Intensive and Critical Care Nursing 40 (2017) 26–34

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Intensive and Critical Care Nursing

j ourna l ho m epage: www.elsev ier .com/ iccn

Original article

An intervention to improve the catheter associated urinary tractinfection rate in a medical intensive care unit: Direct observation ofcatheter insertion procedure

Janet M. Galiczewskia,b,∗, Kathleen M. Shurpina

a Stony Brook University School of Nursing, United Statesb Long Island Jewish Medical Center, United States

a r t i c l e i n f o

Keywords:Catheter Associated Urinary Tract Infection(CAUTI)Direct observationInterventionProtocol based-care intensive care unit(ICU)

a b s t r a c t

Background: Healthcare associated infections from indwelling urinary catheters lead to increased patientmorbidity and mortality.Aim: The purpose of this study was to determine if direct observation of the urinary catheter insertionprocedure, as compared to the standard process, decreased catheter utilization and urinary tract infectionrates.Methods: This case control study was conducted in a medical intensive care unit. During phase I, aretrospective data review was conducted on utilsiation and urinary catheter infection rates when practi-tioners followed the institution’s standard insertion algorithm. During phase II, an intervention of directobservation was added to the standard insertion procedure.Results: The results demonstrated no change in utilization rates, however, CAUTI rates decreased from2.24 to 0 per 1000 catheter days.Conclusion: The findings from this study may promote changes in clinical practice guidelines leading toa reduction in urinary catheter utilization and infection rates and improved patient outcomes.

© 2016 Elsevier Ltd. All rights reserved.

Implications for clinical practice

• Decreasing the incidents of CAUTI not only improves patient outcomes by reducing patient morbidity and mortality but can alsodecrease medical costs.

• Protocol based algorithms for urinary catheter placement must include interventions that focus on adherence to general infectioncontrol principles.

• Evidence supports the intervention of direct observation being added to the catheter placement algorithm to ensure adherence toprotocol.

• An invaluable benefit of direct observation is the ability to provide immediate constructive feedback that may improve practice.

Introduction

Catheter associated urinary tract infections (CAUTI) account for40% of all healthcare associated infections (HAI) in the United States(Fuchs et al., 2011). Internationally, CAUTI rates can increase up to

∗ Corresponding author at: Stony Brook University, School of Nursing HSC Level2- 204 Stony Brook, New York 11794-8240, United States.

E-mail address: Janet.Galiczewski@stonybrook.edu (J.M. Galiczewski).

5% higher depending on the socioeconomic status and resources ofthe country (Rosenthal et al., 2012). Urinary tract infections (UTI)caused by an indwelling catheter lead to a significant increase inpatient morbidity and mortality and generate a financial burdenon health care systems (Leone et al., 2003).

Background and significance

Thei ncidence of CAUTI in the United States has reached almosttwo million cases and has raised healthcare costs to over 400

http://dx.doi.org/10.1016/j.iccn.2016.12.0030964-3397/© 2016 Elsevier Ltd. All rights reserved.

J.M. Galiczewski, K.M. Shurpin / Intensive and Critical Care Nursing 40 (2017) 26–34 27

million dollars per year (Gray, 2010; Vacca and Angelos, 2013).As a result, government funded reimbursement is being lim-ited to encourage hospitals to implement protocols aimed atreducing this HAI (Vacca and Angelos, 2013). The National Health-care Safety Network (NHSN) survey conducted on patients inintensive care units (ICU) revealed that UTIs were the most com-mon HAI found in this vulnerable population (Richards et al.,2000).

In January 2015, the Center for Disease Control and Prevention(CDC) issued changes in the CAUTI definition that may have animpact on urinary catheter infection and utilization rates. The newdefinition will impact how CAUTI is reported to the NHSN. The sig-nificant changes included: (1) bacteria only acceptable causativeagent of UTIs, (2) urine culture threshold criteria increased to1,000,000 CFU/ml, and (3) same pathogen list used for symptomaticUTIs and asymptomatic bacteriuria UTIs (CDC, 2015). The exclu-sion of yeast, mold, fungi and parasite related UTIs will decreasethe often overinflated CAUTI rates (CDC, 2015). Studies are neededpost implementation of the updated CAUTI surveillance definitionto examine the impact on urinary catheter infection and utilizationrates.

