Intensive and Critical Care Nursing (2016) 32, 1—11

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REVIEW

Interventions for the prevention of catheter

associated urinary tract infections in
intensive care units: An integrative review
Janet M. Galiczewski ∗,1

Stony Brook University, United States

Accepted 31 August 2015

KEYWORDS Summary Catheter associated urinary tract infections (CAUTIs) put an unnecessary burden on
patients and health care systems. The purpose of this integrative review was to examine existing
Catheter associated
evidence on preventative interventions and protocols currently implemented in intensive care
urinary tract
units (ICUs) and the impact they have on CAUTI rates and patient outcomes. This review analysed
infection (CAUTI);
14 research articles obtained from electronic databases and included adult patients with urinary
Indwelling urinary
catheters in an ICU setting. Evidence demonstrated interventions that included criteria for
catheter;
catheter use, daily review of catheter necessity and discontinuation of catheter prior to day
Intensive care unit
seven were successful in decreasing CAUTI rates. This review provides a scientific basis for the
(ICU);
effectiveness of these interventions and protocols. Identification and use of interventions with
Interventions;
the greatest positive impact on CAUTI rates are an asset to healthcare professional caring for
Prevention
patients with indwelling catheters and nurse clinicians developing policies.
© 2015 Elsevier Ltd. All rights reserved.

∗ Correspondence to: Stony Brook University, School of Nursing, HSC Level 2, Rm 204, Stony Brook, NY 11794-8240, United States.
E-mail address: Janet.Galiczewski@stonybrook.edu
1 Janet M. Galiczewski is a clinical assistant professor at the Stony Brook University School of Nursing for 12 years and a critical care nurse

for 27 years in the medical and surgical intensive care units at Long Island Jewish Medical Center. She is currently pursuing her Doctor of
Nursing Practice Degree at Stony Brook University.

http://dx.doi.org/10.1016/j.iccn.2015.08.007
0964-3397/© 2015 Elsevier Ltd. All rights reserved.
2 J.M. Galiczewski

Implications for Clinical Practice

• Catheter associated urinary tract infections (CAUTIs) put an unnecessary burden on patients and health care systems.
• Identification of interventions with the greatest positive impact on CAUTI rates would be an asset to healthcare
professional caring for patients with an indwelling catheter and nurse clinicians developing policies.
• CAUTIs cause an increased financial burden on health care facilities.
• This integrative review has shown that studies with interventions that included daily review of catheter necessity or
early discontinuance of urinary catheters (less than seven days) were successful in decreasing the CAUTI rates with
statistical significance.
• Evidence supports that ICU patients should have urinary catheters removed when no longer medically necessary.
• A multidirectional approach that includes evidence-based practices recommended by the Centers for Disease Control
and Prevention, the implementation of the Institute for Healthcare Improvement’s bladder bundle and increasing the
knowledge base of patient care providers is essential to decrease CAUTI events.

