Date of Graduation

Summer 8-11-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project



Problem: Fifteen to twenty-five percent of hospitalized patients receive indwelling urinary catheters (IUCs) during their hospital stay and are at high risk for catheter-associated urinary tract infections, according to the Centers for Disease Control and Prevention (CDC, 2015).

Context: A CAUTI Prevention program was implemented in a community hospital surgical unit to address concerns of high rates of CAUTI.

Interventions: Staff training/education, pre-CAUTI and post-CAUTI prevention survey, hand hygiene, bundle care audit, and staff competency for indwelling urinary catheter insertion were implemented to prevent and reduce CAUTI cases in the surgical unit.

Measures: The Standardized Infection Ratio (SIR) formula, pre-CAUTI, and post-CAUTI prevention survey, and annual competency were the process measures used to evaluate the success of this project.

Results: The 2 and 3 Surgical units had no CAUTI cases as of July 2023. Hand hygiene compliance rate and bundle care audit were improved.

Conclusions: The quality improvement project reevaluated the organization’s current nurse-driven indwelling urinary catheter protocol and implemented several interventions to prevent and reduce CAUTI. The 5 P’s framework used to assess microsystems consists of purpose/policy, patients/participants, professionals, processes, and patterns (Nelson et al., 2007). PDSA cycle (Plan-Do-Study-Act) and Six Sigma were utilized to implement plan of care. Sustainability cycles were created to maintain the quality project plan of care.

Keywords: quality improvement, CAUTI bundle care, catheter-associated urinary tract infections, healthcare-associated infections.