Preventative measures for CAUTI such as catheter avoidancestrategies, hand hygiene, perineal care, and daily necessity reviewto limit catheter days have been associated with decreased CAUTIrates in ICUs (Chenoweth and Saint, 2013). Many institutions bun-dle these interventions into protocol-based guidelines for catheterinsertion to standardize care based on the scientific evidence toimprove patient outcomes (Clearinghouse, 2014). Globally, CAUTIprevention efforts continue and nurses lead the effort to identifyinterventions with the greatest impact on CAUTI rates. The purposeof this quality improvement study is to determine if direct observa-tion of the urinary catheter insertion procedure, as compared to thestandard process, decreases urinary tract infection and utilizationrates.

Review of literature

Protocol -based care

Protocol-based care is used to implement evidence-based inter-ventions which improve patient outcomes and the overall qualityof care (Topal et al., 2005). The use of protocol-based care pro-vides the nurse with increasing autonomy and positively affectsdelivery of care (Ilott et al., 2006; Rycroft-Malone et al., 2008). Clin-ical protocols are developed by healthcare teams and are based onsystematic review of the scientific evidence (Harbour and Miller,2001). The strength of the evidence is graded and agencies devel-oping protocol-based care policies must assess the applicability,consistency and clinical impact of the evidence (Hadorn et al., 1996;Harbour and Miller, 2001).

Ilott et al. (2006) defined protocol-based care as “the stan-dardization of the processes of clinical care in documents, such asprotocols, pathways, algorithms or guidelines” (p. 548). In 1997,the Agency for Healthcare Research and Quality (AHRQ) createdthe National Guideline Clearinghouse (NGC) to represent protocoldevelopment that was in harmony with the Institution of Medicine(IOM) (Clearinghouse, 2014). In 2014, the definition of protocol-based care was revised and defined as the standardization of carebased on the scientific evidence to optimize patient outcomes(Clearinghouse, 2014). The CDC developed guidelines for CAUTI andhospitals that adopted the guidelines and implemented protocol-based care have decreased CAUTI rates (Gray, 2010).

Implementation of protocol-based care bundles to prevent CAUTI

Evidence based research has identified interventions to combaturinary catheter infection and utilization rates and these interven-tions have been incorporated into protocol-based insertion bundles(Flodgren et al., 2013; Gray, 2010). A multi-phase study conductedin an ICU and two step down units (SDUs) in a Brazilian hospitalthat implemented CDC recommended protocols and the Institutefor Healthcare Improvement’s (IHI) bladder bundle (Marra et al.,2011). The results were statistically significant with a reduction inthe CAUTI rate in the ICU from 7.6 to 5 per 1000 catheter days andin the SDUs from 15.3 to 12.9 per 1000 catheter days (Marra et al.,2011). This study was conducted in a single hospital and did notcollect continuous data on the units prior to the implementation ofthe bundle intervention (Marra et al., 2011).

Studies conducted in ICUs of hospitals that are members ofthe International Nosocomial Infection Control Consortium (INICC)were done to assess the impact of a multidimensional infectioncontrol strategy on CAUTI rates (Kanj et al., 2013; Leblebiciogluet al., 2013; Navoa-Ng et al., 2013; Rosenthal et al., 2012). Thisinternational study included 15 developing countrieswith a totalsample size of 56, 429 patients in 57 ICUs (Rosenthal et al., 2012).Rosenthal et al. (2012) conducted a meta-analysis of the multiplestudies involved in the INICC to evaluate the impact of the bundleintervention strategy on CAUTI rates as a whole. The interven-tions included in the bundle were: (1) proper hand hygiene, (2)to maintain collection bag lower than the level of the bladder, (3)to maintain unobstructed urine flow, (4) to empty collection bagat regular intervals and avoid allowing the draining spigot to touchthe collection container, and (5) to monitor CAUTIs using standard-ized criteria (Rosenthal et al., 2012). The results of the combinedstudies were statistically significant with 253,122 urinary catheterdays recorded). The CAUTI rate decreased from 7.68 to 4.95 per1000 catheter days after implementation of the bundle interven-tion (Rosenthal et al., 2012). The strength of these combined studieswere that they took place in multiple institutions, in different typesof adult ICU setting, in different countries and had large samplesizes. Limitations included a lack of resources to collect more dataon process surveillance and compliance with all interventions inthe bundle (Kanj et al., 2013; Leblebicioglu et al., 2013; Navoa-Nget al., 2013; Rosenthal et al., 2012).

