Date of Graduation

Summer 8-13-2021

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Problem: National Healthcare Safety Network (NHSN) has reported U.S. hospitals having 0.2 to 4.8 per 1000 catheter-days for adult inpatient units. The insertion of a catheter and delay in removal have a significant impact on morbidity, mortality, length of stay, and reimbursement.

Context: Post-Acute Care Unit (PACU) is a microsystem that provides rehabilitation services for a patient with various post-surgical procedures. The staff of this unit was well aware of policies of catheterizations that led to prolonged use of urinary catheters and an increased rate of CAUTIs in the last quarter of this year. This project aims to increase staff knowledge, remove catheters per policy and decrease the rate of CAUTI by 90% during the project timeline.

Intervention: The quality improvement project approaches the PACU unit by implementing nurse-led interventions. The nurse-led interventions include monthly staff in-services and education competencies, adding HOUDINI-PROCESS form in new admission bundle, CAUTI auditing binder, weekly auditing by (Clinical Nurse Leader) CNL student and making random rounds on the unit for a patient with Foley Catheter (F/C).

Measures: The project had three process measures, including enhanced communication among physicians and staff, decreased utilization of foley catheter and decreased CAUTIs rate on the unit. The primary outcome measure for this project is to calculate the number of hospitals acquired CAUTI events and utilization of foley catheters during the project timeline.

Result: By the end of this project, the PACU unit remained CAUTI free and succeeded in its aim to decrease the CAUTI rate in the unit.

Conclusion: Implementation of evidence-based practice of nurse-led interventions met the expected outcome with a 100% decrease in the unit’s CAUTI rate. Since the interventions are incorporated in the new admission bundle and daily routine of the report; therefore, the quality improvement project will maintain sustainability in this unit.