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YICCN-2487; No. of Pages 9 ARTICLE IN PRESS

Intensive and Critical Care Nursing xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Intensive and Critical Care Nursing

journal homepage: www.elsevier.com/iccn

Original article

An intervention to improve the catheter associated urinary tract

infection rate in a medical intensive care unit: Direct observation of
catheter insertion procedure
Janet M. Galiczewski a,b,∗ , Kathleen M. Shurpin a
a
Stony Brook University School of Nursing, United States
b
Long Island Jewish Medical Center, United States

a r t i c l e i n f o a b s t r a c t

Keywords:
Catheter Associated Urinary Tract Infection Background: Healthcare associated infections from indwelling urinary catheters lead to increased patient
(CAUTI) morbidity and mortality.
Direct observation
Aim: The purpose of this study was to determine if direct observation of the urinary catheter insertion
Intervention
procedure, as compared to the standard process, decreased catheter utilization and urinary tract infection
Protocol based-care intensive care unit
(ICU) rates.
Methods: This case control study was conducted in a medical intensive care unit. During phase I, a
retrospective data review was conducted on utilsiation and urinary catheter infection rates when practi-
tioners followed the institution’s standard insertion algorithm. During phase II, an intervention of direct
observation was added to the standard insertion procedure.
Results: The results demonstrated no change in utilization rates, however, CAUTI rates decreased from
2.24 to 0 per 1000 catheter days.
Conclusion: The findings from this study may promote changes in clinical practice guidelines leading to
a reduction in urinary catheter utilization and infection rates and improved patient outcomes.
© 2016 Elsevier Ltd. All rights reserved.

Introduction As a result, government funded reimbursement is being lim-

Catheter associated urinary tract infections (CAUTI) account for
40% of all healthcare associated infections (HAI) in the United States
(Fuchs et al., 2011). Internationally, CAUTI rates can increase up to
5% higher depending on the socioeconomic status and resources of
the country (Rosenthal et al., 2012). Urinary tract infections (UTI)
caused by an indwelling catheter lead to a significant increase in
patient morbidity and mortality and generate a financial burden
on health care systems (Leone et al., 2003).
Background and significance
Thei ncidence of CAUTI in the United States has reached almost
two million cases and has raised healthcare costs to over 400
million dollars per year (Gray, 2010; Vacca and Angelos, 2013).
∗ Corresponding author at: Stony Brook University, School of Nursing HSC Level
2- 204 Stony Brook, New York 11794-8240, United States.
E-mail address: Janet.Galiczewski@stonybrook.edu (J.M. Galiczewski).
ited to encourage hospitals to implement protocols aimed at
reducing this HAI (Vacca and Angelos, 2013). The National Health-
care Safety Network (NHSN) survey conducted on patients in
intensive care units (ICU) revealed that UTIs were the most com-
mon HAI found in this vulnerable population (Richards et al.,
2000).
In January 2015, the Center for Disease Control and Prevention
(CDC) issued changes in the CAUTI definition that may have an
impact on urinary catheter infection and utilization rates. The new
definition will impact how CAUTI is reported to the NHSN. The sig-
nificant changes included: (1) bacteria only acceptable causative
agent of UTIs, (2) urine culture threshold criteria increased to
1,000,000 CFU/ml, and (3) same pathogen list used for symptomatic
UTIs and asymptomatic bacteriuria UTIs (CDC, 2015). The exclu-
sion of yeast, mold, fungi and parasite related UTIs will decrease
the often overinflated CAUTI rates (CDC, 2015). Studies are needed
post implementation of the updated CAUTI surveillance definition
to examine the impact on urinary catheter infection and utilization
rates.

http://dx.doi.org/10.1016/j.iccn.2016.12.003
0964-3397/© 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Galiczewski, J.M., Shurpin, K.M., An intervention to improve the catheter associated urinary tract
infection rate in a medical intensive care unit: Direct observation of catheter insertion procedure. Intensive Crit Care Nurs (2017),
http://dx.doi.org/10.1016/j.iccn.2016.12.003
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Implications for Clinical Practice

• Decreasing the incidents of CAUTI not only improves patient outcomes by reducing patient morbidity and mortality but can also
decrease medical costs.
• Protocol based algorithms for urinary catheter placement must include interventions that focus on adherence to general infection
control principles.
• Evidence supports the intervention of direct observation being added to the catheter placement algorithm to ensure adherence to
protocol.
• An invaluable benefit of direct observation is the ability to provide immediate constructive feedback that may improve practice.