Introduction risk assessment for CAUTI to identify high risk patient

Catheter associated urinary tract infections (CAUTI) account
for 36% of all health care associated infections (HAI) in the
United States (Rebmann and Greene, 2010). Internation-
ally, CAUTI rates can be 3—5% higher than the United States
depending on the resources available and the socioeconomic
status of the country (Rosenthal et al., 2012). Urosepsis
from an indwelling catheter leads to a significant increase in
patient morbidity and mortality and generates an economic
and financial burden on health care systems (Leone et al.,
2003). The surge in CAUTI incidence due to the increased use
of catheters over an extended time period has prompted the
development of infection control protocols and initiatives
in health care settings (Marra et al., 2011). The intention
of these programmes is to decrease the global incidence of
CAUTI and improve patient outcomes (Daniels et al., 2014).
Background and significance
The incidence of CAUTI has reached almost two million cases
per year and the Centres of Medicare and Medicaid Services
(CMMS) in the United States has deemed CAUTI a ‘‘never
event’’, limiting government funded reimbursement (Vacca
and Angelos, 2013). A ‘‘never event’’ is considered pre-
ventable. In one calendar year, CAUTI can add up to almost
100,000 hospital days and over 400 million dollars (Gray,
2010). As a result, hospitals have urgently implemented
various programmes and protocols aiming to reduce this
HAI. Preventative measures such as educational strategies,
catheter avoidance, policies for catheter insertion, catheter
selection, daily necessity review and limiting catheter days
have shown success in decreasing CAUTI rates (Nicolle,
2014).
The Centres of Disease Control and Prevention’s National
Healthcare Safety Network is the United States most widely
used HAI tracking system. It has grown to include 12,000
medical institutions of varying types in the last decade
(Control, October 23, 1992). Surveillance data and pub-
lic health research provide supportive evidence that HAIs
are responsible for negative patient outcomes, increased
length of stay and major hospital debt (Control, October
23, 1992; Humphreys et al., 2008). Rebmann and Greene
(2010) suggest health care professionals should conduct
populations. The National Nosocomial (hospital-acquired)
Infections Surveillance System (NNIS, now known as the
National Healthcare Safety Network [NHSN]) conducted on
patients in intensive care units (ICU) revealed that urinary
tract infections (UTI) were the most common infections
found in these critically ill patients (Richards et al., 2000).
UTIs account for 23% of HAIs in the ICU and 95% of these
patients have an indwelling urinary catheter (Burton et al.,
2011). Clearly, patients in the ICU should be considered at
high risk for developing CAUTIs because of multiple insults to
normal defense host mechanisms and interventions to pre-
vent this HAI should be implemented (Barsanti and Woeltje,
2009).
CAUTI prevention efforts have been implemented in
healthcare facilities and ICUs globally, however standardisa-
tion of interventions and protocols was lacking. The Centers
for Disease Control and Prevention Healthcare Infection Con-
trol Practices Advisory Committee revised the guidelines for
CAUTI in 2009; This recent update was the first in nearly
30 years (Gould et al., 2010). Review of the literature has
shown that some ICUs have implemented interventions and
protocols that have been successful in decreasing CAUTI, yet
others who have done so have not been as fortunate (Gray,
2010). With the recent changes in the government funded
policy for CAUTI reimbursement and the negative impact
on patient outcomes, healthcare institutions are looking to
embrace guidelines that are proven to reduce or eradicate
CAUTI events (Burton et al., 2011). This may eventually lead
to the development of required national and international
CAUTI prevention standards and protocols.
Implementation of preventative measures for CAUTI
such as educational strategies, catheter avoidance, policies
for catheter insertion, catheter selection, daily necessity
review and limiting catheter days have been reported
to be associated with decreased CAUTI rates in the ICU
(Chenoweth and Saint, 2013). Identification of interventions
with the greatest positive impact on CAUTI rates would be
an asset to healthcare professional caring for patients with
an indwelling catheter and nurse clinicians developing poli-
cies. The purpose of this integrative review was to examine
the existing evidence on preventative interventions and
protocols being implemented in ICUs and the impact they
had on the CAUTI rates and ultimately patient outcomes.
The knowledge extracted from this review will provide a
Prevention of CAUTI
340 arcles idenfied 161 duplicate arcles
through database search removed
179 arcles screened 30 arcles excluded:
non-English ( n = 12)
Reviews (18)
149 Full arcles assessed for
135 arcles excluded due to
inclusion
variables of interest not
addressed
14 arcles included in
final review
Figure 1 PRISMA flowchart for selection of evidence.