Inappropriate use of urinary catheters, improper insertion tech-nique and poor management of the catheter once inserted havebeen identified as major factors that lead to unnecessary infec-tions (Tatham et al., 2015; Tsai et al., 2015). A study by Tsai et al.(2015) implemented a UTI care bundle that included a staff educa-tion session and an insertion and daily care checklist. The insertionand daily checklist included hand hygiene, perineum washing, careof the urine container, keeping a closed system and daily reviewof catheter necessity. The CAUTI rate decreased significantly afterimplementation of the care bundle from 6.10% in 2013 to 3.47% in2014 (Tsai et al., 2015). Another quality improvement study thatimplemented insertion and maintenance care bundles based onnational guidelines had similar success in decreasing CAUTI ratesand also identified the need to engage staff by conducting educa-tion sessions and providing frequent feedback on patient outcomes(Tatham et al., 2015).

Measuring effectiveness of protocol-based care

Measuring protocol-based care is a challenge. Often, patientoutcomes, reduced length of stay (LOS) and improved documenta-tion are used to determine the effectiveness of standardization ofcare (Rycroft-Malone et al., 2004). A study conducted by Rycroft-Malone et al. (2008) used a multifaceted approach to measureprotocol-based care which included: (1) direct observation of activ-

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ities related to the standardization of care, (2) post-observationinterviews with the multidisciplinary team to explore their viewsabout the use and impact of standardization of care, (3) interviewswith patients about their experience, (4) tracking patients duringtheir course of medical treatment and (5) review of relevant doc-umentation. Quality monitoring using direct observation has beenwell validated as a method to measure effectiveness of a protocol(Larson et al., 2004).

Direct observationHAIs can be associated with several factors such as an inex-

perienced health professional performing the procedure, a gap inknowledge, or failure to adhere to the recommended protocols(Muscedere et al., 2008; Safdar et al., 2002). Protocol-based carebundles were developed for the ICU setting in 2006 to combat allHAIs and when performed reliably should improve patient out-comes (Flodgren et al., 2013). A risk factor for developing CAUTI isfailure to comply with the infection control practices in the protocolbundle during the insertion procedure (Flodgren et al., 2013).

Many studies addressing compliance with and effectivenessof protocol based-care using direct supervision or observationfocused on hand hygiene and central line associated blood streaminfections(CLABSI). A large cross sectional study involving 250 hos-pitals evaluated compliance with the CLABSI intervention bundleand determined that the infection rate was decreased when theinstitution had a clear written protocol, compliance was monitoredthrough direct supervision and documentation, and compliancewas rated as high (Furuya et al., 2011). A study by Frankel (2005)used the corporate Six Sigma performance improvement strategiesto decrease CLABSI rates. The interventions included were directobservation by the attending physician of all central line catheterinsertions along with educational and policy change interventions.The result showed a decrease in CLABSI rates from 11 to 1.7 per1000 catheter days, a 650% improvement (Frankel 2005). Althoughdirect observation was used as an intervention in this study, itsimpact alone cannot be assessed due to it being bundled with SixSigma educational strategies and policy change interventions.