Preventative measures for CAUTI such as catheter avoidance
strategies, hand hygiene, perineal care, and daily necessity review
to limit catheter days have been associated with decreased CAUTI
rates in ICUs (Chenoweth and Saint, 2013). Many institutions bun-
dle these interventions into protocol-based guidelines for catheter
insertion to standardize care based on the scientific evidence to
improve patient outcomes (Clearinghouse, 2014). Globally, CAUTI
prevention efforts continue and nurses lead the effort to identify
interventions with the greatest impact on CAUTI rates. The purpose
of this quality improvement study is to determine if direct observa-
tion of the urinary catheter insertion procedure, as compared to the
standard process, decreases urinary tract infection and utilization
rates.
Review of literature
Protocol -based care
Protocol-based care is used to implement evidence-based inter-
ventions which improve patient outcomes and the overall quality
of care (Topal et al., 2005). The use of protocol-based care pro-
vides the nurse with increasing autonomy and positively affects
delivery of care (Ilott et al., 2006; Rycroft-Malone et al., 2008). Clin-
ical protocols are developed by healthcare teams and are based on
systematic review of the scientific evidence (Harbour and Miller,
2001). The strength of the evidence is graded and agencies devel-
oping protocol-based care policies must assess the applicability,
consistency and clinical impact of the evidence (Hadorn et al., 1996;
Harbour and Miller, 2001).
Ilott et al. (2006) defined protocol-based care as “the stan-
dardization of the processes of clinical care in documents, such as
protocols, pathways, algorithms or guidelines” (p. 548). In 1997,
the Agency for Healthcare Research and Quality (AHRQ) created
the National Guideline Clearinghouse (NGC) to represent protocol
development that was in harmony with the Institution of Medicine
(IOM) (Clearinghouse, 2014). In 2014, the definition of protocol-
based care was revised and defined as the standardization of care
based on the scientific evidence to optimize patient outcomes
(Clearinghouse, 2014). The CDC developed guidelines for CAUTI and
hospitals that adopted the guidelines and implemented protocol-
based care have decreased CAUTI rates (Gray, 2010).
Implementation of protocol-based care bundles to prevent CAUTI
Evidence based research has identified interventions to combat
urinary catheter infection and utilization rates and these interven-
tions have been incorporated into protocol-based insertion bundles
(Flodgren et al., 2013; Gray, 2010). A multi-phase study conducted
in an ICU and two step down units (SDUs) in a Brazilian hospital
that implemented CDC recommended protocols and the Institute
for Healthcare Improvement’s (IHI) bladder bundle (Marra et al.,
2011). The results were statistically significant with a reduction in
the CAUTI rate in the ICU from 7.6 to 5 per 1000 catheter days and
in the SDUs from 15.3 to 12.9 per 1000 catheter days (Marra et al.,
2011). This study was conducted in a single hospital and did not
collect continuous data on the units prior to the implementation of
the bundle intervention (Marra et al., 2011).
Studies conducted in ICUs of hospitals that are members of
the International Nosocomial Infection Control Consortium (INICC)
were done to assess the impact of a multidimensional infection
control strategy on CAUTI rates (Kanj et al., 2013; Leblebicioglu
et al., 2013; Navoa-Ng et al., 2013; Rosenthal et al., 2012). This
international study included 15 developing countrieswith a total
sample size of 56, 429 patients in 57 ICUs (Rosenthal et al., 2012).
Rosenthal et al. (2012) conducted a meta-analysis of the multiple
studies involved in the INICC to evaluate the impact of the bundle
intervention strategy on CAUTI rates as a whole. The interven-
tions included in the bundle were: (1) proper hand hygiene, (2)
to maintain collection bag lower than the level of the bladder, (3)
to maintain unobstructed urine flow, (4) to empty collection bag
at regular intervals and avoid allowing the draining spigot to touch
the collection container, and (5) to monitor CAUTIs using standard-
ized criteria (Rosenthal et al., 2012). The results of the combined
studies were statistically significant with 253,122 urinary catheter
days recorded). The CAUTI rate decreased from 7.68 to 4.95 per
1000 catheter days after implementation of the bundle interven-
tion (Rosenthal et al., 2012). The strength of these combined studies
were that they took place in multiple institutions, in different types
of adult ICU setting, in different countries and had large sample
sizes. Limitations included a lack of resources to collect more data
on process surveillance and compliance with all interventions in
the bundle (Kanj et al., 2013; Leblebicioglu et al., 2013; Navoa-Ng
et al., 2013; Rosenthal et al., 2012).
Inappropriate use of urinary catheters, improper insertion tech-
nique and poor management of the catheter once inserted have
been identified as major factors that lead to unnecessary infec-
tions (Tatham et al., 2015; Tsai et al., 2015). A study by Tsai et al.
(2015) implemented a UTI care bundle that included a staff educa-
tion session and an insertion and daily care checklist. The insertion
and daily checklist included hand hygiene, perineum washing, care
of the urine container, keeping a closed system and daily review
of catheter necessity. The CAUTI rate decreased significantly after
implementation of the care bundle from 6.10% in 2013 to 3.47% in
2014 (Tsai et al., 2015). Another quality improvement study that
implemented insertion and maintenance care bundles based on
national guidelines had similar success in decreasing CAUTI rates
and also identified the need to engage staff by conducting educa-
tion sessions and providing frequent feedback on patient outcomes
(Tatham et al., 2015).
Measuring effectiveness of protocol-based care
Measuring protocol-based care is a challenge. Often, patient
outcomes, reduced length of stay (LOS) and improved documenta-
tion are used to determine the effectiveness of standardization of
care (Rycroft-Malone et al., 2004). A study conducted by Rycroft-
Malone et al. (2008) used a multifaceted approach to measure
protocol-based care which included: (1) direct observation of activ-

Please cite this article in press as: Galiczewski, J.M., Shurpin, K.M., An intervention to improve the catheter associated urinary tract
infection rate in a medical intensive care unit: Direct observation of catheter insertion procedure. Intensive Crit Care Nurs (2017),
http://dx.doi.org/10.1016/j.iccn.2016.12.003
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ities related to the standardization of care, (2) post-observation
interviews with the multidisciplinary team to explore their views
about the use and impact of standardization of care, (3) interviews
with patients about their experience, (4) tracking patients during
their course of medical treatment and (5) review of relevant doc-
umentation. Quality monitoring using direct observation has been
well validated as a method to measure effectiveness of a protocol
(Larson et al., 2004).
required intensive resources (Larson et al., 2004). It has also been
found that individuals who are being observed may change their
behavior to be more compliant (Larson et al., 2004; Pedersen et al.,
1986). An invaluable benefit of direct observation is the ability to
provide immediate constructive feedback that improves practice
and may have a positive effect on patient outcomes (Ellingson et al.,
2014).

