E2 ICU had both a high rate of catheter-associated urinary tract infections (CAUTI) and catheter utilization. There were 18 CAUTI incidences in FY2015, and 25 incidences in FY2016. Average utilization rate was 71% in FY2015 and 72% in FY2016. E2 ICU was responsible for 31% of CAUTIs at SHC in that time frame.


A True Advantage

CAUTI is a common healthcare-associated infection costing healthcare organization $250 million a year. The Centers for Medicare and Medicaid Services no longer reimburses for treatment of certain hospital-acquired complications such as CAUTI. In addition, treatment for CAUTI places patient at risk for development of multi-drug resistant organism infections and C-Difficile Infection.

E2 ICU Catheter-Associated Urinary Tract Infections Reduction Program



CAUTI Taskforce

A CAUTI Taskforce was created, initially with PCM, APM, NPDS, and Infection Prevention. ICU physicians and Infectious Disease. Strategic areas were identified using an A3 process included: reducing catheter use, decreasing length of time catheter in place, prevention of opening closed system, providing alternate means of accurate urine output measurement, reducing false-positive urine cultures and reducing unnecessary cultures. At the end of the first quarter of FY2017 three new products were brought in to allow for accurate urine measurement. New indwelling catheter kits were introduced to prevent opening the closed-system during the changing of drainage bags. At the end of Q2 FY2017, daily Gemba Rounds were performed by APCM/PCM, NPDS and clinical nursing staff on all patients with urinary catheters. These rounds focused on catheter necessity, as well as need for accurate urine output versus hourly urine output.

Data Collection & Analysis

E2 Visibility Wall

Data was collected on catheter utilization by service line, and number of catheters ordered to be removed by protocol.  This data was clearly displayed on the E2 Visibility Wall to raise provider awareness. Nursing compliance was monitored by evaluating the number of catheters that were removed and those that could be removed. This was on ongoing adaptable process; frequent modifications were made as new issues were uncovered in the process.
Data analysis and CAUTI review led to a change in the urine culture process to not culture from a catheter that has been in place for 5 or more days unless it is contradicted to remove catheter. This guideline is now implemented hospital wide. It is now recommended that urinalysis with culture if indicated is performed rather than urine culture alone.


Catheter utilization rate for the first two quarter of FY2017 was 74%. Third quarter was 66% and the final quarter was 54%. In addition, average duration of catheterization decreased from 4.98 days to 2.02 days in CY 2017. CAUTI rate in FY2016 was 2.94, FY2017 1.59, and to date for FY2018 0.76. In six months CAUTIs decreased by 63%.


Through creation of a multidisciplinary team and multi-pronged approach, including consistent daily Gemba Rounds with physicians and clinical nurses, key areas for process and quality improvement can be recognized to result in overall CAUTI reduction.  One major key for success is that teams must be able to adapt and be flexible during this improvement process.

Contributed by: Christine Henley, MSN, RN, CNL TCRN CCRN


300 Pasteur Dr
Palo Alto, 94304​

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