clinical updates

Associate Editors: Elaine L. Smith, EdD, MSN, MBA, NEA-BC, ANEF

Karen L. Rice, DNS, APRN, ACNS-BC, ANP
Authors: Launette Woolforde, EdD, DNP, RN-BC, and Emily Castro, MSN, RN, CCRN

A Nursing Education Strategic Plan for Conquering

Catheter-Associated Urinary Tract Infections

abstract
Catheter-associated urinary tract
infections (CAUTIs) intercept opportunities for hospitals to achieve quality patient care outcomes, maintain
sound financial performance, and
ensure a positive health care experience. Nurse educators play a key
role in designing effective strategies
and establishing important partnerships aimed at reducing CAUTIs in
hospitalized patients.
J Contin Educ Nurs. 2013;44(12):531532.

pproximately 75% of the urinary tract infections (UTIs)

acquired in hospitals are catheterassociated UTIs (CAUTIs) (Centers
for Disease Control and Prevention
[CDC], 2013). CAUTIs contribute to
patient discomfort, unnecessary antimicrobial use, a perception of poor
quality of care, increased morbidity
and mortality (up to 13,000 attributable deaths annually), an unnecessary
increase in hospital length of stay
averaging 2 to 4 days, and increased
health care costs (up to $500 million
per year nationally). More than half
of these infections are preventable
(CDC & National Healthcare Safety
Network [NHSN], 2013). Committed to excellence, nurse educators at

an academic medical center took on

the challenge of eradicating CAUTIs.
BACKGROUND
An early 2013 review of hospitalwide CAUTIs revealed that our facility was far from its goal of a CAUTI
standardized infection ratio (SIR) of
less than 1 within and outside of the
intensive care units (ICUs). The SIR
is calculated by dividing the number
of observed infections by the number of expected infections (CDC &
NHSN, 2013). At the end of 2012,
the ICU CAUTI SIR was 1.54 and
the non-ICU CAUTI SIR was 1.32.
As part of a larger, multiphase,
CAUTI prevention model, nurse
educators developed a six-step comprehensive strategic plan to help
conquer CAUTIs.
1. Establishment and identification of CAUTI goals and allowances
Understanding that overarching
goals may be more readily achieved
through identification of smaller,
discrete steps, nursing education
implemented a goals and allowance framework for units to follow.
Through collaboration with the infection prevention team, both the 2012
unit-specific CAUTI rate and the
2013 year-to-date (YTD) unit-specific
CAUTI rate were identified. A goal
of a 25% reduction from the 2012 rate
was established. The target goal was

Dr. Woolforde is Director and Ms. Castro is Critical Care Nurse Educator, Nursing Education
and Professional Development, North Shore University Hospital, Manhasset, New York.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Launette Woolforde, EdD, DNP, RN-BC, Director, Nursing Education and Professional Development, North Shore University Hospital, 300 Community Drive,
Manhasset, NY 11030; e-mail: LWoolfor@nshs.edu.
doi:10.3928/00220124-20131121-12

The Journal of Continuing Education in Nursing Vol 44, No 12, 2013

identified for each unit, subtracted

from the actual unit-specific YTD
CAUTI rate, and an allowance of
CAUTIs for the remainder of the year
for the unit was established. Progress
toward unit-specific goals is reviewed
routinely at nursing patient care services and nursing quality meetings.
2. Strategic partnerships with
nursing operations and the urinary
catheter product vendor team
One key partnership for nurse educators was with the director of nursing for critical care services and the
critical care nurse managers. The critical areas were experiencing the majority of CAUTIs, so close alignment,
open communication, and team spirit
were essential. Another key partnership was with the urinary catheter
product vendor team. This close partnership expanded the reach of nursing
education through inclusion of the
vendor team nurse educators in unitbased rounding, education on best
practices, scheduling and delivery of
classes, and access to evidence-based
CAUTI prevention resources.
3. Development of a CAUTI Prevention Task Force
It was well-known that an interdisciplinary approach would be necessary to conquer CAUTIs. Thus,
nurse educators helped establish
the CAUTI Prevention Task Force,
composed of staff from nursing education, nursing critical care, nursing
quality, and nurse practitioner and
physician assistant mid-level providers. The Task Force meets as needed
to close the loop on CAUTI ambassador feedback and to integrate other
components of CAUTI prevention,
such as the straight catheterization
531