Direct observation
HAIs can be associated with several factors such as an inex-
Theoretical framework
perienced health professional performing the procedure, a gap in
knowledge, or failure to adhere to the recommended protocols
The chain of infection theory
(Muscedere et al., 2008; Safdar et al., 2002). Protocol-based care
bundles were developed for the ICU setting in 2006 to combat all
The chain of infection is a physiology theory based on the prin-
HAIs and when performed reliably should improve patient out-
ciples of epidemiology. The theory explains the processes that are
comes (Flodgren et al., 2013). A risk factor for developing CAUTI is
required for the transmission of pathogens from their existing envi-
failure to comply with the infection control practices in the protocol
ronment to a patient and for subsequent infection to occur (Mitchell
bundle during the insertion procedure (Flodgren et al., 2013).
and Gardner, 2014). There are six major components of the the-
Many studies addressing compliance with and effectiveness
ory: (1) infectious disease, (2) reservoir, (3) portal of exit, (4) mode
of protocol based-care using direct supervision or observation
of transmission, (5) portal of entry and (6) susceptible host (CDC,
focused on hand hygiene and central line associated blood stream
1992). Modern day infection control practices are put into place
infections(CLABSI). A large cross sectional study involving 250 hos-
to avoid the transmission of pathogens by breaking the chain of
pitals evaluated compliance with the CLABSI intervention bundle
infection (Mitchell and Gardner, 2014). A model has been created
and determined that the infection rate was decreased when the
by the CDC to illustrate this theory and the relationship between
institution had a clear written protocol, compliance was monitored
the components (Fig. 1).
through direct supervision and documentation, and compliance
As HAIs become a global patient safety issue, nurses need to
was rated as high (Furuya et al., 2011). A study by Frankel (2005)
adopt the role of infection preventionists (APIC, 2012). The basic
used the corporate Six Sigma performance improvement strategies
principles of the chain of infection are overlooked by healthcare
to decrease CLABSI rates. The interventions included were direct
workers on a daily basis and their hands are the most common
observation by the attending physician of all central line catheter
vehicle for transmission of pathogens (Allegranzi and Pittet, 2009).
insertions along with educational and policy change interventions.
According to the Association of Professionals in Infection Control
The result showed a decrease in CLABSI rates from 11 to 1.7 per
and Epidemiology (APIC), the infection preventionist nurse needs
1000 catheter days, a 650% improvement (Frankel 2005). Although
to become a new kind of leader who can engage all disciplines
direct observation was used as an intervention in this study, its
to work towards the common goal of breaking the chain of infec-
impact alone cannot be assessed due to it being bundled with Six
tion. Nurses spend the most time caring for patients; they need to
Sigma educational strategies and policy change interventions.
address this endemic patient safety issue and champion the cam-
In 2004, Larson et al. conducted a study comparing two methods
paign to improve infection rates and patient outcomes.
of assessing compliance with hand hygiene practices; they looked
at direct observation and self-reporting using a daily diary. The
sample size was adequate with 119 nurses yielding 1071 diary
entries and 206 hours of direct observation. The results showed that
the total number of hand hygiene episodes with direct observation Methods
were greater than with self reporting, however the results were
statistically insignificant (p = 0.32) (Larson et al., 2004). Limitations Setting and study design
to this study were most of the observation times occurred on the
day shift and in one hour intervals which were not representative This quasi-experimental case control study was conducted in
of the entire time period being studied. the medical ICU of a 603 bed tertiary academic medical center
A three phase observational study by Earl et al. (2001) was con- located in the northeastern section of the United States. This ICU
ducted in two SICUs and a MICU to monitor if the availability of provided acute care to adults with primarily medical illnesses.
alcohol-based gels conveniently located increased hand hygiene. Approval from the Quality Improvement/Nursing Research Com-
Phase1 consisted of observing hand hygiene practices with soap mittee was obtained prior to the start of this project. Informed
and water, phase 2 monitored hand hygiene after gel dispensers consent was not required as only de-identified aggregate data was
were placed in each unit and phase 3 monitored the adherence collected and there was no change in the standard of care.
rate of hand hygiene 10–14 weeks post intervention (Earl et al., The study was carried out in two phases. During phase I (n = 74),
2001). The results showed, with statistical significance, an increase a retrospective data review was conducted on utilization and
in adherence to hand hygiene in all of the units from phase 1 to 3; urinary catheter infection rates when practitioners followed the
the SICUs improved 58.9% and the MICU 29.4% from baseline (Earl institution’s standard insertion algorithm (Fig. 2). Catheter inser-
et al., 2001). Direct observation by educated personnel was used tion policies were based on the APIC and CDC guidelines (APIC,
to measure compliance with the hand hygiene protocol. This study 2014; CDC, 2015). During phase II (n = 64), an intervention of direct
consisted of 402 observational hours and was conducted during the observation by an educated observer was added to the standard
day and night to capture compliance on both shifts. insertion procedure. The practitioners on the unit served as the
Direct observation has become the “gold standard” of surveil- observers. Five day nurses and four night nurses volunteered to be
lance methods (Larson et al., 2004). It provides a direct measure trained as observers. This allowed the intervention to take place on
of compliance with and effectiveness of protocol-based care; how- both the day and night shift and capture all eligible patients at no
ever it is rarely used due to its high cost, time consumption and additional cost to the institution.

