CLINICAL MANAGEMENT OF THE
OLDER ADULT
Effect of a Multimodal Educational Intervention on Use of
Urinary Catheters in Hospitalized Individuals
Richard E. Norman, MD, MASc,* Rebecca Ramsden, MN,† Leanne Ginty, MEd,† and
Samir K. Sinha, MD, DPhil*‡§
BACKGROUND/OBJECTIVES: Urinary catheters are fre-
quently used in hospital inpatients despite their association
with greater morbidity and mortality. Reducing their
unnecessary use can improve patient care. The objective of
the current study was to determine the effectiveness of a
multimodal nursing and physician education intervention
to reduce the unnecessary use of urinary catheters in adult
inpatients.
DESIGN: Quasi-experimental interrupted time series study.
SETTING: General internal medicine and surgical services
of a large urban teaching hospital.
PARTICIPANTS: Admissions to the services under study
during the study period (September 2009 to February
2013) (N = 21,550).
INTERVENTION: A multimodal educational intervention
incorporating educational posters, small-group teaching
sessions, and changes to the hospital’s electronic health
records and nursing clinical documentation systems were
introduced to nurses and physicians.
MEASUREMENTS: Mean catheter days per patient
(CDPP) and incidence of urinary catheterization, measured
at monthly intervals throughout the study period.
RESULTS: A decrease in mean CDPP of 5.6 and 6.5 days
(P < .001) respectively was observed on the medical and
surgical services following the intervention. The monthly
incidence of catheterization decreased by 3.0 percentage
points on medical units and 6.4 percentage points on sur-
gical units immediately after the intervention, from an
From the *Department of Medicine, University of Toronto; †Department
of Nursing, Sinai Health System; ‡Division of General Internal Medicine
and Geriatrics, Department of Medicine, Sinai Health System and
University Health Network; and §Institute of Health Policy, Management
and Evaluation, University of Toronto, Toronto, Ontario, Canada.
Presented at the Plenary Session of the 2016 Annual Scientific Meeting of
the American Geriatrics Society on May 19, 2016 in Long Beach,
California.
Address correspondence to Dr. Samir Sinha, Sinai Health System, Suite
475, 600 University Avenue, Toronto, ON M5G 1X5, Canada. E-mail:
samir.sinha@sinaihealthsystem.ca
DOI: 10.1111/jgs.15074
JAGS 2017
© 2017, Copyright the Authors
Journal compilation © 2017, The American Geriatrics Society
average of 14.5% and 15.0%, respectively, before the
intervention. Similar degrees of improvement were
observed for individuals of all ages, although older adults
remained more likely to be catheterized. The effect per-
sisted over nearly 3 years of observed follow-up.
CONCLUSIONS: A relatively simple multimodal educa-
tional intervention targeting nurses and physicians resulted
in a significant and sustained reduction in CDPP and the
proportion of participants catheterized. J Am Geriatr Soc
2017.
Key words: urinary catheter; patient safety; quality
improvement; hospitalization
U rinary catheterization is a frequent procedure in inpa-
tient settings. It is estimated that 16% to 25% of hos-
pitalized individuals have an indwelling catheter placed at
some point during their stay1 and that as many as 86% of
those undergoing major operations are catheterized.2
Although sometimes clinically indicated, studies have
shown that 21% to 52% of catheters are used unnecessar-
ily.3–5 This is problematic because urinary catheters expose
people to significant morbidity, including greater risk of
urinary tract infection (UTI) and bacteremia,6 as well as a
greater likelihood of functional decline.7 For older adults,
who are more likely to be catheterized than younger indi-
viduals,8 the associated risks related to urinary catheteriza-
tion are even more significant because they contribute to
longer hospital stays, greater risk of being discharged to a
location other than home, and greater risk of death while
in the hospital and within 90 days of discharge.7 The
strong association between functional decline and urinary
catheterization has been attributed to the fact that urinary
catheters serve as single-point restraints, tethering people
to their beds and preventing the early mobilization that is
particularly needed for older adults to help prevent and
reverse functional loss.1,9–11
Several authors have identified a lack of familiarity
with the specific indications for urinary catheterization
0002-8614/17/$15.00
2 NORMAN ET AL.
as a significant contributor to inappropriate catheteriza-
tion.1,12–14 Examples of inappropriate indications
include urinary incontinence, cognitive impairment, lim-
itations in activities of daily living, inconvenience of
care, and multiple comorbidities.2,3,7,14,15 All of these
problems are more common in older adults. Other pre-
viously identified barriers to evidence-based use of uri-
nary catheters include communication problems
between doctors and nurses regarding the use of cathe-
ters, lack of clear criteria for when their removal is
warranted, incontinence, and lack of familiarity of
nurses with perineal care principles.12,13 Addressing the
knowledge gaps identified in these studies therefore is
a logical opportunity to inform the safer, more-appro-
priate use of urinary catheters.
