Date of Graduation

Fall 12-14-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Nancy Taquino, DNP



Problem: Hospital-acquired infections are preventable harm that occurs to patients while in the hospital. Catheter-associated urinary tract infection (CAUTI) is a preventable hospital-acquired infection that continues to plague hospitals nationwide. The Centers for Disease Control and Prevention estimates that there are more than 13,000 CAUTI related deaths in the United States annually (Scanlon, 2017). In addition to the harm caused to patients by CAUTIs, the estimated $500 million yearly cost for CAUTI treatment has created a fiscal burden on healthcare systems (Scanlon, 2017). Decreasing the rate of CAUTI by decreasing overall number of catheters is the goal of this performance improvement project.

Context: Within a large northern California healthcare system, at one Santa Clara, California hospital, the medical neurology unit, Department 430, is an inpatient hospital unit that provides care to a diverse patient population. This unit had 7 CAUTIs in 2017, which was the most of any unit within this hospital. A strengths, weaknesses, opportunities, and threats analysis of the unit revealed there was no daily process in which catheter necessity was discussed between the multidisciplinary team. This unit was also identified to have more catheter line days than expected by the National Healthcare Safety Network.

Intervention: The main intervention of this performance improvement project is a daily catheter rounding team, which consists of a nurse quality consultant, physician lead, department nursing leader, and infection control nurse. The rounding team reviews catheter patients daily and discusses catheter removal in real time. The catheter rounding team is expected to decrease the overall number of line days and, therefore, decrease infection rates.

Measures: During project development, a family of measures was identified to help track project goals and to identify if the project made a change. The specific outcome measures for this project will be a 30% reduction in catheter line days and a 30% reduction in the unit’s CAUTI rate per 1,000-line days from the project initiation. The two process measures that will evaluate the success of the project’s outcome metric are number of catheters removed during rounds and the percent of patients who have a catheter correctly placed using the bladder scanning protocol. A balancing measure of patient falls will also be tracked to ensure that there is no correlation between catheter removal and patients falling when using the toilet.

Results: After implementation of the main intervention of the catheter rounding team, the unit saw an overall decrease in line days by 31.4% from the same period the previous year. In addition to line day reduction, the CAUTI rate per 1,000-line days decrease by 36.4% from the start of the project.

Conclusions: The introduction of the catheter rounding team was successful at decreasing the overall number of line days, as well as the CAUTI rate. The introduction of tools for the frontline staff to utilize when making decisions to contact the physicians regarding line necessity were suspected of spreading an increased overall awareness of daily catheter necessity evaluation. Without full-time equivalents to continue the rounding team, the unit leadership and physician lead will be crucial in the sustainability of the unit’s CAUTI reduction success. In conclusion, the implications for practice based on this project include the introduction of a catheter rounding team to increase awareness of catheters that are in place, decrease the overall catheter line days and CAUTI rate, and reduce unnecessary harm to patients.