Please cite this article in press as: Galiczewski, J.M., Shurpin, K.M., An intervention to improve the catheter associated urinary tract
infection rate in a medical intensive care unit: Direct observation of catheter insertion procedure. Intensive Crit Care Nurs (2017),
http://dx.doi.org/10.1016/j.iccn.2016.12.003
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Fig. 1. CAUTI Chain of Infection Model adapted from CDC 2002.

Instrument transferred to the medical ICU, (3) required an indwelling urinary

A 13 item critical element checklist was developed based on
the urinary catheter insertion algorithm of the institution which
was based on the APIC and CDC guidelines for the prevention of
CAUTI (Fig. 3). This established the validity of interventions on
the checklist. It required yes/no answers on 12 of the 13 critical
safety elements. If the observer identified one of the elements was
incorrect, they corrected the action of the practitioner inserting the
catheter and when the item was completed properly, theymarked
the corrected box on that item. This ensured that all the elements
of the algorithm were followed based on the insertion protocol.
One of the checklist elements required the observer to choose a
reason for catheter use from a list of 10 hospital approved indica-
tions for catheter insertion. The checklist included directions for
use and before the start of phase II, the medical ICU practitioners
that volunteered to be observers were given a 30 minute education
session. The education session included a review of the institution’s
urinary catheter insertion procedure, directions on the use of the
checklist and the purpose of the quality improvement project. The
checklist did not include any patient or staff identifiers. To estab-
lish fidelity (compliance with the checklist), the investigators of
the study spent time on both shifts to ensure catheter insertions
were being observed and the checklist was used correctly. Compli-
ance with the checklist was defined as completion of the checklist
for every urinary catheter insertion observed in the medical ICU
during the intervention phase of the study.
Sample
The study population consisted of a convenience sampling of
140 patients that had a urinary catheter placed during their stay in
the medical ICU. There were 74 patients recruited in phase I and
66 patients in phase II. Selection of inclusion and exclusion criteria
were determined prior to the start of the study. The inclusion cri-
teria were: (1) patients ≥18years of age, (2) patients admitted or
catheter, and (4) catheter was placed in the medical ICU. The exclu-
sion criteria were: (1) patients <18 years of age and (2) patients
with a urinary catheter placed in another unit of the hospital prior
to being transferred or admitted to the medical ICU.
Definitions. CAUTI surveillance is performed on a monthly basis
by the nurse administrators on the medical ICU and reported to the
quality management practitioner who calculates CAUTI and utiliza-
tion rates based on the 2015 CDC definition guidelines. CAUTI rates
are calculated by dividing the number of CAUTIs by the number
of urinary catheter device days multiplied by 1000 (Elpern et al.,
2009). The catheter utilization ratio is defined as the number of
urinary catheter days divided by the number of patient days and is
reported as a percentage (Marra et al., 2011).
Statistical analysis
Using the program Statistical Package for the Social Sciences
Software (SPSS) version 22, descriptive statistics were calculated
on selected patient variables. Frequencies were calculated for cat-
egorical variables. Means and standard deviations were calculated
for continuous variables. The categorical variables in this study
included gender, reason for catheter placement, catheter place-
ment observation and development of a CAUTI. The continuous
variables included age in years and the day on which a CAUTI was
identified following catheter placement. If the checklist was incor-
rectly filled out during observation of a urinary catheter insertion or
if the checklist had missing data, the patient was not included in the
study. The hypotheses of this study were that urinary catheter uti-
lization and infection rates would decrease during the intervention
phase compared to the pre-intervention phase. An independent
samples t-test was used to determine if there was a statistically
significant difference (p < 0.05) in mean monthly catheter utiliza-
tion and urinary catheter infection rates between the two samples.
Additionally, a Fisher’s exact test was used to determine if the
percentage of patients who developed a CAUTI between the two

Please cite this article in press as: Galiczewski, J.M., Shurpin, K.M., An intervention to improve the catheter associated urinary tract
infection rate in a medical intensive care unit: Direct observation of catheter insertion procedure. Intensive Crit Care Nurs (2017),
http://dx.doi.org/10.1016/j.iccn.2016.12.003
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Fig. 2. * Based on Stony Brook Medicine Urinary Catheter Insertion for the Adult & Pediatric Patient Protocol algorithm (2015). Based on the APIC and the CDC Guidelines
(2015).

samples was statistically different (p < 0.05). Fisher’s exact test was regards to sex. The Chi Square test demonstrated that the percent-
used in place of the chi square test due to the small sample size. age of males and females was not different between the two groups
(p = 0.935).
Results

Urinary catheter utilization rates

Sample demographics
In this two phase study, the total sample size was n = 140.
Table 1 describes the demographics of the sample during phase
I compared to Phase II of the study. An independent samples t-
test was used to compare the mean age of patients in phase I
to patients in phase II. Levene’s test was non-significant (.912)
indicating that the assumption of equal variances was not vio-
lated. The samples t-test demonstrated there was no significant
difference between the two groups (p = 0.754). A Chi-Square test
was performed to compare phase I patients to phase II patients in
Phase I of the study was conducted from April 2015 through July
2015. During this phase, the total recorded patient days were 1954
and the total recorded catheter days were 1403. The MICU utiliza-
tion rates during this period ranged from 67% to 78% (mean 71%).
Phase II began in October 2015 and data collection was completed
in February 2016. During this phase, the total recorded patient days
were 2348 and the total recorded catheter days were 1675. The
MICU utilization rates during this period ranged from 66% to 72%
(mean 71%). There was no difference in the mean utilization rate
between phase I and Phase II of this study.