scientific basis for the effectiveness of these interventions
and protocols.
Method
This integrative review analysed the research of interven-
tions and protocols used to control or prevent CAUTI in
an ICU setting. Selection of inclusion and exclusion criteria
were determined prior to the start of the literature search.
The inclusion criteria were: (a) primary research articles
addressing prevention and control of CAUTI and (b) sam-
ple patient population ≥18 years of age with an indwelling
urinary catheter in an ICU setting. Excluded were: (a) non-
English written studies, (b) studies addressing intermittent
urinary catheterisation, (c) studies addressing prophylactic
use of antibiotics for the prevention of CAUTI and (d) arti-
cles that did not contain an abstract. Years searched were
not limited.
The survey of articles occurred in September 2014 and
included free electronic databases. The databases searched
were PubMed, Cochrane Review, and the Cumulative Index
of Nursing and Allied Health Literature (CINAHL). Key terms
searched in PubMed and CINAHL included catheter associ-
ated urinary tract infections, prevention and control and
intensive care unit. In the Cochrane Review database the
key term searched was catheter associated urinary tract
infections. Articles were selected by reviewing the abstract
first to determine if the criteria for inclusion were met, fol-
lowed by review of the full version text. Three hundred and
forty articles were evaluated for inclusion. Duplicate stud-
ies (n = 161), studies written in language other than English
(n = 12) and reviews (n = 18) were removed. Additional stud-
ies were excluded (n = 135) due to the variables of interest
not being addressed (Fig. 1). Fourteen studies were included
in this review. To further enhance reliability and validity,
each study included in the review was read in its entirety.
3
Results
This literature review sample was made up of 14 studies,
of which 10 (71.5%) were classified as quasi-experimental,
1 (7.1%) was a meta-analysis, 1 (7.1%) was a random con-
trol trial (RCT), 1 (7.1%) was a secondary data analysis
and 1 (7.1%) was a time-sequenced non-randomized study.
All of the articles were written in English but the studies
originated in many different countries including the United
States. The studies were published between the years 1998
and 2014.
Of the 14 articles used in this study, eight (57%) identi-
fied multiple interventions used collaboratively in a bundle
or protocol to combat CAUTI and five (35.7%) used a single
intervention to combat CAUTI. One (7.1%) study did not iden-
tify an intervention it described the presence of adherence
to CAUTI policy and the relationship between prevention
policies and CAUTI rates. This literature review organised
the results into two main themes (a) implementation of a
single intervention to control and prevent CAUTI (Table 1)
and (b) implementation of a bundle of interventions to con-
trol and prevent CAUTI (Table 2).
Implementation of a single intervention to
control and prevent CAUTI
Hospitals often seek out best practice protocols and inter-
ventions to control and prevent CAUTI events within their
institution. One study conducted in a tertiary academic cen-
ter’s five ICUs implemented an algorithm for management
of urinary retention (Fuchs et al., 2011). It included inter-
ventions established by the Duke Infection Control Outreach
Network (DICON) (Network, 2009). It required practitioners
to complete a daily checklist identifying the presence of a
catheter and if the patient continues to meet the criteria
set forth in the algorithm to maintain the catheter (Fuchs
et al., 2011). The results demonstrated a decline in CAUTI
rates from 2.88 to 1.46 per 1000 catheter days (Fuchs et al.,
2011). However this finding was not statistically significant.
The combined number of catheter days in two of the ICUs
decreased from 402 to 380 after intervention and was both
clinically and statistically significant (Fuchs et al., 2011).
This study was limited by a delay in implementation of the
checklist in three out of the five ICUs and this could have
affected the overall clinical outcomes of the study. Another
issue of concern was compliance with the checklist. The
health care team was reported to be 75% compliant and
only 42% responded to the provider survey on satisfaction
with the checklist (Fuchs et al., 2011).
Lai and Fontecchio (2002) examined a specific type of uri-
nary catheter material to see if it decreased the incidence
of CAUTI in hospitalised patients. The use of silver-hydrogel
urinary catheters was initiated and the CAUTI rate decreased
to 2.7 per 1000 days, a reduction rate of 45% (Lai and
Fontecchio, 2002). The results were found not to be sta-
tistically significant. The investigators also estimated the
annual net savings for the hospital equaled $142,314.72 (Lai
and Fontecchio, 2002). This estimate took into consideration
the cost of CAUTI events with the new catheters minus the
cost of the new more expensive urinary catheters. Limita-
tions to this study were that it was conducted in a single
 4
Table 1 Single Intervention for CAUTI Prevention.