In 2004, Larson et al. conducted a study comparing two methodsof assessing compliance with hand hygiene practices; they lookedat direct observation and self-reporting using a daily diary. Thesample size was adequate with 119 nurses yielding 1071 diaryentries and 206 hours of direct observation. The results showed thatthe total number of hand hygiene episodes with direct observationwere greater than with self reporting, however the results werestatistically insignificant (p = 0.32) (Larson et al., 2004). Limitationsto this study were most of the observation times occurred on theday shift and in one hour intervals which were not representativeof the entire time period being studied.

A three phase observational study by Earl et al. (2001) was con-ducted in two SICUs and a MICU to monitor if the availability ofalcohol-based gels conveniently located increased hand hygiene.Phase1 consisted of observing hand hygiene practices with soapand water, phase 2 monitored hand hygiene after gel dispenserswere placed in each unit and phase 3 monitored the adherencerate of hand hygiene 10–14 weeks post intervention (Earl et al.,2001). The results showed, with statistical significance, an increasein adherence to hand hygiene in all of the units from phase 1 to 3;the SICUs improved 58.9% and the MICU 29.4% from baseline (Earlet al., 2001). Direct observation by educated personnel was usedto measure compliance with the hand hygiene protocol. This studyconsisted of 402 observational hours and was conducted during theday and night to capture compliance on both shifts.

Direct observation has become the “gold standard” of surveil-lance methods (Larson et al., 2004). It provides a direct measureof compliance with and effectiveness of protocol-based care; how-ever it is rarely used due to its high cost, time consumption and

required intensive resources (Larson et al., 2004). It has also beenfound that individuals who are being observed may change theirbehavior to be more compliant (Larson et al., 2004; Pedersen et al.,1986). An invaluable benefit of direct observation is the ability toprovide immediate constructive feedback that improves practiceand may have a positive effect on patient outcomes (Ellingson et al.,2014).

Theoretical framework

The chain of infection theory

The chain of infection is a physiology theory based on the prin-ciples of epidemiology. The theory explains the processes that arerequired for the transmission of pathogens from their existing envi-ronment to a patient and for subsequent infection to occur (Mitchelland Gardner, 2014). There are six major components of the the-ory: (1) infectious disease, (2) reservoir, (3) portal of exit, (4) modeof transmission, (5) portal of entry and (6) susceptible host (CDC,1992). Modern day infection control practices are put into placeto avoid the transmission of pathogens by breaking the chain ofinfection (Mitchell and Gardner, 2014). A model has been createdby the CDC to illustrate this theory and the relationship betweenthe components (Fig. 1).

As HAIs become a global patient safety issue, nurses need toadopt the role of infection preventionists (APIC, 2012). The basicprinciples of the chain of infection are overlooked by healthcareworkers on a daily basis and their hands are the most commonvehicle for transmission of pathogens (Allegranzi and Pittet, 2009).According to the Association of Professionals in Infection Controland Epidemiology (APIC), the infection preventionist nurse needsto become a new kind of leader who can engage all disciplinesto work towards the common goal of breaking the chain of infec-tion. Nurses spend the most time caring for patients; they need toaddress this endemic patient safety issue and champion the cam-paign to improve infection rates and patient outcomes.

Methods

Setting and study design

This quasi-experimental case control study was conducted inthe medical ICU of a 603 bed tertiary academic medical centerlocated in the northeastern section of the United States. This ICUprovided acute care to adults with primarily medical illnesses.Approval from the Quality Improvement/Nursing Research Com-mittee was obtained prior to the start of this project. Informedconsent was not required as only de-identified aggregate data wascollected and there was no change in the standard of care.

The study was carried out in two phases. During phase I (n = 74),a retrospective data review was conducted on utilization andurinary catheter infection rates when practitioners followed theinstitution’s standard insertion algorithm (Fig. 2). Catheter inser-tion policies were based on the APIC and CDC guidelines (APIC,2014; CDC, 2015). During phase II (n = 64), an intervention of directobservation by an educated observer was added to the standardinsertion procedure. The practitioners on the unit served as theobservers. Five day nurses and four night nurses volunteered to betrained as observers. This allowed the intervention to take place onboth the day and night shift and capture all eligible patients at noadditional cost to the institution.