Please cite this article in press as: Galiczewski, J.M., Shurpin, K.M., An intervention to improve the catheter associated urinary tract
infection rate in a medical intensive care unit: Direct observation of catheter insertion procedure. Intensive Crit Care Nurs (2017),
http://dx.doi.org/10.1016/j.iccn.2016.12.003
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Fig. 3. Indwelling Urinary Catheter Insertion Checklist.

* Based on Stony Brook Medicine Urinary Catheter Insertion for the Adult & Pediatric Patient Protocol algorithm (2015). Catheter insertion policies are based on the Association
for Professionals in Infection Control and Epidemiology (APIC) and the CDC Guidelines (2015)
Directions for use of Indwelling Urinary Catheter Insertion Checklist
1. One practitioner is responsible for observing catheter insertion procedure and completing the checklist.
2. If practitioner inserting indwelling catheter misses completing a step or does so incorrectly, the observer is to correct the practitioner ensuring all steps are followed. For
example: if sterile technique is broken and the practitioner inserting the catheter continues with the procedure, the observer is to point out the mistake and a new sterile
catheter is to be used to continue. In this case the observer would check the no box for this step and then the corrected box when the step is completed correctly.
3. For the indications for indwelling catheter section, please place the corresponding number that closely describes why the patient is receiving the catheter.
4. If a step is not applicable, put a N/A in the completed box.
5. Thank you for your time and participation in this quality improvement project.

Table 1
Demographics.

Variables Phase I Not Observed (n = 74) Phase II Observed (n = 66)

t Mean Age 67.03 (SD = 16.35) 66.15 (SD = 16.58)

Male 56.8% 56.1%
CAUTI identified 4.1% 0%
Mean Day CAUTI identified 5 N/A

CAUTI: Catheter Associated Urinary Tract Infection; N/A: Not applicable.

Catheter associated urinary tract infection rates
The monthly rate of CAUTI ranged from 0 to 3.26 per 1000
catheter days with a mean of 2.24 during phase I. The overall mean
monthly rate of CAUTI in the MICU declined from 2.24 to 0 per 1000
catheter days in phase II when direct observation was added to the
urinary catheter insertion protocol. This change was not statisti-
cally significant (p = 0.098). Prior to the intervention, 3 out of 74
patients (4.1%) developed an infection attributable to the urinary
catheter based on 2015 CDC guidelines. There were zero CAUTI