protocol and urinary residual algorithm. Additionally, the Task Force

performs unit rounds to assess, support, and reinforce CAUTI prevention standards of care.
4. Comprehensive education program on indwelling urinary catheter
(IUC) insertion and care
A comprehensive program of education was developed to disseminate
best practice on CAUTI prevention
and catheter care. A priority ranking
methodology was used to organize the
implementation of the education plan.
The 10 units with the highest SIRs and
incidences of CAUTIs through 2013
were targeted. The Emergency Department, Operating Room, and Post
Anesthesia Care Unit rounded out the
13 priority areas. Unit-based education
for these targeted areas was organized
and provided through the partnership
with the IUC vendor nurse educator.
Mutually agreeable times were established in cooperation with the unit
nurse managers. Education sessions
usually occurred during the prescheduled huddle times on the unit. This
methodology fostered smooth delivery of the in-service, decreased the time
needed to assemble staff, and fostered a
partnership because the nurse manager
helped establish the time and structure
for the session.
5. Competency validation process
for IUC insertion and care
IUC insertion was adopted as a
house-wide core competency for
2013. An improved insertion competency was developed using the
existing competency, best practice
recommendations from the CDC,
a local federally designated quality
improvement organization, internal
infection prevention, hospital policy,
and CAUTI collaborative guidelines
established within the parent health
care system. The competency went
beyond the usual basic insertion steps
and included CDC guidelines on
when an IUC should be inserted and
maintenance steps to reduce infection.
532

6. Implementation of the CAUTI

prevention ambassador model
The CAUTI prevention ambassador model focused on identification of a minimum of six registered
nurse (RN) CAUTI prevention ambassadors per unit: three on the day
shift and three on the night shift. The
CAUTI prevention ambassador is a
resource person on the unit, represents the unit, reports CAUTI performance data at the hospital nursing
quality council, performs or assists
with oversight of the CAUTI prevention and IUC care practices, and,
through peer review, serves as the
IUC insertion validator for other RN
staff on the unit.
Dates and times of preparation
sessions for ambassadors were based
on the work schedules of the identified ambassadors. Ambassadors were
assigned to a particular session. The
targeted scheduling plan allowed for
accurate anticipation of the number
of attendees, assurance that return
demonstration time and manikin
availability would be sufficient, and
prevention of waiting in line to
perform return demonstrations.
During each session, the ambassadors received comprehensive education on the implications of CAUTIs
and best practices for CAUTI prevention, including a demonstration
of the new IUC product being introduced to the hospital. Ambassadors were then validated by the nurse
educator on IUC insertion using
manikins. Finally, for ambassadors in
select areas where bladder scanning
would be performed by staff RNs,
competency on bladder scanning was
validated during the session.
OUTCOMES
One hundred eighty-eight CAUTI
ambassadors have been trained since
the inception of the program. CAUTI
prevention ambassadors have helped
identify concerns, including whether
a new insertion kit should be used

each time if IUC insertion is unsuccessful, how often an order is required

after the initial 48-hour postinsertion order, and, because breaking the
closed system is highly undesirable,
how Emergency Department nurses
should manage patients who arrive
with an IUC already in place.
From January to July 2013, the
hospital had an average of 15 CAUTIs
per month. In August, the house-wide
CAUTI rate dropped to 7. Several
units have been free of CAUTIs for 2
or more consecutive months, including the Medical ICU, the Respiratory Care Unit, and the Neuroscience
Unit. The quarterly ICU CAUTI
incidence is trending downward, decreasing from 28 (Q1) to 22 (Q2) to
16 (Q3). The non-ICU CAUTI incidence is following a similar pattern,
decreasing from 18 (Q1) to 11 (Q2)
to 8 (Q3). The quarterly ICU SIR is
steadily decreasing2.313 (Q1) to
1.984 (Q2) to 1.02 (Q3). Similarly, the
quarterly non-ICU SIR has exceeded
organizational goals, decreasing from
1.562 (Q1) to 1.121 (Q2) to 0.53 (Q3).
SUMMARY
Although many factors contribute
to these and other successful quality
outcomes, nursing education plays a
critical role in meeting organizational
goals related to quality and nursesensitive indicators. Through education, knowledge and skills validation,
and the integration of data, measurement, goals, and outcomes, nursing
education can realize true partnership
and leadership in the achievement of
positive patient care outcomes.
REFERENCES
Centers for Disease Control and Prevention.
(2013). Catheter-associated urinary tract
infections (CAUTI). Retrieved from http://
www.cdc.gov/HAI/ca_uti/uti.html
Centers for Disease Control and Prevention
& National Healthcare Safety Network.
(2013). Device associated module: CAUTI.
Retrieved from http://www.cdc.gov/nhsn/
pdfs/pscmanual/7psccauticurrent.pdf

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