Implementing a Nurse-Driven Protocol to
Reduce Catheter-Associated Urinary Tract
Infections in a Long-Term Acute Care Hospital
Joyce Zurmehly, PhD, DNP, RN, NEA-BC
abstract
Background: Catheter-associated urinary tract infec-
tions (CAUTIs) are the second most common health care-
associated infection. CAUTIs represent a serious threat
to chronic critically ill patients in long-term acute care
hospitals (LTACHs). Evidence-based guidelines have been
shown to reduce the risk of infection in acute care set-
tings but are not well documented in LTACHs.
Method: An evidence-based urinary catheter proto-
col was developed and implemented across three units
in a large LTACH. RNs were oriented to the new protocol
through online educational modules. During the evalua-
tion period, 120 patients were admitted with a urinary
catheter who qualified for chart review for CAUTI inci-
dence. Overall catheter-days and CAUTI rates were com-
pared, and changes in practice were noted.
Results: After the education intervention, overall uri-
nary catheter-days decreased by 10.1%, and CAUTI inci-
dence decreased by 74% (4.82 CAUTI per 1,000 patient-
days to 1.24). The absolute risk reduction was 3.58
infections per 1,000 catheter-days. The findings were
statistically significant (z = 1.00, p , .03).
Conclusion: Significant reductions were noted in total
catheter-days, and CAUTI rates improved after implemen-
tation of an education program and an evidence-based
urinary catheter protocol in an LTACH.
J Contin Educ Nurs. 2018;49(8):372-377.
I
n the United States, advances in technology, aging
population, and chronicity of diseases have resulted
in a patient population classified as chronic critically
ill (CCI; Kahn et al., 2015). The CCI patient survives
an initial critical illness only to suffer prolonged depen-
372
dency and the need for longer term therapeutic interven-
tions. Also, improvements in critical care have resulted in
shorter stays and shifts to long-term acute care hospitals
(LTACHs) for CCI patients. The Centers for Medicare
and Medicaid Services (CMS) defines LTACHs as acute
hospitals with a mean length of stay at least 25 days and
patients transitioning from an average of 3 or more days
in an intensive care unit (Miller, 2016).
LTACH patients are frequently admitted with urinary
catheters. Many are critically ill, with multiple risk fac-
tors resulting in immune exhaustion, leaving them vulner-
able to health care-associated infection (HAIs), including
catheter-associated urinary tract infections (CAUTIs).
Indwelling urinary catheters are primary sources of bac-
teremia in health care settings; CAUTIs are the second
most frequently diagnosed HAI and the most common
cause for hospitalization with a bacterial infection (Genao
& Buhr, 2012). Annually, an estimated 720,000 CAUTIs
occur, accounting for more than 13,000 deaths (Centers
for Disease Control and Prevention [CDC], 2016) and
estimated costs of $340 million to $450 million (Strouse,
2015).
In addition to urinary catheter presence, duration
(catheter-days) also contributes to CAUTI risk. Like-
lihood increases 3% to 7% daily; by 1 month, the risk
is nearly 100% (Institute for Healthcare Improvement
Dr. Zurmehly is Associate Professor of Clinical Nursing, Director, Doc-
tor of Nursing Practice Program, College of Nursing, Ohio State University,
Columbus, Ohio.
The author has disclosed no potential conflicts of interest, financial or
otherwise.
Address correspondence to Joyce Zurmehly, PhD, DNP, RN, NEA-BC,
Associate Professor of Clinical Nursing, Director, Doctor of Nursing Prac-
tice Program, College of Nursing, Ohio State University, 318 Newton Hall,
1585 Neil Avenue, Columbus, OH 43210; e-mail: zurmehly.8@osu.edu.
Received: February 12, 2017; Accepted: November 13, 2017
doi:10.3928/00220124-20180718-08
Copyright © SLACK Incorporated
[IHI], 2011). The CDC (2015b) defines a CAUTI risk
in any patient who has a urethral catheter in place for
more than 2 days. CMS identified CAUTI as an HAI
that would not be reimbursed unless documented upon
admission (CDC, 2015b). In LTACHs, a potential for
a higher incidence of inappropriately retained indwell-
ing urinary catheters exists due to a misunderstanding of
their necessity or lack of clear removal orders. LTACHs
have a higher rate than almost all other health care sites
for CAUTI pooled mean rates and urinary catheter de-
vice use ratios (CDC, 2015b; National Healthcare Safety
Network [NHSN], 2014). Patients in LTACHs depend
on nurses to provide optimal care, including controlling
nosocomial-type infections. Keeping current with best
practices is critical to providing quality care.