We thus introduced a multimodal educational inter-
vention targeting nurses and physicians aimed at reducing
the unnecessary use of urinary catheters. This study pre-
sents the outcomes of this intervention in a large cohort of
individuals over a 3-year period.
METHODS
Study Setting and Population
Mount Sinai Hospital is a 472-bed acute care teaching
hospital in Toronto, Canada, that is part of the Sinai
Health System. The study population included individu-
als admitted to the medical and surgical services
between September 2009 and February 2013. We pur-
posefully excluded people admitted to the dentistry,
ophthalmology, otolaryngology, and vascular surgery
services because of the minimal use of urinary catheters
in these specialties. We further excluded individuals
admitted to the urology service because the specific use
of catheters remains fundamental to their interventions.
Approval was obtained from the local institutional
review board.
Multimodal Educational Intervention
The educational interventions consisted of passive mea-
sures (educational posters reinforcing the appropriate
indications for catheters) and active measures (nurse-led
small-group sessions to discuss the appropriate use of
urinary catheters). These measures emphasized evidence-
based indications for the use of urinary catheters and
management techniques (e.g., insertion and maintenance)
in keeping with recommendations that the Centers for
Disease Control and Prevention provided at the time of
the intervention.16 The hospital’s electronic medical
record (EMR) was modified to display urinary catheter
insertion and removal dates, allowing all healthcare pro-
viders to observe directly how much time any individual
had spent catheterized. A second phase of interventions
was introduced during the follow-up period, including
admission orders with prompts for appropriate indica-
tions for catheterization and introduction of nursing rep-
resentatives to disseminate best practices. All nurses
working on the services during the study period were
exposed to the educational interventions. All physicians
were exposed to modifications to the EMR.
2017 JAGS
Measures and Statistical Analysis
Data were collected using the hospital’s EMR. Catheter
use data were used to calculate two primary outcome
parameters: mean catheter days per patient (CDPP) for
individuals who were catheterized, and the incidence of
individuals who underwent indwelling urinary catheteriza-
tion in a given month (% catheterized). These data were
extracted from the hospital’s EMR, which tracks the pres-
ence or absence of a urinary catheter on a per-nursing shift
basis; nurses completed data entry as part of routine chart-
ing.
The data collected over the study period were struc-
tured as a time series with monthly intervals, with mean
CDPP and incidence of catheterization calculated for each
interval. The effect of the educational intervention on the
primary outcome measures was assessed using a segmented
regression analysis of the time series. This analytical method
is described extensively elsewhere.17,18 Briefly, it is a linear
regression technique that includes a coefficient to reflect the
immediate effect of an intervention, a coefficient to identify
and adjust for any preintervention baseline trend, and a
coefficient to identify and adjust for any postintervention
change in trend. The observed intervention effect is a con-
stant, the baseline trend is a linear slope, and the change in
trend is a change in the slope. Terms that are statistically sig-
nificant within the model are relevant predictors of the out-
come. For example, if an intervention term is statistically
significant, then the intervention is deemed to have had a
significant effect on the outcome despite adjustment for pre-
or postintervention trends. In the case of nonsignificant
terms in the full model, the most-parsimonious model
including only statistically significant terms was selected
using stepwise regression.17 This most-parsimonious model
is provided as the final result.
The timing of the introduction of the educational
intervention was February 2010. A 2-month transition per-
iod (March and April 2010), similar to the one that others
have used,17,19 was assumed to allow the various interven-
tions to take effect. This period was not included in the
analysis. The absence of autocorrelation was confirmed
using the Durbin-Watson statistic and inspection of the
residuals.
To explore age-related patterns in catheter use, we
compared the CDPP and incidence of urinary catheteriza-
tion according to age group (<65, 65–74, 75–84, ≥85) for
four distinct periods: the 6 months preceding the interven-
tion (September 2009–February 2010), the 6 months
immediately after the transition period (May 2010–Octo-
ber 2010), the 6 months after the second phase of inter-
ventions (June 2011–November 2011), and the 6 months
at the end of the follow up period (September 2012–Febru-
ary 2013). Histograms were constructed for the pre- and
postintervention period to examine the duration of
catheterization. Regression was performed using SPSS
Statistics version 20 (IBM, Armonk, NY). Reported
P-values are two-sided.
RESULTS
The data collected for the study are summarized in
Table 1. Of 21,550 unique admissions to the medical and
JAGS 2017 REDUCING URINARY CATHETER USE IN HOSPITALS 3

