Background: Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-acquired infection nationally, and in the era of publically reporting and reimbursement based on outcomes, represents a preventable hospital-acquired infection that harms patients and institutions. The rate of CAUTI at our institution was higher than state and national averages, and a multidisciplinary team was tasked with designing interventions.

Purpose: To reduce CAUTI at our institution through design and implementation of novel, evidence-based processes

Description: A major CAUTI risk factor is prolonged catheterization. To combat physician inattention as a barrier to timely urinary catheter removal, a nurse-driven protocol for urinary catheter removal was designed to allow nurses to removal catheters once no longer indicated.

A literature search on CAUTI and asymptomatic bacteriuria was performed, which yielded important principles that informed two new processes. Given the prevalence of asymptomatic bacteriuria in patients with indwelling urinary catheters, a nursing process was developed to remove or replace urinary catheters prior to obtaining a urine culture to address catheter colonization.  Given that treatment of asymptomatic patients is against guidelines, and infectious symptoms specific to the urinary tract are rare in catheterized patients, an algorithm was developed to encourage stewardship of urine cultures to reduce false diagnoses of infection and antibiotic misuse.

A study of ICU patients with urinary catheters showed that a negative urinalysis ruled out CAUTI. A reflex urine protocol was designed to use the urinalysis as a tool to decrease false positive urine cultures in catheterized patients.

To obtain support from staff and administration, these processes were presented to institution-level standing committees that oversee critical care, infection prevention and quality improvement, with iterative refinement incorporating feedback. The final form of the four-fold intervention was approved by the executive committee of medical staff, with support from senior administration.

For the two nursing protocols, unit-based nursing education was performed by nursing leadership. Implementation was staged, first in pilot units before hospital-wide adoption. For the reflex urine culture protocol, a multidisciplinary effort between the CAUTI committee, laboratory, and clinical informatics led to the creation of a new electronic order, operationalized at the level of laboratory.

A hospital-wide education campaign was conducted by to educate all house staff and mid-level providers on these novel processes with emphasis on the stewardship algorithm. These processes were also presented to department heads to be disseminated to medical staff.

Conclusions: Through literature review of evidence and best practices, a four-fold intervention—the Catheter Reduction and Urine Culture Stewardship or CRUX Initiative—was designed and implemented at our institution (Figure 1). Data collection is ongoing to assess the impact of this intervention.