The Joint Commission’s 2012 National Patient Safety
Goals called for the use of evidence-based practice to pre-
vent CAUTIs (Mori, 2014). Several evidence-based CAU-
TI prevention guidelines exist that support a decrease of
catheter-days through nurse-led initiatives. Mori (2014)
conducted a quality improvement (QI) project with a
nurse-driven protocol that included criteria for catheter
removal. Urinary catheter usage decreased from 37.6% to
27.7% and CAUTI rates from 0.77% to 0.35%. Magers
(2013) conducted a QI initiative using a seven-step ev-
idence-based practice (EBP) approach in an LTACH. A
nurse-driven protocol decreased CAUTI rates by 33% and
the mean number of catheter-days from 13.12 to 9.69.
A systematic review and meta-analysis concluded that a
reminder and stop orders appeared to reduce CAUTIs by
53% (Meddings, Rogers, Macy, & Saint, 2010).
The primary prevention actions for CAUTIs are avoid-
ing unnecessary catheter placement and minimizing
catheter-days (Gould, 2010; Lo et al., 2014). IHI spe-
cifically addressed the need to modify admission processes
to include checking, verification, and removal of urinary
catheters if unnecessary (IHI, 2011). Chen et al. (2013)
indicated that 41% of physicians and nurses failed to fol-
low CDC recommendations to evaluate and determine
whether a catheter should be removed. In a recent sur-
vey conducted by hospitals, it was estimated more than
50% did not monitor which patients were catheterized,
and up to 75% did not monitor duration or discontinua-
tion (CDC, 2015a; Gould, 2010). Thus, CAUTIs may be
linked directly to health care professionals inconsistently
assessing the need to remove unnecessary urinary cath-
eters. Nurses, as the primary health care providers directly
interacting with patients, are in the best position to re-
move unnecessary catheters. Although there is a growing
body of evidence for catheter care in the acute care setting,
limited evidence exists for catheter care for CCI patients
in the LTACH setting.
The Journal of Continuing Education in Nursing · Vol 49, No 8, 2018
At the LTACH in this study, CAUTI incidence was
tracked through infection control surveillance. The CAUTI
standardized infection ratio goal rate was defined by CMS
in 2015 as 1.03 per 1,000 catheter-days (CDC, 2015a). In
2015, surveillance showed the CAUTI rate for the study
LTACH was above the national rate (CDC, 2016); thus,
CAUTIs became a target for rate reduction. This study’s
purpose was to develop and implement a nurse-led EBP
urinary catheter protocol (UCP) and measure the impact
on catheter-days and CAUTI rates among CCI patients in
a large LTACH. Goals included meeting national quality
metric benchmarks for CAUTIs and implementing edu-
cation based on current best practice evidence.
THEORETICAL FRAMEWORK
The theoretical framework chosen for this study was
the Iowa model of EBP to promote quality (Doody &
Doody, 2011) because it promotes integration of evidence
into practice, with the goal of improving patient outcomes
while providing the opportunity for nurses to make a sig-
nificant contribution to quality care (Titler et al., 2001).
There are several steps outlined within the model that were
used to frame a process to decrease CAUTIs. The initial
step of the model includes knowledge- and problem-
focused triggers that lead to the identification of gaps in
nursing practice (Titler et al., 2001). The current rate of
CAUTIs was identified as a knowledge-focused trigger
given that many of the nurses were not aware of recent
CDC urinary catheter guidelines. In addition, a practice-
focused trigger was identified because the organizational
CAUTI rates were above the national average.
Following an initial assessment, the evidence-based
framework following the Iowa model was further developed,
outlining current best practices to improve CAUTI rates. An
intensive literature review to establish the state of the science
related to CAUTIs in LTACHs was performed. Highlights
from the literature review were summarized and used to plan
an intervention. Current nursing practices were evaluated
against CDC recommendations. Based on findings, practice
changes were identified, with the goal of improving CAU-
TI rates among LTACH patients. Next, stakeholders were
identified to act as a CAUTI Reduction Task Force (RTF)
to support change, remove barriers, and act as champions
for evidence-based care. The RTF revised the existing admis-
sions protocol to include current best practice, with an em-
phasis on first assessment upon admission into the LTACH.
