospital mortality: quantitative survey. BMJ
2010;340:c1234.
23. Healthcare Infection Control Practices Advisory Committee. CAUTI guideline
fast facts. Available from: http://www.cdc.gov/hicpac/CAUTI_fastFacts.html.
2010. Accessed March 15, 2017.
24. Hakvoort RA, Thijs SD, Bouwmeester FW, Broekman AM, Ruhe IM, Vernooij MM,
et al. Comparing clean intermittent catheterization and transurethral indwelling
catheterization for incomplete voiding after vaginal prolapse surgery: a
multicentre randomised trial. BJOG 2011;118:1055-60.
25. Johansson I, Athlin E, Frykholm L, Bolinder H, Larsson G. Intermittent versus
indwelling catheters for older patients with hip fractures. J Clin Nurs
2002;11:651-6.
26. Patel MI, Watts W, Grant A. The optimal form of urinary drainage after acute
retention of urine. BJU Int 2001;88:26-9.
27. Pilloni S, Krhut J, Mair D, Madersbacher H, Kessler TM. Intermittent
catheterisation in older people: a valuable alternative to an indwelling catheter?
Age Ageing 2005;34:57-60.
28. Tang MW, Kwok TC, Hui E, Woo J. Intermittent versus indwelling urinary
catheterization in older female patients. Maturitas 2006;53:274-81.