and 15.0% for surgical units. Immediately after the inter-

Table 1. Participant Characteristics
vention, there were absolute decreases in the monthly inci-
Total, Medicine, Surgery, dence of urinary catheterization of 3.0 percentage points
Characteristic N = 21,550 n = 6,444 n = 15,106 and 6.4 percentage points, respectively, that were sus-
tained during the 32-month postintervention period.
Catheterized, n (%) 2,540 (11.7) 609 (10.4) 1,931 (14.7) Before the intervention, CDPP was decreasing by 1.34
Age, mean  standard 57.0  20.3 64.4  20.2 53.5  19.5
catheter days per month on the medical service. After the
deviation
Male, n (%) 10,065 (46.7) 3,033 (47.1) 7,032 (46.6) intervention, this baseline trend leveled off (as demon-
Length of stay, days, strated by the observed positive trend change after the
Median 4 5 4 intervention of 1.31 catheter days per month, resulting in
Mean 7.6 9.4 6.9 a net slope of 0.03 catheter days per month). A similar
baseline trend and leveling off after the intervention was
seen for CDPP on the surgical units. There was a baseline
surgical services, 2,540 (11.7%) received a urinary catheter trend of decreasing incidence of catheterization on the
as part of their care. medicine units of 0.12% per month during the 32-month
Plots of the two outcome parameters for each service postintervention period. The surgical services had no pre-
are shown in Figure 1. The results of the segmented regres- existing trend regarding incidence of catheterization but
sion analysis show that mean CDPP decreased by 6.5 days developed a trend of decreasing incidence of catheteriza-
on the medical services and 5.6 days on the surgical ser- tion of 0.13% per month as well.
vices immediately after the intervention (P < .001) CDPP and incidence of catheterization stratified
(Table 2). The average preintervention monthly incidence according to age are shown in Table 3. The findings
of urinary catheterization was 14.5% for medical units were similar to those of the primary analysis, with

Figure 1. The two primary outcome parameters, mean catheter days per patient (CDPP) and monthly incidence of urinary
catheterization (% catheterized), for the two services measured over the study period. The transition period, indicated by the grey
regions, reflects the time required for the various interventions to take place and was not included in the statistical analysis. The
postintervention period begins immediately after this transition period.
4 NORMAN ET AL. 2017 JAGS

