Date of Graduation

Winter 12-11-2020

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Liesel Buchner, MSN, RN, CNL

Second Advisor

Catherine Coleman

Third Advisor

Dave Ainsworth



Problem: Catheter-associated urinary tract infection (CAUTI) remains the leading cause of hospital-acquired infection (HAI) despite being preventable. CAUTI increases the length of stay, morbidity, mortality, readmissions, and costs. There is also increasing antimicrobial resistance in pathogens causing CAUTI. Thus, reducing HAIs such as CAUTI should be a priority for every institution.

Context: The microsystem for this CAUTI quality improvement project is a 24-bed adult medical-telemetry unit in an acute care teaching hospital with excessive CAUTI. This project aims to improve the unit’s CAUTI standardized infection ratio (SIR) from a baseline of 2.54 to 1.75 by October 2020. A SIR of 1.75 for the microsystem translates to zero CAUTI events per month during the project timeline.

Interventions: The quality improvement project has three themes of intervention. The first theme of interventions is the provision of CAUTI prevention education to frontline staff. The second theme of interventions is to reduce infection by the daily review of patients with an indwelling urethral catheter (IUC) and a requirement to notify the physician when the IUC is no longer indicated, or an alternative can be used. A visual tracking board for the prompt removal of IUC and a smart phrase in the electronic medical record (EMR) was created to standardized communication between nurses and physicians regarding urinary catheter necessity. The third theme of intervention is to reduce misdiagnosis due to colonization by using the organization's regional urine culture algorithm for sending urine cultures from patients with an IUC.

Measures: A family of measures for the project was developed. The outcome measures for the project are the CAUTI Standardized Infection Ratio (SIR) and number of CAUTI events per month during the project timeline.

Results: By the end of the project, the microsystem achieved zero monthly CAUTI events and a CAUTI SIR score of 1.73.

Conclusions: Implementing the interventions led to the achievement of zero CAUTI events, thus preventing harm to patients. The interventions are also incorporated in the daily processes of the microsystem and, therefore, sustainable.

Keywords: catheter associated urinary tract infection, daily review of urinary catheters, visual tracking board, urine culture algorithm