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Fig. 1. CAUTI Chain of Infection Model adapted from CDC 2002.

Instrument

A 13 item critical element checklist was developed based onthe urinary catheter insertion algorithm of the institution whichwas based on the APIC and CDC guidelines for the prevention ofCAUTI (Fig. 3). This established the validity of interventions onthe checklist. It required yes/no answers on 12 of the 13 criticalsafety elements. If the observer identified one of the elements wasincorrect, they corrected the action of the practitioner inserting thecatheter and when the item was completed properly, theymarkedthe corrected box on that item. This ensured that all the elementsof the algorithm were followed based on the insertion protocol.One of the checklist elements required the observer to choose areason for catheter use from a list of 10 hospital approved indica-tions for catheter insertion. The checklist included directions foruse and before the start of phase II, the medical ICU practitionersthat volunteered to be observers were given a 30 minute educationsession. The education session included a review of the institution’surinary catheter insertion procedure, directions on the use of thechecklist and the purpose of the quality improvement project. Thechecklist did not include any patient or staff identifiers. To estab-lish fidelity (compliance with the checklist), the investigators ofthe study spent time on both shifts to ensure catheter insertionswere being observed and the checklist was used correctly. Compli-ance with the checklist was defined as completion of the checklistfor every urinary catheter insertion observed in the medical ICUduring the intervention phase of the study.

Sample

The study population consisted of a convenience sampling of140 patients that had a urinary catheter placed during their stay inthe medical ICU. There were 74 patients recruited in phase I and66 patients in phase II. Selection of inclusion and exclusion criteriawere determined prior to the start of the study. The inclusion cri-teria were: (1) patients ≥18years of age, (2) patients admitted or

transferred to the medical ICU, (3) required an indwelling urinarycatheter, and (4) catheter was placed in the medical ICU. The exclu-sion criteria were: (1) patients <18 years of age and (2) patientswith a urinary catheter placed in another unit of the hospital priorto being transferred or admitted to the medical ICU.

Definitions. CAUTI surveillance is performed on a monthly basisby the nurse administrators on the medical ICU and reported to thequality management practitioner who calculates CAUTI and utiliza-tion rates based on the 2015 CDC definition guidelines. CAUTI ratesare calculated by dividing the number of CAUTIs by the numberof urinary catheter device days multiplied by 1000 (Elpern et al.,2009). The catheter utilization ratio is defined as the number ofurinary catheter days divided by the number of patient days and isreported as a percentage (Marra et al., 2011).

Statistical analysis

Using the program Statistical Package for the Social SciencesSoftware (SPSS) version 22, descriptive statistics were calculatedon selected patient variables. Frequencies were calculated for cat-egorical variables. Means and standard deviations were calculatedfor continuous variables. The categorical variables in this studyincluded gender, reason for catheter placement, catheter place-ment observation and development of a CAUTI. The continuousvariables included age in years and the day on which a CAUTI wasidentified following catheter placement. If the checklist was incor-rectly filled out during observation of a urinary catheter insertion orif the checklist had missing data, the patient was not included in thestudy. The hypotheses of this study were that urinary catheter uti-lization and infection rates would decrease during the interventionphase compared to the pre-intervention phase. An independentsamples t-test was used to determine if there was a statisticallysignificant difference (p < 0.05) in mean monthly catheter utiliza-tion and urinary catheter infection rates between the two samples.Additionally, a Fisher’s exact test was used to determine if thepercentage of patients who developed a CAUTI between the two

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Fig. 2. * Based on Stony Brook Medicine Urinary Catheter Insertion for the Adult & Pediatric Patient Protocol algorithm (2015). Based on the APIC and the CDC Guidelines(2015).

samples was statistically different (p < 0.05). Fisher’s exact test wasused in place of the chi square test due to the small sample size.