lasting effect on how healthcare providers use these

Table 2. Results of Segmented Regression Analysis
devices. The results show, after adjustment for baseline
Coefficient (95% trends, a marked and enduring decrease in the incidence of
Regression Model Confidence Interval) P-Value catheterization across the age spectrum, in many cases by
almost half. Furthermore, the duration of catheterization
Medicine decreased significantly for individuals who received a
Catheter days per patient
catheter, with a majority catheterized for 2 days or less
Baseline trend 1.34 ( 2.43 to 0.25) .018
Effect of intervention 6.52 ( 9.45 to 3.58) <.001 after the intervention. These findings have several positive
Trend change 1.31 (0.21–2.40) .021 implications for delivering high-quality hospital care.
after intervention We observed a significant decrease in the incidence of
Monthly incidence of catheterization, percent urinary catheterization after our intervention. Multiple
Baseline trend 0.12 ( 0.18 to 0.06) <.001 previous studies have examined the effect of educational
Effect of intervention 3.03 ( 5.00 to 1.06) .004 interventions on urinary catheter use.12,20–27 Several of
Surgery these studies focused on interventions introduced on an
Catheter days per patient
individual unit or service, limiting a direct comparison
Baseline trend 0.34 ( 0.59 to 0.09) .008
Effect of intervention 5.64 ( 6.31 to 4.97) <.001 with this work, which introduced an intervention across a
Trend change 0.34 (0.09–0.59) .010 whole hospital. Another study28 found an approximately
after intervention 63% reduction in the incidence of urinary catheterization
Monthly incidence of catheterization, percent across a cohort of internal medicine patients exposed to an
Effect of intervention 6.35 ( 8.91 to 3.80) <.001 intervention incorporating a more-restrictive catheteriza-
Trend change 0.13 ( 0.21 to 0.05) .002 tion policy. Similarly, a 51% reduction in the incidence of
after intervention urinary catheterization on admission was found in individ-
uals admitted to a general internal medicine service after
introducing order entry and nursing order changes.29 For
CDPP and incidence of catheterization dropping in the surgical services, a 48% reduction was observed in the
postintervention period in all age groups. Older adults incidence of catheterization on an orthopedics unit after
were catheterized more frequently. By the end of the fol- introducing a protocol incorporating evidence-based indi-
low-up period, CDPP had decreased by 7.6 to 14.3 days cations for catheterization,30 whereas a more-modest 14%
(64–86%) on the medical services and 5.5 to 12.7 days reduction in urinary catheterization was found postopera-
(38–78%) on the surgical services depending on age group. tively after posters and educational sessions were intro-
The incidence of catheterization similarly decreased by duced.31 The results presented here were similar in
35% to 52% on the medical services and 38% to 50% on magnitude to those of the other studies, with incidence of
the surgical services by the end of the study period. The catheterization decreasing by 35% to 52%, and lend fur-
histograms of pre- and postintervention CDPP are shown ther credence to the value of the approaches incorporated
in Figure 2. Before the intervention, the proportion of indi- in our intervention and those of others. Our study also
viduals catheterized for 2 days or less was 12% for medi- demonstrates that these benefits are generalizable to a
cine and 8% for surgery. A marked change in the mixed population of medical and surgical patients.
distribution was observed after the intervention, with 51% Many previous studies of urinary catheterization have
and 44% catheterized for 2 days or less respectively. focused on its role as a risk factor for the development of
catheter-associated UTI (CAUTI), particularly if a catheter
remains in place for long periods.6 Although we did not
DISCUSSION
examine CAUTI as an outcome measure, we examined a
This study demonstrates that a multimodal educational related measure, CDPP. Studies examining CAUTI have
intervention encouraging evidence-based use of urinary estimated that, after the first 48 hours of urinary catheteri-
catheters in an entire hospital can have an immediate and zation, each additional day increases the risk of CAUTI by

Table 3. Outcome Measures According to Age

<65 65–74 75–84 ≥85
Outcome Measure
Medicine Surgery Medicine Surgery Medicine Surgery Medicine Surgery