Please cite this article in press as: Galiczewski, J.M., Shurpin, K.M., An intervention to improve the catheter associated urinary tract
infection rate in a medical intensive care unit: Direct observation of catheter insertion procedure. Intensive Crit Care Nurs (2017),
http://dx.doi.org/10.1016/j.iccn.2016.12.003
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Table 2
Percentages of Patients who Developed CAUTI.
Urinary Catheter Insertion Percentage of Patients
that did Not develop
CAUTI
Not Observed 95.9% (71 patients)
Phase I
Observed 100% (66 patients)
Phase II
CAUTI = Catheter Associated Urinary Tract Infection.
occurrences reported for the 66 patients who had the catheter
insertion procedure observed during phase II of the study (Table 2).
While the results of this study were not statistically significant
(p = 0.253), they may be clinically relevant.
Discussion
Reducing the incidents of CAUTI not only improves patient
outcomes but can also decrease medical costs. It has been well
established that CAUTI can lead to bacteremia and a prolonged
LOS (Chen et al., 2005).Treating a single episode of uncomplicated
CAUTI costs between 1000 and 5000 dollars and increases LOS by
2 to10.3 days (Gray, 2010; Laupland et al., 2002; Umscheid et al.,
2011). CAUTIs are the second leading cause of blood stream infec-
tions and can add over 36,000 dollars per episode to the cost
(Titsworth et al., 2012). In addition, eliminating CAUTI has become
a global priority due to government funded insurance companies
no longer providing payment for treatment (Burton et al., 2011).
Every CAUTI event exponentially increases an institutions financial
burden.
Up to 70% of CAUTI cases may be preventable if evidence based
protocols are followed during catheter insertion (Umscheid et al.,
2011). There is so much to gain, in terms of decreased mortal-
ity rates and healthcare costs, if practitioners adhere to infection
control practices. The finding of zero CAUTI occurrences during
Fig. 4. Indications for Urinary Catheter Insertion.
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infection rate in a medical intensive care unit: Direct observation of catheter insertion procedure. Intensive Crit Care Nurs (2017),
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7
Percentage of Patients Total Patients
that developed CAUTI
4.1% (3 patients) 74
0 66
the intervention phase of direct observation of the catheter inser-
tion procedure, although not statistically significant, will decrease
healthcare costs and impact patient safety. Therefore, decreasing
CAUTI rates in vulnerable ICU patients is clinically relevant.
One of the most successful strategies to combat CAUTI is to
decrease the use of indwelling catheters. Most hospitals have devel-
oped indications for use of indwelling catheters that are often part
of the catheter insertion algorithm or protocol (Titsworth et al.,
2012). The indications are included to guide the practitioner in
determining if the patient requires a urinary catheter. The checklist
used in phase II of this study included a section for recording the
hospital approved indication for use of the urinary catheter (Fig. 4).
This type of data was not collected during the retrospective data
review (phase I) so therefore it could not be compared to data from
phase II.
During both phases of this quality improvement study, the mean
utilization rate remained the same at 71%. It was hypothesized
that utilization rates would decrease during phase II when urinary
catheterizations were being observed and the indications for usage
were strictly adhered to. Currently in this MICU, Clinical Nurse Edu-
cators perform daily urinary catheter rounds and remind the ICU
practitioners of indications for catheter usage. These rounds were
common practice during both phases of this study and therefore
could account for no change in utilization rate. Although this unit
made great strides since 2013 to decrease their utilization rate
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from 84% to 71%, it remains above the NHSN catheter utilization
benchmark of 61% for critical care units (Casey et al., 2015)
A limitation of this study is that it was conducted in a single ICU
of a large tertiary academic teaching hospital and thus the gener-
alizability of the results may be limited to hospitals of similar size
and type. Additionally, indication for catheter usage was only col-
lected during phase II of the study and although the information
was informative, it could not be compared to phase I. Another lim-
itation was the NHSN CAUTI definitions were updated in January
2015 and all hospitals had to comply with the new reporting guide-
lines by April 2015. Although all data from this study was collected
under the new guidelines, it cannot be compared to data prior to
January 2015.
This study has provided a potential framework to understand
the impact of direct observation during the insertion procedure
as an intervention to prevent CAUTI. Previous studies address-
ing compliance with protocol based-care using direct observation
have demonstrated a statistically significant decrease of infection
rates, however, they focused on CLABSI (Furuya et al., 2011). More
research is needed on implementing a protocol based care bun-
dle for catheter insertion that includes direct observation of the
procedure.
Conclusion
Reducing CAUTI rates in the ICU setting is a complex process
that involves a multidirectional approach. Protocol based algo-
rithms for urinary catheter placement must include a bundle of
interventions that focus on adherence to general infection control
principles (Meddings et al., 2014). Urinary catheter infections can
be associated with several factors such as an inexperienced health
professional performing the procedure, a gap in knowledge, or fail-
ure to adhere to the recommended protocols (Muscedere et al.,
2008; Safdar et al., 2002). Evidence from phase II of this quality
improvement study supports the intervention of direct observation
being added to the catheter placement algorithm to ensure adher-
ence to protocol. An invaluable benefit of direct observation is the
ability to provide immediate constructive feedback that improves
practice (Ellingson et al., 2014). Findings from this study may pro-
mote changes in clinical practice guidelines leading to a reduction
in urinary catheter utilization and infection rates and improved
patient outcomes.
Financial and funding disclosure
None.
References
APIC, 2012. APIC strategic plan 2020, board of directors’ report. Am. J. Infect. Control
40 (4), 291–293, http://dx.doi.org/10.1016/j.ajic.2012.03.003.
APIC, 2014. APIC Implementaion Guide: Guide to Preventing Catheter- Associ-
ated Urinary Tract Infections, Retrieved April 19, 2015 from http://apic.org/
Resource /EliminationGuideForm/0ff6ae59-0a3a-4640-97b5-eee38b8bed5b/
File/CAUTI 06.pdf.
Allegranzi, B., Pittet, D., 2009. Role of hand hygiene in healthcare-associated infec-
tion prevention. J. Hosp. Infect. 73 (4), 305–315, http://dx.doi.org/10.1016/j.jhin.
2009.04.019.
Burton, D.C., Edwards, J.R., Srinivasan, A., Fridkin, S.K., Gould, C.V., 2011. Trends in