Citation Purpose Design/Setting Intervention Single Results

Huang et al., To evaluate the efficacy of Design: Time sequenced Daily reminders to The duration of urinary catheterization was significantly
Infect Control nurse generated daily non-randomized study. physicians from the nursing reduced during the intervention phase (from 7.0 ± 1.1 days to
Hosp Epidemiol, reminders to physicians to Setting: 5 adult ICUs of a staff to remove 4.6 ± 0.7 days; P < .001). CAUTI rate was reduced (from
2004 remove unnecessary tertiary university medical unnecessary urinary 11.5 ± 3.1 to 8.3 ± 2.5 patients with CAUTI per 1000 catheter
urinary catheters 5 days centre. catheters 5 days after days; P = .009). There was a linear relationship between the
after insertion. Sample: All patients insertion. monthly average duration of indwelling urinary catheters and
admitted to the hospitals 5 the rate of CAUTI (r = 0.50; P = .01).
adult ICUs during a 2 year
time frame.
Lai and To determine the effect of Design: The implementation of the The excess monthly cost of antibiotics for CAUTI was
Fontecchio, Am silver-hydrogel urinary Quasi-experimental. use of silver-hydrogel decreased by 69% (from $4021 ± $1800 to $1220 ± $941;
J Infect Control, catheters on the incidence Setting: 375 bed tertiary urinary catheters. P = .004).
2002 of CAUTIs in hospitalized teaching hospital. CAUTI rate decreased 45% from 4.9/1000 patient-days to
patients. Sample: All hospital 2.7/1000 patient-days. (P = .1) Average cost of CAUTI with the
To analyse the cost of patients with a indwelling non-coated catheters was $626,640.72 compared to $365,326
CAUTI events. urinary catheter. with the silver-hydrogel catheters. Cost of the silver-hydrogel
catheters was approximately $120,000 annually. Net savings of
$142,314.72 annually for the hospital.
Elpern et al., Am J To implement and evaluate Design: Daily evaluation of Catheter use was reduced by 238.6 days/month from the
Crit Care, 2009 the efficacy of an Quasi-experimental. Guideline adherence of all previous rate of 311.7 days/month.
intervention to reduce Setting: Medical ICU in a patients in the medical ICU CAUTI events per 1000 days of use decreased from a mean of
CAUTI in a medical ICU by 613 bed academic medical with an indwelling 4.7/month to zero during the intervention period.
decreasing use of urinary centre. catheter.
catheters. Sample: n = 337 Medical Recommendations were
ICU patients with urinary made to discontinue the
catheters. catheter for patients that
did not meet the criteria.