Results

Sample demographics

In this two phase study, the total sample size was n = 140.Table 1 describes the demographics of the sample during phaseI compared to Phase II of the study. An independent samples t-test was used to compare the mean age of patients in phase Ito patients in phase II. Levene’s test was non-significant (.912)indicating that the assumption of equal variances was not vio-lated. The samples t-test demonstrated there was no significantdifference between the two groups (p = 0.754). A Chi-Square testwas performed to compare phase I patients to phase II patients in

regards to sex. The Chi Square test demonstrated that the percent-age of males and females was not different between the two groups(p = 0.935).

Urinary catheter utilization rates

Phase I of the study was conducted from April 2015 through July2015. During this phase, the total recorded patient days were 1954and the total recorded catheter days were 1403. The MICU utiliza-tion rates during this period ranged from 67% to 78% (mean 71%).Phase II began in October 2015 and data collection was completedin February 2016. During this phase, the total recorded patient dayswere 2348 and the total recorded catheter days were 1675. TheMICU utilization rates during this period ranged from 66% to 72%(mean 71%). There was no difference in the mean utilization ratebetween phase I and Phase II of this study.

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Fig. 3. Indwelling Urinary Catheter Insertion Checklist.* Based on Stony Brook Medicine Urinary Catheter Insertion for the Adult & Pediatric Patient Protocol algorithm (2015). Catheter insertion policies are based on the Associationfor Professionals in Infection Control and Epidemiology (APIC) and the CDC Guidelines (2015)Directions for use of Indwelling Urinary Catheter Insertion Checklist1. One practitioner is responsible for observing catheter insertion procedure and completing the checklist.2. If practitioner inserting indwelling catheter misses completing a step or does so incorrectly, the observer is to correct the practitioner ensuring all steps are followed. Forexample: if sterile technique is broken and the practitioner inserting the catheter continues with the procedure, the observer is to point out the mistake and a new sterilecatheter is to be used to continue. In this case the observer would check the no box for this step and then the corrected box when the step is completed correctly.3. For the indications for indwelling catheter section, please place the corresponding number that closely describes why the patient is receiving the catheter.4. If a step is not applicable, put a N/A in the completed box.5. Thank you for your time and participation in this quality improvement project.

Table 1Demographics.

Variables Phase I Not Observed (n = 74) Phase II Observed (n = 66)

t Mean Age 67.03 (SD = 16.35) 66.15 (SD = 16.58)Male 56.8% 56.1%CAUTI identified 4.1% 0%Mean Day CAUTI identified 5 N/A

CAUTI: Catheter Associated Urinary Tract Infection; N/A: Not applicable.

Catheter associated urinary tract infection rates

The monthly rate of CAUTI ranged from 0 to 3.26 per 1000catheter days with a mean of 2.24 during phase I. The overall meanmonthly rate of CAUTI in the MICU declined from 2.24 to 0 per 1000

catheter days in phase II when direct observation was added to theurinary catheter insertion protocol. This change was not statisti-cally significant (p = 0.098). Prior to the intervention, 3 out of 74patients (4.1%) developed an infection attributable to the urinarycatheter based on 2015 CDC guidelines. There were zero CAUTI

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Table 2Percentages of Patients who Developed CAUTI.

Urinary Catheter Insertion Percentage of Patientsthat did Not developCAUTI

Percentage of Patientsthat developed CAUTI

Total Patients

Not ObservedPhase I

95.9% (71 patients) 4.1% (3 patients) 74

ObservedPhase II

100% (66 patients) 0 66

CAUTI = Catheter Associated Urinary Tract Infection.

occurrences reported for the 66 patients who had the catheterinsertion procedure observed during phase II of the study (Table 2).While the results of this study were not statistically significant(p = 0.253), they may be clinically relevant.