OBJECTIVE
The study evaluated the effectiveness of a nursing
quality improvement education program on CAUTI
rates within an LTACH. The study included all nursing
staff implementing a UCP specifically outlining criteria
373
for catheter removal within three adjacent units in an
LTACH. The study focused on staff education, catheter
care, and patient surveillance.
METHOD
Using a quasi-experimental design, this project was
conducted within a large LTACH located in a midwestern
state. An evidence-based educational protocol on catheter
care was implemented, and its effect was measured with
a pretest–posttest design that used a convenience sample.
Specifically, this study implemented a prevention educa-
tion program outlining a new protocol flow chart high-
lighting catheter awareness and prevention of CAUTIs to
all nurses. In addition, CAUTI rates and absolute risk re-
duction were also calculated to compare outcomes.
A convenience sample of 70 RNs was recruited from
across three units, and their awareness and performance
in CAUTI prevention was measured. Participants were as-
sured their responses would be confidential and would not
be released to their employer. Respondents were further
informed that their participation was voluntary and would
not influence their employment. The inclusion criteria in-
cluded RNs employed within the LTACH; exclusion cri-
teria applied to agency nurses. The local review board and
ethics committee determined this to be a quality initiative
and therefore exempt from institutional board review.
INTERVENTION
The intervention was a UCP based on best evidence
that provided guidelines for nurses in a large LTACH
caring for CCI patients. Key elements included educa-
tion, implementation, and evaluation. This initiative in-
cluded revision of existing policy and introduction of an
evidence-based UCP, competency education for nurses,
and evaluation of CCI patient outcomes in the LTACH.
PROCEDURE
Following the Iowa model, the researcher investigated
literature on CAUTI management and analyzed the cur-
rent infection rate for LTACH and its guidelines for infec-
tion management. The new protocol was developed based
on the American Nurses Association’s (ANA) evidence-
based tool to help reduce CAUTIs (ANA, 2016). The new
CAUTI protocol was reviewed by content experts on the
RTF. The tool outlines key strategies for practice in re-
ducing CAUTIs, including decreased catheter insertion,
proper maintenance, timely removal, and postremoval
assessment. The CAUTI program was developed during
September 2015 by integrating the best practice evidence-
based aspects of previous studies of intervention programs
into a multidimensional program. The project was first in-
troduced to the nurses via the secure e-mail server, along
374
with posters placed in the break area, and at monthly staff
meetings.
Participants’ understanding of the content and edu-
cational objective was assessed using an online pretest–
posttest format. A 10-item CAUTI questionnaire, in-
cluding nursing interventions and catheter assessment
and care, was developed, and five experts in the field
confirmed its validity. True-or-false, multiple choice, and
matching question formats were used. Following comple-
tion, examination scores were downloaded onto a nurse
education competency database specifically designed for
this study. Test results were coded with a corresponding
number, and any potential nurse identifiers were removed.
The nurses received feedback via staff meetings and weekly
e-mails. The participants’ initial understanding of CAU-
TIs was assessed using an online pretest during the month
of October. The CAUTI prevention program was imple-
mented following the initial knowledge assessment from
November 1 to November 30.
CAUTI PROTOCOL
The evidence-based CAUTI practice protocol includ-
ed initial assessment by the admitting nurse who initi-
ated the UCP in the electronic medical record (EMR)
for any patient who had a urinary catheter in place upon
admission. The criteria for a urinary catheter include the
need for accurate intake and output; end-of-life care; as-
sisting healing in incontinent patients; neurogenic blad-
der; acute urinary retention, obstruction, or bleeding;
and patient-required prolonged immobilization. Fol-
lowing the protocol, the nurses were able to determine
whether to maintain or remove the catheter. If criteria
for a urinary catheter were not met, the nurse removed
the catheter per the UCP. When assessment criteria were
met and the catheter was to remain intact, key areas of
education for the CCI patient were highlighted on the
UCP protocol. Following patient admission onto the
unit, nurses were notified to the UCP automatically
linked in the EMR with an electronic alert indicating the
need to reassess the patient every 12 hours to determine
whether criteria for a urinary catheter were continually
met. If none of the criteria for a urinary catheter were
met, the nurse removed the catheter. The physician was
notified by an electronic alert to the number of days the
catheter was in place and whether the catheter was con-
tinued or discontinued.
