Date of Graduation

Fall 12-15-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

Liesel Buchner


Background: Urinary tract infections (UTIs) are the most common type of healthcare-acquired infection (HAI), with 75% approximately associated with urinary catheter use. The key to preventing UTIs is to avoid the use of indwelling urinary catheters (IUCs). This study explores denominator data extract logic modifications to increase IUC data capture and accuracy. It is set in a 249-bed acute care, teaching hospital in the Diablo Service Area in Northern California.

Problem: The electronic system used to extract the CAUTI denominator data is inconsistently capturing the IUC device days from the electronic medical record (EMR). This has regulatory reporting ramifications and negatively impacts CAUTI metrics, specifically the Standardized Infection Ratio (SIR) and the Urinary Catheter Standardized Utilization Ratio (SUR).

Interventions: Enhancing the Infoview Foley Days report aims to maximize device capture and increase data accuracy. The three-pronged approach involves modifying the extract logic to focus on individual inpatient encounters, applying inpatient admission status as the date of admission, and modifying the data extract time.

Outcome Measures: Two hundred forty Infoview cases validated against the EMR from January to June 2023 yielded 100% data capture and accuracy, exceeding intervention targets.

Results: Data extract logic modification using the set criteria and applying additional exclusion criteria improved the CAUTI denominator data quality by 40%.

Conclusion: Infoview modification increased the data quality for CAUTI surveillance and reporting, also improving the CAUTI SUR. The improved SUR is utilized as an adjunct to the CAUTI SIR for tailored data-driven infection prevention initiatives. The project’s success led to the implementation of the revised logic across the Northern California hospital system and will be rolled out as the enterprise-wide model for standardized CAUTI denominator data extract.