J.M. Galiczewski

Fuchs et al., J To assess the utility and
Nurs Care Qual, acceptance of a checklist
2011 to reduce CAUTI events.
To measure compliance of
the health care team with
the use of the checklist.
To assess the outcomes of
the intervention: CAUTI
rate, catheter days and
number of urine cultures
preformed.
Chen et al., Am J To determine if a reminder
Crit Care, 2013 approach reduces use of
urinary catheters and
incidence of CAUTIs.
Conway et al., Am To describe the presence
J Infect Control, of and adherence to CAUTI
2012 prevention policies in ICUs.
T o identify variations in
polices based on
organisational
characteristics.
To determine whether a
relationship exists
between prevention
policies and CAUTI rates.
ICU: intensive care unit; CAUTI: catheter associated urinary tract infection.
Design:
Quasi-experimental.
Setting: 924 bed tertiary
academic medical centre
— 5 adult ICUs.
Sample: Healthcare
personnel n = 408 Patients
with indwelling urinary
catheters in the ICU.
Design: Random Control
trial (RCT).
Setting: 2 respiratory ICUs.
Sample: n = 278 patients.
Design: Secondary data
analysis data retrieved
from the National
Healthcare Safety Network
(NHSN) data.
Sample: n = 441 hospitals
that participated in the
NHSN.
Prevention of CAUTI
CAUTI prevention checklist Provider survey: Response rate 42% (n = 164) 83% reported
was implemented in 2 of relevance to practice, 64% satisfaction with implementation,
the 5 ICUs. 68% ease of use, 90% compliance with daily checklist.
Compliance with the use of the checklist by the health care
team in all 5 ICUs was 75% (range 50—100%).
Compliance, defined as use of the checklist on every patient
with indwelling catheter in the 2 ICUs that participated was
61%in Neuro ICU and 82.9% in the medical ICU.
Clinical outcomes: The combined number of urinary catheter
days in the neuro ICU and the medical ICU combined
decreased from 402 to 380.
The CAUTI rates fell from 2.88/1000 catheter days to
1.46/1000.
There was no statistically significant differences in CAUTI
rates, urinary catheter days and number of urine cultures
following the intervention.
Intervention group — use Utilisation rate of indwelling catheter decreased by 22%.
of a criteria-based The intervention decreased the median duration of
reminder to remove the catheterization (7days verse 11 days for the control group).
catheter. The success rate for removing the catheter in the intervention
Control group — no group by day 7 was 88%.
reminder. The reminder intervention reduced the incidence of CAUTIs by
48% in the intervention group compared to the control group.
None 57% of the hospitals surveyed responded.
41.2% was from North East region of the United States 42.2%
(n = 174) ICUs reported having at least 1 of the 4 CAUTI policies
in place: Bladder ultrasonography 26%, condom catheter use
20%, catheter removal reminders 12%, nurse initiated
discontinuation 10%.
ICUs in larger hospitals >500 beds were half as likely to have
adopted at least 1 policy (odds ratio, 0.52; 95% confidence
interval: 0.33—0.86).
ICUs in hospitals where the infection control director had
access to key decision makers for planning were more than
twice as likely as those with less access to have adopted a
policy (odds ratio, 2.41; 95% confidence interval: 1.56—3.72).
5

