Document Type


Original Publication Date


Journal/Book/Conference Title

Virginia Organization for Nurse Leaders (VONL) Conference

Date of Submission

November 2023



The purpose of this performance improvement project was to decrease the harm to patients related to catheter associated urinary tract infections (CAUTIs) in the Neuroscience Intensive Care Unit (NSICU). Historically, the NSICU had the highest CAUTI rates in our organization with as many as 6 CAUTIs per calendar year quarter. A core group of nurses partnered with providers, hospital infection preventionists and nursing leaders to improve practices for placing, removing, and managing urinary catheters and to implement guidelines for urine testing stewardship.


Significance: In 2020, the NSICU had 12 CAUTIs, the highest number of CAUTIs in the entire healthcare enterprise (n=16). The Standard Infection Ratio (SIR) reached a high of 5.12 despite a Standard Utilization Ratio (SUR) less than 1.0. Catheter associated urinary tract infection is a common healthcare associated infection. Approximately 14% of hospitalized adults will have a urinary catheter during their hospitalization and with each day the risk of CAUTI increases by 3- 7%. CAUTIs are associated with increased length of stay, increased cost and increased mortality and morbidity (NHSN, 2023). With an estimated additional cost of $14,000 to treat a CAUTI, reducing this HAI in NSICU was a top organizational priority.


The NSICU had previously implemented multiple strategies to reduce CAUTIs (male and female alternative devices, daily review for necessity, chlorhexidine (CHG) bath treatment, and utilization of the organizational nurse-led bladder management algorithm for urinary catheter removal). We included these strategies as well as compliance with CAUTI related process measures (hand hygiene, CHG bathing, daily review for necessity) in our annual education. We held skills fairs for nursing team members to demonstrate aseptic insertion technique, daily catheter care and best practices for management of the system. Each CAUTI was thoroughly investigated, and, seeing no change in our CAUTI rates, nurses were asked to redouble their efforts in catheter care and maintenance and timely removal. Due to the lack of overall improvement in CAUTI rates, we consulted with our infection preventionist (IP) who provided data on urine testing practices in the NSICU. Like many other providers, NSICU physicians routinely ordered urine cultures as part of a fever work-up. Urine cultures without the presence of indication is considered inappropriate based on CDC guidelines. Our IP noted that many of our patients did not have clinical indications for urine culture testing. It was possible that our CAUITs were the result of colonization of the catheter with the development of biofilm or catheter-associated asymptomatic bacteriuria (CDC, 2019). As this pattern of inappropriate urine testing emerged, we decided to add urine testing stewardship (UTS) to our bundle of strategies to reduce CAUTIs. Our goal was to obtain urine cultures only when indicated (i.e. recent kidney transplant recipients, neutropenia, recent genitourinary surgery, known genitourinary obstruction or stents, pregnancy, spinal cord injury with signs or symptoms of autonomic dysreflexia, organ donor or patient with classic signs of urinary tract infection without alternative explanation).


In November 2020 NSICU nurse leaders partnered with the IP and medical director to identify opportunities to implement UTS. All strategies were developed with the understanding that this was not simply a practice change but also a culture change. Team meetings (nursing and physician) were held to discuss the new approach to urine testing. Signs with testing criteria were affixed to each computer so that providers would use that information when placing orders. To ensure adherence to the change, in January 2021 all orders for urine cultures were to be reviewed by nurse leaders before being obtained. Nurse leaders were well versed in the literature supporting the reduction of unnecessary testing and frequently provided just-in-time education to nurses and providers to answer any questions and address concerns about urine testing.

Evaluation and Implications for Nursing Practice and Patient Outcomes:  

With the addition of urine testing stewardship, CAUTI rates dropped from a high of 5.12 in 2020 Q3 to 0.0 in 2021 Q3. Between 2020 Q1 and 2021 Q3 there were 16 CAUTIs. From May 27, 2021 to April 24, 2023 (696 days) there were no CAUTIs. As of July 2023, no patients hospitalized in the NSICU with an indwelling urinary catheter were readmitted with a UTI or urosepsis. In addition to the CAUTI in April 2023, there was a second patient with a CAUTI on July 23, 2023. In both cases, the patients did not meet testing criteria nor were nursing leaders notified of the order.

Combined with previous strategies, the introduction of urine testing stewardship reduced patient harm. We eliminated the unnecessary use of antimicrobials which, in turn, increases the proliferation of resistant organisms (AHRQ, May 2023). Furthermore, providers have become more likely to approve catheter removal earlier in the course of hospitalization.   These initiatives were successful in that we reduced our CAUTI rates and changed the culture on the unit. Implementation of UTS in particular required collaboration among all team members and support from providers. Nurses are more confident in asking the “why” for other tests and procedures ordered on their patients. Nurse leader review of routine urine cultures was adopted as a best practice across the organization.


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