Catheter Associated Urinary Tract Infection (CAUTI)

The Catheter Associated Urinary Tract Infection (CAUTI) Prevention committee has spent the past two years focused on interventions that support reduction of infections and align with evidence based guiding principles:

  • Only insert a urinary catheter for approved reasons
  • Remove the urinary catheter as soon as possible
  • Ensure properly trained personnel insert aseptically and properly maintain the urinary catheter

The CAUTI Prevention Committee developed a deep dive process that encourages bedside staff to investigate each CAUTI for potential causes and areas for improvement. Results are shared monthly at CAUTI Prevention committee meetings and aggregate deep dive data are reviewed quarterly. This review of trended data identified adult critical care as the area with greatest opportunity for improvement. As a result, a Rapid Improvement Event (RIE) that included members of the CAUTI prevention team was held for 5MHC unit (September 2014). RIE interventions included:

  • Developed and implemented standard work
  • Developed and implemented visual management tools to help support the CAUTI guiding principles

These strategies were disseminated to all remaining adult critical care areas within Spectrum Health Grand Rapids (SHGR) in February 2015.

Technology is also utilized to support the CAUTI guiding principles. The Catheter-Related Infection Cerner Lighthouse module, implemented in March 2015, sends alerts to providers and nursing staff regarding proper ordering, proper reasons for insertion, and prompt removal. Since this intervention, there has been a decrease in the number of CAUTIs resulting in a decrease in the CAUTI rate and the CAUTI Standard Infection Ratio (SIR). The SIR is calculated by dividing the observed number of CAUTI by the expected number of CAUTI.

Other CAUTI prevention interventions include:

    • Implementation of a nurse driven indwelling urinary catheter removal protocol as part of the Lighthouse module to provide nurses with guidelines and support to remove catheters as soon as possible (March 2015)
    • Creation and dissemination of quarterly newsletters addressing questions from clinical staff and/or resources to provide support to the bedside staff (October 2015 to October 2016)
    • Creation and implementation of a link within I-view documentation to easily access the urinary catheter removal protocol (April 2016)

Following spread of the CAUTI prevention strategies across Adult Critical Care nursing units and implementation of the Catheter-Related Infection Lighthouse module, a process shift in the SHGR CAUTI data occurred between July 2015 and March 2016. The CAUTI rate decreased from a rate of 2.0 CAUTI per 1000 Catheter Days to 1.09 CAUTI per 1000 Catheter Days. This process shift represents a 46% improvement in the CAUTI rate. Current improvement efforts remain focused on the guiding principles and changing the culture around urinary catheters.


CAUTI Committee Members

Dorine Berriel-Cass BSN, MA, RN, CIC
Mary Dougherty DNP, RN, AOCNS
Amanda Himes MSN, RN-BC, NE-BC
Ann Shupe MSN, RN, CNOR
Jennifer Wheaton BSN, RN, PCNN
Janet Wilks BSN, RN, CCRN, NE-BC
Maggie Carriker MSN, RN, CCRN
Heather Githu BSN, RN
Mary Morrell RN BSN, CCRN
Crystal L. Newcombe RN
Ashley Schuitema RN
Cheryl Houseman MSN, RN-BC, ACNS-BC
Caryn Steenland MSN, RN, CCRN
Mary Tibbe BSN, RN, CCRN
Gaby Iskander MD
Andrew Maternowski MD
Carlos Rodriguez MD, FACS
James Codman BSN, RN
Mallory Davis MS
Luann Huizinga BSN, RN
Molly Kane-Carbone BSN, RN, MED, CIC
Tia Klein BSN, RN, CCRN
Jessica McClusky BSN, RN, CPN
Chau Nguyen MS
Nella Ostrander Admin. Support
Sandi Pearce MSN, RN

logo