catheter-associated urinary tract infections in adult intensive care units-United
States, 1990–2007. Infect. Control Hosp. Epidemiol. 32 (8), 748–756, http://dx.
doi.org/10.1086/660872.
CDC, 1992. Principles of Epidemiology, Retrieved March 30, 2015 from
www.cdc.gov/OPHSS/CSELS/DSEPD/SS1978.
CDC, 2015. National Healthcare Safety Network, Retrieved March 24, 2015 from
http://www.cdc.gov/nhsn/about.html.
Casey, M., Distel, E., Evenson, A., 2015. Reporting of health-care associated infections
by critical access hospitals. Am. J. Infect. Control 43 (3), 206–221, http://dx.doi.
org/10.1016/j.ajic.2014.11.014.
Please cite this article in press as: Galiczewski, J.M., Shurpin, K.M., An intervention to improve the catheter associated urinary tract
infection rate in a medical intensive care unit: Direct observation of catheter insertion procedure. Intensive Crit Care Nurs (2017),
http://dx.doi.org/10.1016/j.iccn.2016.12.003
Chen, Y.Y., Chou, Y.C., Chou, P., 2005. Impact of nosocomial infection on cost of illness
and length of stay in intensive care units. Infect. Control Hosp. Epidemiol. 26 (3),
281–287, http://dx.doi.org/10.1086/502540.
Chenoweth, C., Saint, S., 2013. Preventing catheter-associated urinary tract infec-
tions in the intensive care unit. Crit. Care Clin. 29 (1), 19–32, http://dx.doi.org/
10.1016/j.ccc.2012.10.005.
Clearinghouse, N.G., 2014. Guideline Attributes, Retrieved February 17, 2015 from
http.//www.guideline.gov/about/template-of-attributes.aspx.
Earl, M.L., Jackson, M.M., Rickman, L.S., 2001. Improved rates of compliance with
hand antisepsis guidelines: a three-phase observational study. Am. J. Nurs. 101
(3), 26–33.
Ellingson, K., Haas, J.P., Aiello, A.E., Kusek, L., Maragakis, L.L., Olmsted, R.N., Yokoe,
D.S., 2014. Strategies to prevent healthcare-associated infections through hand
hygiene. Infect. Control Hosp. Epidemiol. 35 (Suppl. 2), S155–178.
Elpern, E.H., Killeen, K., Ketchem, A., Wiley, A., Patel, G., Lateef, O., 2009. Reducing
use of indwelling urinary catheters and associated urinary tract infections. Am.
J. Crit. Care 18 (6), 535–542, http://dx.doi.org/10.4037/ajcc2009938.
Flodgren, G., Conterno, L.O., Mayhew, A., Omar, O., Pereira, C.R., Shepperd, S., 2013.
Interventions to improve professional adherence to guidelines for prevention of
device-related infections. Cochrane Database Syst. Rev. 3, Cd006559, http://dx.
doi.org/10.1002/14651858.cd006559.pub2.
Frankel, H., 2005. Use of six sigma performance-improvement strategies to reduce
incidence of catheter-related bloodsteam infections in a surgical ICU. J. Am. Coll.
Surg. 201 (3), 349–358.
Fuchs, M.A., Sexton, D.J., Thornlow, D.K., Champagne, M.T., 2011. Evaluation of an
evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-
associated urinary tract infections in intensive care units. J. Nurs. Care Qual. 26
(2), 101–109, http://dx.doi.org/10.1097/NCQ.0b013e3181fb7847.
Furuya, E.Y., Dick, A., Perencevich, E.N., Pogorzelska, M., Goldmann, D., Stone, P.W.,
2011. Central line bundle implementation in US intensive care units and impact
on bloodstream infections. PLoS One 6 (1), e15452, http://dx.doi.org/10.1371/
journal.pone.0015452.
Gray, M., 2010. Reducing catheter-associated urinary tract infection in the critical
care unit. AACN Adv. Crit. Care 21 (3), 247–257, http://dx.doi.org/10.1097/NCI.
0b013e3181db53cb.
Hadorn, D.C., Baker, D., Hodges, J.S., Hicks, N., 1996. Rating the quality of evidence
for clinical practice guidelines. J. Clin. Epidemiol. 49 (7), 749–754.
Harbour, R., Miller, J., 2001. A new system for grading recommendations in evidence
based guidelines. BMJ 323 (7308), 334–336.
Ilott, I., Patterson, M., Turgoose, C., Lacey, A., 2006. What is protocol-based care? A
concept analysis. J. Nurs. Manag. 14, 544–552.
Kanj, S.S., Zahreddine, N., Rosenthal, V.D., Alamuddin, L., Kanafani, Z., Molaeb, B.,
2013. Impact of a multidimensional infection control approach on catheter-
associated urinary tract infection rates in an adult intensive care unit in Lebanon:
International Nosocomial Infection Control Consortium (INICC) findings. Int. J.
Infect. Dis. 17 (9), e686–e690, http://dx.doi.org/10.1016/j.ijid.2013.01.020.
Larson, E.L., Aiello, A.E., Cimiotti, J.P., 2004. Assessing nurses’ hand hygiene practices
by direct observation or self-report. J. Nurs. Meas. 12 (1), 77–85.
Laupland, K.B., Zygun, D.A., Davies, H.D., Church, D.L., Louie, T.J., Doig, C.J., 2002.
Incidence and risk factors for acquiring nosocomial urinary tract infection in the
critically ill. J. Crit. Care 17 (1), 50–57.
Leblebicioglu, H., Ersoz, G., Rosenthal, V.D., Nevzat-Yalcin, A., Akan, O.A., Sirmatel,
F., Bacakoglu, F., 2013. Impact of a multidimensional infection control approach
on catheter-associated urinary tract infection rates in adult intensive care units
in 10 cities of Turkey: International Nosocomial Infection Control Consortium
findings (INICC). Am. J. Infect. Control 41 (10), 885–891, http://dx.doi.org/10.
1016/j.ajic.2013.01.028.
Leone, M., Albanese, J., Garnier, F., Sapin, C., Barrau, K., Bimar, M.C., Martin, C., 2003.
Risk factors of nosocomial catheter-associated urinary tract infection in a poly-
valent intensive care unit. Intensive Care Med. 29 (7), 1077–1080, http://dx.doi.
org/10.1007/s00134-003-1767-2.
Marra, A.R., Sampaio Camargo, T.Z., Gonçalves, P., Sogayar, A.M.C.B., Moura, D.F.,
Guastelli, L.R., Edmond, M.B., 2011. Preventing catheter-associated urinary tract
infection in the zero-tolerance era. Am. J. Infect. Control 39 (10), 817–822, http://
dx.doi.org/10.1016/j.ajic.2011.01.013.
Meddings, J., Rogers, M.A.M., Krein, S.L., Fakih, M.G., Olmsted, R.N., Saint, S., 2014.
Reducing unnecessary urinary catheter use and other strategies to prevent
catheter-associated urinary tract infection: an integrative review. BMJ Qual. Saf.
23 (4), 277–289, http://dx.doi.org/10.1136/bmjqs-2012-001774.
Mitchell, B.G., Gardner, A., 2014. Addressing the need for an infection prevention
and control framework that incorporates the role of surveillance: a discussion
paper. J. Adv. Nurs. 70 (3), 533–542, http://dx.doi.org/10.1111/jan.12193.
Muscedere, J., Dodek, P., Keenan, S., Fowler, R., Cook, D., Heyland, D., the Canadian
Critical Care Trials, G., 2008. Comprehensive evidence-based clinical practice
guidelines for ventilator-associated pneumonia: diagnosis and treatment. J. Crit.
Care 23 (1), 138–147, http://dx.doi.org/10.1016/j.jcrc.2007.12.008.
Navoa-Ng, J.A., Berba, R., Rosenthal, V.D., Villanueva, V.D., Tolentino, M.C., Genuino,
G.A., Mantaring 3rd, J.B., 2013. Impact of an International Nosocomial Infec-
tion Control Consortium multidimensional approach on catheter-associated
urinary tract infections in adult intensive care units in the Philippines: Interna-
tional Nosocomial Infection Control Consortium (INICC) findings. J. Infect. Public
Health 6 (5), 389–399, http://dx.doi.org/10.1016/j.jiph.2013.03.002.
Pedersen, D.M., Keithly, S., Brady, K., 1986. Effects of an observer on conformity to
handwashing norm. Percept. Mot. Skills 62 (1), 169–170, http://dx.doi.org/10.
2466/pms.1986.62.1.169.
G Model
YICCN-2487; No. of Pages 9 ARTICLE IN PRESS
J.M. Galiczewski, K.M. Shurpin / Intensive and Critical Care Nursing xxx (2017) xxx–xxx 9