Table 2 Bundle interventions for CAUTI prevention.
Citation Purpose
Dumigan et al., To decrease CAUTI rates in
Clin Perform 3 ICU’s to at or below the
Qual Health National Nosocomial
Care, 1998 Infection Surveillance
System (NNISS) pooled
mean for similar units.
Kanj et al., Int J To assess the impact of a
Infect Dis, 2013 multidimensional infection
control approach to reduce
CAUTI in an adult ICU of a
hospital that is part of the
International Nosocomial
Infection Control
Consortium (INICC) in
Lebanon.
Leblebicioglu To assess the impact of a
et al., Am J multidimensional infection
Infect Control, control approach to reduce
2013 CAUTI in adult ICUs of
hospitals that are part of
the International
Nosocomial Infection
Control Consortium (INICC)
in Turkey
Design/setting
Design:
Quasi-experimental.
Setting: 500 bed community
teaching hospital.
Sample: Patients in the
medical, surgical and
coronary ICUs with urinary
catheters.
Design:
Quasi-experimental.
Setting: Tertiary university
medical centre in Lebanon.
Sample: ICU patients
(n=1506).
Design:
Quasi-experimental.
Setting: 13 ICUs in 10
hospitals in Turkey.
Sample: ICU patients
(n = 4231).
Intervention bundle
Protocol instituted that allowed the
Registered Nurse to remove catheters
without a physicians’ order when no
longer medically necessary.
A computer prompt created to assure
that all urinary cultures are followed
by UA.
Implementation of the infection
control bundle.
(1) To perform hand hygiene before
insertion and manipulation of UC.
(2) Keep collection bag lower than
the level of the bladder.
(3) Maintain unobstructed urine flow.
(4) Empty collecting bag regularly
and avoid allowing the draining spigot
to touch the collecting container.
(5) To monitor CAUTIs using
standardised criteria to identify
patients with CAUTIs and to collect
UC days as denominators.
Implementation of the infection
control bundle.
(1) To perform hand hygiene before
insertion and manipulation of UC
(2) Keep collection bag lower than
the level of the bladder.
(3) Maintain unobstructed urine flow.
(4) Empty collecting bag regularly
and avoid allowing the draining spigot
to touch the collecting container.
(5) To monitor CAUTIs using
standardised criteria to identify
patients with CAUTIs and to collect
UC days as denominators.
6
Results
The incidence of CAUTI decreased 17% in
the surgical ICU, 29% in the medical ICU
and 45% in the Coronary ICU.
RN compliance with removing the UC per
protocol was 88%.
Physicians compliance with ordering a
UA following a urine culture was 93%.
The improvement only reached
statistical significance in the medical
ICU and the coronary ICU in a one-tailed
analysis.
A total of 9829 urinary catheter days:
306 in phase 1 and 9523 in phase 2 were
recorded.
The rate of CAUTI was 13.07/1000
urinary catheter days in phase 1, and
was decreased by 83% in phase 2 to
2.21/1000 urinary catheter days (risk
ratio 0.17; 95% confidence interval
0.06—0.5; P = .0002).
A total of 41,871 urinary catheter (UC)
days were recorded: 5080 in phase 1 and
36,791 in phase 2. During phase 1, the
rate of CAUTI was 10.63/1000 UC-days
and was significantly decreased by 47%
in phase 2 to 5.65/1000 UC days
(relative risk, 0.53; 95% confidence
interval: 0.4—0.7; P value .0001).
J.M. Galiczewski

Marra et al., Am J To examine the effects of a
Infect Control, series of interventions
2011 implemented in an ICU and
two step down units (SDU)
to reduce the incidence of
CAUTIs and to analyse the
difference in CAUTI rates
and causative
microorganisms.
Titsworth et al. J To investigate the
Neurosurg, 2012 implementation of a UTI
prevention bundle to
decrease the CAUTI rate.
Navoa-Ng et al., J To assess the impact of a
Infect Public multidimensional infection
Health, 2013 control approach to reduce
CAUTI in an adult ICU of a
hospital that is part of the
International Nosocomial
Infection Control
Consortium (INICC) in
Philippines.
Design: Quasi-experimental Phase 1: Implementation of CDC
interrupted time series recommended evidence based
design. practices for patients with urinary
Setting: Private tertiary catheters.
hospital in Brazil. Phase 2: Performance monitoring at
Sample: Patients with the bedside bundle interventions:
urinary catheters in a 38 1. Hand hygiene
bed ICU and two 20 bed 2. Creation of a UC insertion cart
SDUs. 3. Chlorhexidine skin and meatal
antisepsis
4. Sterile field and sterile gloves
5. One catheter per insertion attempt
6. Adequate balloon inflation
7. Daily review of need for UC with
prompt removal if not needed
Design: Implementation of a comprehensive
Quasi-experimental. evidence based UTI bundle
Setting: 626 bed tertiary (avoidance of catheter insertion,
hospital with 142 critical maintenance of sterility, product
care beds. standardisation and early catheter
Sample: All patients removal).
admitted to the neuro ICU
(30 beds) over a 30 month
period.
Design: Implementation of the infection
Quasi-experimental. control bundle:
Setting: 4 adult ICUs in 2 (1) To perform hand hygiene before
hospitals in Philippines. insertion and manipulation of UC.
Sample: ICU patients (2) Keep collection bag lower than
(n = 3183). the level of the bladder.
(3) Maintain unobstructed urine flow.
(4) Empty collecting bag regularly
and avoid allowing the draining spigot
to touch the collecting container.
(5) To monitor CAUTIs using
standardised criteria to identify
patients with CAUTIs and to collect
UC days as denominators.
Prevention of CAUTI
A statistically significant reduction in the
rate of CAUTI in the ICU, from 7.6/1000
catheter-days (95% confidence interval
[CI], 6.6—8.6) before the intervention to
5.0/1000 catheter-days (95% CI,
4.2—5.8; P = .001) after the intervention.
There also was a statistically significant
reduction in the rate of CAUTI in the
SDUs, from 15.3/1000 catheter-days
(95%CI, 13.9—16.6) before the
intervention to 12.9/1000 catheter-days
(95% CI, 11.6—14.2) after the
intervention (P = .014). 67.0% (81/121)
of all microorganisms identified in ICU
phase 1 were gram-negative phase 2, the
distribution of microorganisms was 72.1%
(57/79) Gram-negative, (15.2%; 12/79)
fungi and (12.7%; 10/79) Gram-positive.
Urinary catheter utilisation rate dropped
from 100% to 73.3% (P < .001).
CAUTI rate was decreased from 13.3 to
4/1000 catheter days (P = .001).
There was a linear relationship between
the decreased quarterly catheter
utilisation rate and the decreased CAUTI
rate (r2 = 0.79, P < .0001).
A total of 8720 UC days were recorded:
819 at baseline and 7901 during
intervention. The rate of CAUTI was
11.0/1000 UC-days at baseline and was
decreased by 76% to 2.66/1000 UC-days
during intervention [rate ratio [RR],
0.24; 95% confidence interval [CI],
0.11—0.53; P value, .0001].
7

