Date of Graduation

Spring 5-19-2016

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Dr. Elena A Capella



Center for Control and Disease Prevention (CDC), estimates that 40% of all Urinary Tract Infections (UTIs) are related to Hospital-acquired Infections (HAIs) (CDC, 2013). The Facility where the project was done consists of oncology, orthopedic, medical-surgical, telemetry, incentive care, and step-down units. This hospital with 242 licensed beds has approximately 51,571 ER visits and a total of 10,606 admissions per year.The prevalence of Cather-associated Urinary Tract Infections (CAUTIs) on the 4th floor, the medical-surgical unit with 42 beds was significantly higher than other units. The hospital goal is to increase patient safety and satisfaction as well as reduce and prevent financial burden related to CAUTIs such as financial penalties from Centers for Medicare and Medicaid Services (CMS).

The global aim of this project is to prevent CAUTIs through utilizing CAUTI Surveillance Bundle and implementing new interventions such as daily Chlorohexidine Gluconate (CHG) bathing for patients with Foley catheter. Besides, nurses’ adherence to policy and procedures for urinary catheter management including early removal of unnecessary Foley are reevaluated. This project aims to reduce CAUTI occurrence by 41% by December, 31st, 2016. Fishbone Diagram, SWOT Analysis, Process Map, the Lewin’s Change Model, and Plan-Do-Study-Act (PDSA) Improvement Model will be used concurrently to implement the project. Data collected by chart audit and CAUTI bundle surveillance audit indicated the need for re-education of nurses for Foley maintenance. This project highlights different roles of CNLs curriculum elements such as Nursing Leadership, Care Environment, and Clinical Outcome Management (AACN, 2013).