CAUTI EDUCATION PROGRAM
The education initiative was a self-study guided mod-
ule and a 10-item questionnaire. As supported by EBP,
an online education module was used as the educational
platform. Online education was provided to the RNs in
Copyright © SLACK Incorporated

PRE- AND POST-PROTOCOL IMPLEMENTATION DOCUMENTATION
Preintervention
Urinary Catheter Protocol (n = 120)
Documentation 58
Not documented 62
each unit and the unit manager, who was then respon-
sible for staff education and administrative support of
UCP implementation. Following approval by the facil-
ity quality approval committee, the RTF developed the
education program and an evaluation strategy. The QI
team provided initial information education sessions for
charge nurses and interested physicians over a 3-week pe-
riod. Prior to implementing the UCP, system-wide man-
datory education sessions were provided via synchronous
e-learning sessions to all nurses. Nurses were notified of
module availability via weekly e-mails until the education
was completed. In addition to online accessibility, study
materials were also available in an educational toolkit lo-
cated in the facility education center. The toolkit included
one complete self-study module booklet, a copy of the
new policy and protocol, the EMR flow chart outlining
processes, and a urinary catheter kit with supplies for any
RN to use. In addition, each nurse received a quick refer-
ence pocket guide to use as a resource with CDC indica-
tions of catheter device usage. The module included best
practices, with information on topics related to CAUTI,
epidemiology and scope of the problem, risk factors, defi-
nitions, prevention, strategies to reduce CAUTI, and the
new UCP. The module took approximately 45 minutes to
complete.
PATIENT SELECTION
Patients were enrolled in the study that met the inclu-
sion criteria of an existing urinary catheter upon admis-
sion into the LTACH. Patients were excluded from the
project if they were scheduled for discharge or at risk for
sudden death. The primary source of baseline data were
preexisting deidentified quality metric data of enrollment
date, age, gender, date of birth, date of admissions, and
the date and duration of cauterization, and these were
monitored by the QI director.
DATA ANALYSIS
Data were analyzed with SPSS® version 21.0. Repeat-
ed measures analysis of variance was used to compare
nurses’ awareness and performance of CAUTI preven-
tion before and after intervention. Demographic data
The Journal of Continuing Education in Nursing · Vol 49, No 8, 2018
TABLE
Postintervention
(n = 115) Results (Change) p
115 198.27% , .001
0 1100% , .001
for all RNs were collected and analyzed, along with re-
sults of the pretest–posttest and CAUTI rates. CAUTI
rates were measured using the CDC/NHSN surveillance
tool (CDC, 2015b; NHSN, 2014), which divides num-
ber of UTIs by Foley catheter-days multiplied by 1,000
(UTIs per 1,000 Foley catheter-days). These calculations
are considered standard for catheter-days (CDC, 2010).
CAUTI rates were compared with chi-square analysis. All
tests were one-tailed at the p , .05 level of significance.
CAUTI rates and catheter-days were included in quality
metric reports. The quality metrics report included data
for the 3-month retrospective period for August, Sep-
tember, and October prior to UCP implementation and
the 3-month prospective period for December, January,
and February post-protocol implementation. Dependent
sample t test was used for comparison of pre- and post-
protocol implementation and the pre- and post-rate dif-
ferences (Rosner, 2000). The absolute risk reduction was
used to assess the likelihood of reduced risk if the UCP
was followed.
RESULTS
Overall, 70 nurses completed the educational pro-
gram. Demographic data revealed most RNs were female
(97%), with an average age of 48 years, approximately
2 years younger than the national average (Health Re-
sources and Services Administration, 2013). Most RNs
held an associate degree (65%) in nursing, followed by
bachelor’s (30%), and master’s (5%). Most (67%) had
less than 2 to 3 years of LTACH experience. Before UCP
education, the mean total score on nurses’ awareness
and performance of CAUTI prevention was 8.75 of 10
(SD = 1.16). Directly after the education intervention,
that increased to 9.83 (SD = 0.45). Posttest analysis in-
dicated a statistically significant (p , .05) difference in
nurses’ total knowledge level after the CAUTI interven-
tion [F(2,36) = 4.476, p = .021] Most RNs (93%) had a
perfect score on the posttest; the rest (7%) scored 90%.
After changes in practice patterns, CAUTI incidence de-
creased significantly (p = .001). The post-protocol mea-
surement revealed that 100% of the nurses were docu-
menting the UCP on the EMR (Table).
375

Figure. Comparison of reeducation and compliance, and overall
catheter-associated urinary tract infection (CAUTI) rates.
