Date of Graduation

Spring 5-17-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions



The project goal is to reduce and eliminate CAUTI occurrences on the med-surgical unit by increasing staff knowledge on CAUTIs and applying the ANA CAUTI prevention tool to improve patient outcomes. The project objectives are (1) enhanced staff knowledge about CAUTIs, (2) staff adherence to the implemented the ANA CAUTI prevention tool, and (3) maintained CAUTI rate below benchmark. The CNL role in the project is to function as an educator and outcomes manager, which serves as the foundation for the project. The department consists of a 34-bed med-surgical unit with the adult patient population mix of oncology, surgical, and cardiac patients. The unit currently utilizes the ANA CAUTI Prevention Tool; however, the rate of CAUTIs continues to increase. The current CAUTI rate for the medical-surgical unit is 1.52 for year 2017 which is above the national benchmark through National Healthcare Safety Network (NHSN). The project goal is to decrease or eliminate CAUTI rate on the unit by 54% for 2018 to bring the rate below the benchmark. The risk factors from root-case, stakeholders and SWOT analysis are categorized into four categories such as human factors, environmental factors, administrative factors and material factors. The project status is in progress. The evaluation plan includes data collection, data analysis, and data comparison. The CAUTI incidences will be measured and collected by infection control daily audit tool explicitly created to CAUTIs. The infection control nurse will be responsible for obtaining this information. Data analysis includes Catheter days, indications, and compliance with ANA tool will be measured through chart review by CAUTI task force and infection control daily audit. The risk analysis department will compare the data to evaluate the quarterly trend and address barriers. The data will help evaluate the reduction in CAUTI rate and staff compliance with ANA CAUTI prevention tool. The project will be sustained through (1) stakeholders’ support, (2) CAUTI task force involvement, (3) by using ANA CAUTI prevention tool appropriately, (4) providing continuous education support, (5) address barriers and challenges and (6) staff recognition. The frontline nursing staff can make the most difference through sound knowledge of CAUTIs, current practice guidelines, and ANA prevention tool.