Catheter days per patient, mean  standard deviation

Before intervention 16.7  15.9 8.5  10.4 11.8  12.6 8.9  13.3 17.0  14.9 11.6  10.4 10.8  7.5 16.3  9.9
After intervention 4.9  10.9 2.9  1.7 2.5  1.5 2.9  2.5 4.7  5.7 4.0  2.3 3.6  2.9 3.5  2.0
After second phase 4.6  4.6 2.6  2.4 5.4  10.6 3.0  2.7 5.6  7.0 3.2  4.0 3.8  3.1 3.9  2.4
End of study period 2.4  1.3 2.9  4.3 4.2  3.8 3.4  2.0 3.9  5.5 3.3  2.6 2.9  4.3 3.6  2.9
Catheterized, %
Before intervention 8.6 15.9 14.3 27.2 14.7 31.1 27.1 32.0
After intervention 4.3 12.1 7.6 20.2 17.2 21.3 22.3 24.2
After second phase 3.8 8.7 10.5 12.2 13.2 17.4 12.7 17.2
End of study period 4.1 8.7 9.3 13.6 9.6 19.2 14.1 16.5
JAGS 2017
Figure 2. Histograms of catheter use in the 6-month preintervention period and the 6-month postintervention period immediately
after the transition period. Because of differences in patient volumes between services, the scale varies between the plots.
5% to 10%.2 If a urinary catheter is necessary, the dura-
tion of catheterization should hence be minimized, ideally
to less than 48 hours,2,16 a period during which the indi-
vidual is at essentially no greater risk of infection than
someone who was not catheterized.2,12 Although we
observed a greater reduction in CDPP than in a previous
study involving individuals undergoing surgery,12 the abso-
lute CDPP of 2.2 days reported in that study was lower
than for surgical inpatients at our hospital. This suggests
that, although our intervention had a significant effect,
there may be room for improvement. A study of 2,965
U.S. acute care hospitals demonstrated that their CDPP for
individuals undergoing surgery averaged 3.5 days,2 versus
2.9 days at the end of the study period at our hospital,
suggesting that it is an above-average performer.
The proportion of individuals catheterized for
48 hours or less also dramatically increased after the inter-
vention at our hospital. A cohort of individuals with
extended catheterizations, in some cases 15 days or more,
were far less numerous (Figure 2) after the intervention.
Although it is difficult to confirm the reasons behind these
previous lengthy urinary catheterizations, it is possible that
this subgroup may at least in part have consisted of indi-
viduals whose urinary catheter was left in place for longer
than necessary.
We observed a higher frequency of urinary catheter
use in older adults, particularly those aged 85 and older.
This has been well demonstrated.7,8 Although we did not
have the opportunity to audit reasons for individual cathe-
ter placements, previous research suggests that, in many
cases, older adults may be inappropriately catheterized.2,14
We observed a marked reduction in catheter use in older
adults after our intervention, which aimed to educate pro-
viders on appropriate indications for catheterization. The
rates at the end of the study period in our hospital
(Table 3) compares favorably with estimates collected
from 183 U.S. hospitals, which found that 23.6% of all
inpatients are catheterized.32 Given that the indications for
catheterization are the same for all patients and are quite
REDUCING URINARY CATHETER USE IN HOSPITALS 5
strict (see the Centers for Disease Control and Prevention
guidelines16 for supported indications), the continued dis-
parity between younger and older individuals suggests that
there may be further opportunity for improvement. We
have introduced additional interventions as an ongoing
component of this work, including automated stop
orders,33 daily catheter rounds to review ongoing catheter-
izations,34 and an Acute Care for Elders orderset,35 avail-
able to all older adults admitted to the General Internal
Medicine service.
One additional concern that this study addressed is
whether the changes in catheter use identified immediately
after intervention wane with time, requiring further inter-
vention. Other studies have suggested that multiple inter-
ventions may be necessary to maintain adherence.36 The
analysis presented here, which includes almost 3 years of
follow-up, has not identified evidence that this is the case.
The segmented regression approach, which specifically
tests for any ongoing linear trends in the outcomes of
interest, did not identify any meaningful trends suggestive
of a reversion to previous behaviors after the initial inter-
vention, although there were further second-phase inter-
ventions deployed in 2011 that may have served to
reinforce behaviors. The hospital is continuing surveillance
of the parameters described here to observe whether repeat
interventions are necessary.
This study has several limitations. One area of uncer-
tainty is what the potential unintended consequences of not
catheterizing are. One common concern is whether these
interventions result in greater use of other continence man-
agement approaches, particularly depending more on the
use of incontinence products, which are expensive. Although
this was not explicitly examined at our hospital, we are not
aware of any significant increases in the use of incontinence
products. A second limitation of our study is that we did not
have a control group to compare our results with. This is
largely a consequence of the design of the educational inter-
vention, which emphasized word-of-mouth spread and
changes to the hospital’s EMR, making it difficult to isolate
6 NORMAN ET AL.
an area of the hospital from the intervention, although the
use of segmented regression allowed us to test for secular
trends in our data suggestive of exogenous factors, of which
none were found. A third limitation of this study is that we
were unable to differentiate the relative effectiveness of the
different interventions undertaken, so to replicate the results
presented in this study, another hospital would probably
have to replicate all of the interventions. A fourth limitation
of this study is that we did not have access to individual
charts to review individual indications for catheterization.
Having this data would have allowed us to assess whether
indications for urinary catheterization were being applied
appropriately and whether there was any change in behavior
after the intervention. It also limits our ability to comment
on diagnoses and comorbidities and their relationship with
urinary catheterization.
In conclusion, a multimodal educational intervention
emphasizing evidence-based use of urinary catheters pro-
duced significant changes in postintervention catheter use,
including fewer CDPP and lower incidence of urinary
catheterization in a broad cross-section of individuals.
These effects endured over a lengthy follow-up period. The
results from this study suggest that a relatively simple bun-
dle of educational interventions can result in dramatic and
sustained health outcome improvements.
ACKNOWLEDGMENTS
Conflict of Interest: None of the authors have any actual
or potential conflicts of interest to declare with respect to
this work.
Author Contributions: Dr. Norman and Dr. Sinha
designed the study, collected and analyzed the data, and
prepared the manuscript. Ms. Ramsden and Ms. Ginty
developed the educational interventions and delivered the
front-line education sessions.
Sponsor’s Role: There was no external sponsor for this
work.
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