Table 2 (Continued)
Citation Purpose
Rosenthal et al., To evaluate the impact of a
Infection, 2012 multidimensional infection
control strategy for the
reduction of the incidence
of catheter-associated
urinary tract infection
(CAUTI) in patients
hospitalized in adult
intensive care units (AICUs)
of hospitals which are
members of the
International Nosocomial
Infection Control
Consortium (INICC), from 40
cities of 15 developing
countries.
Alexaitis and To develop a nurse driven
Broome, J Nur protocol to decrease
Care Qual, 2014 CAUTIs.
ICU: intensive care unit; CAUTI: catheter associated urinary infection; UA: urine analysis; UC: urinary catheter; CDC: Centers for Disease Control and Prevention; UTI: urinary tract
infections; NSICU: neurosurgical intensive care unit tract.
Design/setting
Design: Meta-analysis of a
multidimensional infection
control strategy on CAUTI
rates in the adult critical
care units of 15 developing
countries: Findings of the
INICC.
Setting: 57 Adult ICUs in 43
hospitals in 40 cities of 15
developing countries.
Sample: ICU patients
(n = 56,429).
Design:
Quasi-experimental.
Setting: Neurosurgical
intensive care unit (NSICU).
Sample: n = 183 patients
with urinary catheters
n = 107 NSICU nurses.
Intervention bundle
Implementation of the infection
control bundle:
(1) To perform hand hygiene before
insertion and manipulation of UC.
(2) Keep collection bag lower than
the level of the bladder.
(3) Maintain unobstructed urine flow.
(4) Empty collecting bag regularly
and avoid allowing the draining spigot
to touch the collecting container.
(5) To monitor CAUTIs using
standardised criteria to identify
patients with CAUTIs and to collect
UC days as denominators.
Protocol developed/interventions
included:
(1) Criteria based discontinuation of
catheters (stop orders).
(2) Bladder ultrasonography to
prevent needless catheterizations.
(3) Use of intermittent
catheterization to reduce indwelling
catheter days.
(4) Computer based education
provided to nurses prior to protocol
implementation to assess
competency with performing
sonograms and interpreting results, a
written multiple choice
scenario-based test to measure
knowledge acquisition of the
protocol, and a 15 item checklist
used during simulation to assess
proficiency in performing bladder
ultrasound procedures.
8
Results
253,122 UC-days were recorded: 30,390
in Phase 1 and 222,732 in Phase 2. In
Phase 1, before the bundle intervention,
the CAUTI rate was 7.86/1000 UC-days,
and in Phase 2, after intervention, the
rate of CAUTI decreased to 4.95/1000
UC-days [relative risk (RR) 0.63 (95%
confidence interval [CI] 0.55—0.72)],
showing a 37% rate reduction.
Catheter duration decreased by 2.5
days.
Average catheter utilisation increased
from 74.1% to 76.2%.
CAUTI rate decreased from 3.85 to 3.06
per 1000 catheter days (20%).
CAUTIs per month decreased 14.1%.
Average cost of medications and supplies
associated with CAUTI decreased by
40.7%.
Average LOS for patients with CAUTI
increased by 8.14% during.
Nurses: 86% (n = 96) completed
simulation with a 100% proficiency in
sonogram technique.
92% (n = 102) received a post education
test score of 90% on sonogram procedure
and interpretation.
85% (n = 95) completed exam measuring
J.M. Galiczewski
knowledge acquisition of protocol with a
average test score of 95%.
Prevention of CAUTI
institution and patient demographics and risk factors were
not collected so there may have been confounding variables
that affected the results (Lai and Fontecchio, 2002).
Multiple studies implemented a criteria or protocol
based reminder to remove the indwelling urinary catheter
(Chen et al., 2013; Elpern et al., 2009; Huang et al.,
2004). A random control trial conducted by Chen et al.
(2013) found that when patients in the intervention group
were evaluated by using a criteria based reminder sheet
to determine if they still clinically needed the indwelling
catheter, the duration of catheterisation decreased to
seven days compared with 11 days in the control group.
This is highly significant because it has been shown that the
risk of developing a CAUTI increases in patients with urinary
catheters greater than seven days (Shapiro et al., 1984).
Eighty-eight percent of patients in the intervention group
had their catheters removed by day seven and the reminder
intervention reduced the incidence of CAUTI events by 48%
in the intervention group compared to the control group
(Chen et al., 2013). The strength of this study was that it
contained a control group and the demographics and risk
factors for all patients were analysed. A limitation to this
study was that it was implemented in two respiratory care
units where the patients tend to be similar so it cannot be
generalised to all ICU types.
Additional studies conducted using the daily reminder to
review catheter necessity and to remove catheters when
not medically needed have also shown positive results
(Elpern et al., 2009; Huang et al., 2004). A study by Huang
et al. (2004) identified that there was a linear relationship
between the monthly average duration of indwelling uri-
nary catheters and the rate of CAUTI events. When daily
reminders to physicians from the nursing staff to remove
unnecessary urinary catheters five days after insertion were
implemented, the duration of catheterisation was reduced
to 4.6 days from seven days and CAUTI events were reduced
to 8.3 per 1000 catheter days from 11.5 per 1000 catheter
days (Huang et al., 2004). In a similar study by Elpern et al.
(2009), catheter use was reduced to 238.6 days per month
from 311.7 days per month and CAUTI events decreased
significantly as well. Limitations to these two studies were
that, although their sample sizes were large, they were both
conducted in a single hospital.
A secondary data analysis included in this integrative
review used data retrieved from the National Healthcare
Safety Network (NHSN) database. The objective of this
analysis was to determine the presence of and adher-
ence to CAUTI prevention and control policies in ICUs
(Conway et al., 2012). This study identified that 42.2%
of ICUs reported having at least one of the following
CAUTI prevention and control interventions in place: (1)
bladder ultrasound 26%, (2) condom catheter usage 20%,
(3) catheter removal reminders 12% and (4) nurse initiated
discontinuation 10% (Conway et al., 2012). The investigators
found that ICUs in hospitals with greater than 500 beds
were less likely to have adopted at least one of the above
mentioned interventions (Conway et al., 2012). The quality
initiatives at the time of this study were lacking and little
was achieved nationally to combat CAUTI events (Conway
et al., 2012). The limitations to this study were only 57%
of the hospitals surveyed responded and a large portion of
those (41.2%) were from the North East region of the United
9
States (Conway et al., 2012). In addition, this study only
captured hospitals that report to the NHSN.
Implementation of a bundle of interventions
to control and prevent CAUTI
ICU patients have a high prevalence of urinary catheteriza-
tions and co-morbidities which increase their risk for devel-
oping UTIs (Gray, 2010). The implementation of evidence-
based protocols and prevention programmes in ICUs may
diminish the risk of developing a CAUTI in these catheter-
ized patients (Gray, 2010). A study conducted in a private
hospital in Brazil implemented a series of interventions in an
ICU and two step down units (SDU) to reduce the incidence
of CAUTI (Marra et al., 2011). This was a multi-phase study
in which the investigators implemented CDC recommended
evidence-based protocols and the Institute for Healthcare