Richards, M.J., Edwards, J.R., Culver, D.H., Gaynes, R.P., 2000. Nosocomial infections
in combined medical-surgical intensive care units in the United States. Infect.
Control Hosp. Epidemiol. 21 (8), 510–515, http://dx.doi.org/10.1086/501795.
Rosenthal, V., Todi, S., Álvarez-Moreno, C., Pawar, M., Karlekar, A., Zeggwagh, A.,
Ulusoy, S., 2012. Impact of a multidimensional infection control strategy on
catheter-associated urinary tract infection rates in the adult intensive care units
of 15 developing countries: findings of the International Nosocomial Infec-
tion Control Consortium (INICC). Infection 40 (5), 517–526, http://dx.doi.org/
10.1007/s15010-012-0278-x.
Rycroft-Malone, J., Fontenla, M., Seers, K., 2008. Protocol-based care: impact on roles
and service delivery. J. Eval. Clin. Pract. 14 (5), 867–873.
Rycroft-Malone, J., Morrell, C., Bick, D., 2004. The research agenda for protocol-based
care. Nurs. Stand. 19 (6), 33–36, http://dx.doi.org/10.7748/ns2004.10.19.6.33.
c3730.
Safdar, N., Kluger, D.M., Maki, D.G., 2002. A review of risk factors for catheter-related
bloodstream infection caused by percutaneously inserted, noncuffed central
venous catheters: implications for preventive strategies. Medicine (Baltimore)
81 (6), 466–479.
Tatham, M.M.G., MacRae, M., Tully, V., Craig, K., 2015. Development and implemen-
tation of a catheter associated urinary tract infection (CAUTI) ‘toolkit’. Br. Med.
J. Qual. Improv. Rep. 4, 1–7.
Titsworth, W.L., Hester, J., Correia, T., Reed, R., Williams, M., Guin, P., Mocco, J., 2012.
Reduction of catheter-associated urinary tract infections among patients in a
neurological intensive care unit: a single institution’s success. J. Neurosurg. 116
(4), 911–920, http://dx.doi.org/10.3171/2011.11.jns11974.
Topal, J., Conklin, S., Camp, K., Morris, V., Balcezak, T., Herbert, P., 2005. Prevention of
nosocomial catheter-associated urinary tract infections through computerized
feedback to physicians and a nurse-directed protocol. Am. J. Med. Qual. 20 (3),
121–126, http://dx.doi.org/10.1177/1062860605276074.
Tsai, M.C.M., Wang, N., Chang, F., 2015. Expereinces of implementing UTI bundle care
in an emergency intensive care unit of a medical center. J. Microbiol. Immunol.
Infect. 48 (2), S93–S94.
Umscheid, C.A., Mitchell, M.D., Doshi, J.A., Agarwal, R., Williams, K., Brennan, P.J.,
2011. Estimating the proportion of healthcare-associated infections that are rea-
sonably preventable and the related mortality and costs. Infect. Control Hosp.
Epidemiol. 32 (2), 101–114, http://dx.doi.org/10.1086/657912.
Vacca, M., Angelos, D., 2013. Elimination of catheter-associated urinary tract infec-
tions in an adult neurological intensive care unit. Crit. Care Nurse 33 (6), 78–80,
http://dx.doi.org/10.4037/ccn2013998.

Please cite this article in press as: Galiczewski, J.M., Shurpin, K.M., An intervention to improve the catheter associated urinary tract
infection rate in a medical intensive care unit: Direct observation of catheter insertion procedure. Intensive Crit Care Nurs (2017),
http://dx.doi.org/10.1016/j.iccn.2016.12.003