PATIENT OUTCOMES
Evaluation also included patient CAUTI rates. There
were 115 qualifying patient admissions during this evalu-
ation period. Primary outcomes measured were number
of catheter-days and hospital-acquired CAUTI rates. Data
were collected for 3 months before and 3 months after pro-
tocol implementation for 4,689 patient-days before and
4,759 patient-days after protocol implementation. Overall
urinary catheter-days decreased from 2,697 to 2,423, a re-
duction of 274 catheter-days (10.1%). CAUTI rates were
calculated using the number of hospital-acquired urinary
tract infections per number of catheter-days multiplied
by 1,000. After the education sessions, CAUTI incidence
decreased from 13 to 3 (77%). This number represented
a statistically significant (z = 1.0, p , .03, two-tailed) re-
duction of CAUTIs following the educational interven-
tion. Subsequently, the hospital-acquired CAUTI rate per
1,000 catheter-days decreased from 4.82 to 1.24 (74%),
although the total number of patient-days increased by
1.3%. The absolute risk reduction to determine event
rates was 3.58 infections per 1,000 catheter-days.
DISCUSSION
Changes on test scores indicated that the 30-minute
targeted education module increased nurses’ awareness
of CAUTI prevention. Awareness was measured by post-
education test and performance of CAUTI prevention
noted in RNs’ practice, including compliance with UCP
and reduction of total catheter-days and CAUTI rates.
After the education, 98% of audited records showed in-
creased documentation and assessment of catheter-days,
a significant improvement from preeducation (52%),
showing an overall positive shift in compliance with UCP
implementation. This finding represents a significant im-
provement compared with preeducation compliance and
overall CAUTI rates (Figure). There was a 74% reduction
in CAUTIs; CAUTI rates went from 4.82 to 1.24, well
376
below the national average of 5.0 but still above the de-
sired baseline of 0.92 (Health Resources and Services Ad-
ministration, 2016). It can be estimated that, maintain-
ing the current trajectory, as a trend of on average three
fewer CAUTIs per month, the CAUTI rate over 6 months
could be equal to or lower than national benchmark stan-
dards. The cost per patient with a CAUTI is estimated to
be $1,200 to $4,700 (Miller, 2016). Thus, for the project
LTACH and 115 patients, the estimated savings ranged
from $138,000 to $540,500.
Findings support earlier studies on educational out-
comes with CAUTI (Genao & Buhr, 2012; Lo et al.,
2014; Magers, 2013; Mori, 2014). Also, according to a
recent study, CAUTI rates can be significantly reduced if
Foley catheter protocols include best practice and educa-
tional methods are used to engage nurses in quality care
(Parry, Grant, & Sestovic, 2013).
The UCP in this study appeared to be effective, as dem-
onstrated by the increase in nurses’ test scores and decrease
in patient infection rate. Results suggested that use of the
UCP significantly contributed to reducing patients’ risk of
CAUTI. Thus, this study supported implementation of a
nurse-driven protocol to reduce CAUTIs.
LIMITATIONS
Although this was a small target group evaluated in a
short time, even a small number of occurrences can signif-
icantly affect infection rates, making statistical outcomes
difficult to interpret. RNs’ awareness of being evaluated
before and after educational sessions may have led to more
conscientious catheter care. To help minimize the Haw-
thorne effect, randomly selected EMRs were reviewed. Al-
though this evaluation focused on a nurse-led UCP, other
factors were not addressed, such as additional health care
providers who complete catheter care. Another limiting
factor was the nonevaluation of the new UCP. Although
the ANA CAUTI tool was used, it was incorporated into
a best practice protocol. It is impossible to determine
whether the tool alone influenced CAUTI rates. Also,
there was no control group to compare findings and evalu-
ate reliability of the test questions.
CONCLUSION
Historically, LTACH quality metric reporting has been
isolated from public review. However, with recent changes
in regulations, health care transparency and public access
to data require LTACHs to ensure a culture of safety and
accountability. Continuous improvement is needed to
obtain and sustain quality patient outcomes and control
health care costs. Consistent high-quality care requires a
collaborative approach in providing EBP to patients. As
demonstrated by this study, nurses can take the lead in us-
Copyright © SLACK Incorporated
ing evidence-based prevention strategies to validate exist-
ing best practice evidence and change practice.   HowtoGuidePreventCatheterAssociatedUrinaryTractInfection.aspx
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