Discussion

Reducing the incidents of CAUTI not only improves patientoutcomes but can also decrease medical costs. It has been wellestablished that CAUTI can lead to bacteremia and a prolongedLOS (Chen et al., 2005).Treating a single episode of uncomplicatedCAUTI costs between 1000 and 5000 dollars and increases LOS by2 to10.3 days (Gray, 2010; Laupland et al., 2002; Umscheid et al.,2011). CAUTIs are the second leading cause of blood stream infec-tions and can add over 36,000 dollars per episode to the cost(Titsworth et al., 2012). In addition, eliminating CAUTI has becomea global priority due to government funded insurance companiesno longer providing payment for treatment (Burton et al., 2011).Every CAUTI event exponentially increases an institutions financialburden.

Up to 70% of CAUTI cases may be preventable if evidence basedprotocols are followed during catheter insertion (Umscheid et al.,2011). There is so much to gain, in terms of decreased mortal-ity rates and healthcare costs, if practitioners adhere to infectioncontrol practices. The finding of zero CAUTI occurrences during

the intervention phase of direct observation of the catheter inser-tion procedure, although not statistically significant, will decreasehealthcare costs and impact patient safety. Therefore, decreasingCAUTI rates in vulnerable ICU patients is clinically relevant.

One of the most successful strategies to combat CAUTI is todecrease the use of indwelling catheters. Most hospitals have devel-oped indications for use of indwelling catheters that are often partof the catheter insertion algorithm or protocol (Titsworth et al.,2012). The indications are included to guide the practitioner indetermining if the patient requires a urinary catheter. The checklistused in phase II of this study included a section for recording thehospital approved indication for use of the urinary catheter (Fig. 4).This type of data was not collected during the retrospective datareview (phase I) so therefore it could not be compared to data fromphase II.

During both phases of this quality improvement study, the meanutilization rate remained the same at 71%. It was hypothesizedthat utilization rates would decrease during phase II when urinarycatheterizations were being observed and the indications for usagewere strictly adhered to. Currently in this MICU, Clinical Nurse Edu-cators perform daily urinary catheter rounds and remind the ICUpractitioners of indications for catheter usage. These rounds werecommon practice during both phases of this study and thereforecould account for no change in utilization rate. Although this unitmade great strides since 2013 to decrease their utilization rate

Fig. 4. Indications for Urinary Catheter Insertion.

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from 84% to 71%, it remains above the NHSN catheter utilizationbenchmark of 61% for critical care units (Casey et al., 2015)

A limitation of this study is that it was conducted in a single ICUof a large tertiary academic teaching hospital and thus the gener-alizability of the results may be limited to hospitals of similar sizeand type. Additionally, indication for catheter usage was only col-lected during phase II of the study and although the informationwas informative, it could not be compared to phase I. Another lim-itation was the NHSN CAUTI definitions were updated in January2015 and all hospitals had to comply with the new reporting guide-lines by April 2015. Although all data from this study was collectedunder the new guidelines, it cannot be compared to data prior toJanuary 2015.

This study has provided a potential framework to understandthe impact of direct observation during the insertion procedureas an intervention to prevent CAUTI. Previous studies address-ing compliance with protocol based-care using direct observationhave demonstrated a statistically significant decrease of infectionrates, however, they focused on CLABSI (Furuya et al., 2011). Moreresearch is needed on implementing a protocol based care bun-dle for catheter insertion that includes direct observation of theprocedure.

Conclusion

Reducing CAUTI rates in the ICU setting is a complex processthat involves a multidirectional approach. Protocol based algo-rithms for urinary catheter placement must include a bundle ofinterventions that focus on adherence to general infection controlprinciples (Meddings et al., 2014). Urinary catheter infections canbe associated with several factors such as an inexperienced healthprofessional performing the procedure, a gap in knowledge, or fail-ure to adhere to the recommended protocols (Muscedere et al.,2008; Safdar et al., 2002). Evidence from phase II of this qualityimprovement study supports the intervention of direct observationbeing added to the catheter placement algorithm to ensure adher-ence to protocol. An invaluable benefit of direct observation is theability to provide immediate constructive feedback that improvespractice (Ellingson et al., 2014). Findings from this study may pro-mote changes in clinical practice guidelines leading to a reductionin urinary catheter utilization and infection rates and improvedpatient outcomes.

Financial and funding disclosure

None.

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