Improvement’s (IHI) bladder bundle (Marra et al., 2011). The
bundle of interventions included: (1) hand hygiene, (2) cen-
tralisation of items need to insert a urinary catheter, (3)
sterile technique, (4) meatal cleansing with chlorhexidine,
(5) use of one catheter per catheterisation attempt, (6) ade-
quate balloon inflation and (7) daily review with prompt
removal of all unnecessary catheters (Marra et al., 2011).
The results were statistically significant with a reduction in
the CAUTI rate in the ICU to 5 per 1000 catheter days from
7.6 per 1000 catheter days and a reduction in the CAUTI rate
in the two SDUs to 12.9 per 1000 catheter days from 15.3 per
1000 catheter days (Marra et al., 2011). This study contained
limitations. It was conducted in a single hospital and did not
collect continuous data on the units prior to the implemen-
tation of the bundle intervention (Marra et al., 2011).
The purpose of multiple studies conducted in ICUs of
hospitals that are members of the International Nosocomial
Infection Control Consortium (INICC) was 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 is a
international consortium study that included 15 developing
countries and had a total sample size of 56, 429 patients
in 57 adult 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
interventions 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 con-
tainer and (5) to monitor CAUTIs using standardised criteria
(Rosenthal et al., 2012). The results of the combined studies
were statistically significant with 253,122 urinary catheter
days being recorded (Rosenthal et al., 2012). Before the
intervention, the CAUTI rate was 7.68 per 1000 catheter
days and after implementation of the bundle intervention it
decreased to 4.95 per 1000 catheter days (Rosenthal et al.,
2012). The strengths 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 (Kanj et al., 2013; Leblebicioglu et al., 2013;
Navoa-Ng et al., 2013; Rosenthal et al., 2012). Limitations
10
included 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).
Other studies investigated the implementation of a bun-
dle of interventions or nurse driven protocol to decrease
CAUTI rates; All included criteria for urinary catheter inser-
tion and daily review of catheter necessity (Alexaitis and
Broome, 2014; Dumigan et al., 1998; Titsworth et al.,
2012). Titsworth et al. (2012) reported a linear relation-
ship between the decreased quarterly catheterisation rate
(100—73.3%) and decreased CAUTI rate (13.3 per 1000 to
4 per 1000 catheter days). Similarly, Alexaitis and Broome
(2014) found after the implementation of a urinary catheter
protocol the average CAUTI rate decreased from 3.85 per
1000 catheter days to 3.06 per 1000 catheter days. How-
ever, in this study, the average utilisation rate increased
from 74.1% to 76.2% and the results were not statistically sig-
nificant (Alexaitis and Broome, 2014). Another study which
investigated implementation of a protocol that allowed
a Registered Nurse (RN) to remove a catheter without a
doctors order when it was no longer indicated, showed a
decreased incidence rate of CAUTI in all 3 of the ICUs (17%
in surgical ICU, 29% in medical ICU and 45% in the coronary
ICU) (Dumigan et al., 1998). The results were only statistical
significant in the medical and coronary ICUs and the nurses
compliance with removing the urinary catheter as per the
new protocol was 88% (Dumigan et al., 1998). Dumigan’s
(1998) study also included implementing a computer gen-
erated prompt for physicians to ensure all urinary cultures
are followed by a urinalysis. Limitations to all three of these
studies were that they were conducted in a single hospital.
Discussion
The incidence of CAUTI in the ICU setting is directly linked
to the increased use of catheters in this area (Gray, 2010).
Bacteriuria develops at a rate of 3—10% per catheterisation
day and it has been shown that CAUTI rates rise in patients
with urinary catheters greater than 7 days (Chenoweth and
Saint, 2013; Shapiro et al., 1984). This integrative review has
shown that studies with a single intervention that included
daily review of catheter necessity or early discontinuance
of urinary catheters (less than seven days) were successful
in decreasing the CAUTI rates with statistical significance
(Chen et al., 2013; Elpern et al., 2009; Fuchs et al., 2011;
Huang et al., 2004). In addition, most of the protocols
or bundled interventions included a detailed criteria for
urinary catheter use and a stop order to prevent the contin-
uation of catheters beyond the point of medical necessity
(Alexaitis and Broome, 2014; Dumigan et al., 1998; Marra
et al., 2011). Whether implemented as a single intervention
or within a CAUTI prevention bundle, these interventions
have been proven to decrease a patient’s risk for developing
a CAUTI while in the ICU.
The use of alternate types of urinary catheter materi-
als, such as silver hydrogel, have decreased CAUTI rates but
not with statistical significance and the results did not eval-
uate short term verse long term catheterization (Lai and
Fontecchio, 2002). There have been studies performed in
urological patients outside of the ICU setting that suggested
J.M. Galiczewski
there was a delay in patients developing bacteriuria with
short term (up to one week) catheterisation with use of
silver-hydrogel catheters; However, there was no significant
difference in long-term (two weeks) catheterised patients
(Verleyen et al., 1999). More studies analyzing alternate
catheter types need to be conducted.
Evidence supports that ICU patients should have urinary
catheters removed as quickly as possible, catheters should
be maintained aseptically with a closed containment
system, and daily assessment of need should be included
in team rounds (Lo et al., 2008). These interventions have
been a common variable in research studies that span over
30 years. Review of literature has shown that although
many interventions exist that have been proven successful
in reducing CAUTIs, not all of them are used in tandem
to create a protocol that would assure better patient
outcomes. Evidence- based research has demonstrated that
an integrated infection control policy that includes strict
protocols and surveillance can reduce HAI by at least 30%
(Haley et al., 1985).
A limitation of this integrative review was that it included
research studies conducted in an ICU setting, therefore the
results cannot be generalised to other patient settings such
as long-term nursing facilities. This review does not address
all interventions that may minimise a catheterised patients
risk for developing a CAUTI. It is recommended that further
clinical studies be pursued in different hospital settings and
on different patient populations to develop evidence-based
protocols to decrease this preventable HAI.
Conclusion
It is imperative for practitioners to recognise and estab-
lish protocols to combat CAUTI in all healthcare settings.
A multidirectional approach that includes evidence-based
practices recommended by the Centers for Disease Con-
trol and Prevention, the implementation of the Institute for
Healthcare Improvement’s bladder bundle and increasing
the knowledge base of patient care providers is essen-
tial. Hospitals need to establish committees to oversee the
implementation of these protocols and continue vigilant
surveillance efforts.
Acknowledgements
I am the sole author of this manuscript. I confirm that no
organization funded this Integrative review study.
Funding: There are no financial disclosures associated
with this manuscript.
Conflict of interest: The authors have no conflict of inter-
est to declare.
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