Nursing Standard of Practice Protocol: Prevention of Catheter-Associated Urinary Tract Infection Prevention
Annemarie Dowling-Castronovo and Christine Bradway
The information in this "In Depth" section is organized according to the following major components of the NURSING PROCESS:
I. GOALS: To ensure that nurses in acute care are able to:
A. Define catheter-associated urinary tract infection (CAUTI)
B. Understand the epidemiology of CAUTI
C. Define indications for indwelling urinary catheters (IUC)
D. Identify evidence-based strategies and interventions for the prevention of
E. Understand how to engage an interdisciplinary team in the management of
CAUTIs in your setting
A. CAUTIs are the single most common hospital-acquired infection (HAI),
accounting for 34% of all HAIs and associated with significant morbidity and
excess health care costs.
B. Since 2008, the Centers for Medicare and Medicaid Services (CMS) no longer
reimburse for additional costs required to treat nosocomial urinary tract infec-
C. Between 2008 and 2010, at least six evidence-based practice strategies, recom-
mendations, and/or guidelines for preventing CAUTI in hospitals and long-
term care have been published.
D. In light of these rapid changes in the field, the review of policies, procedures,
practices, and products is imperative for all health care facilities.
III. BACKGROUND AND STATEMENT OF PROBLEM
1. There are more than 500,000 UTIs in the United States annually. At a
mean cost of $589 per episode, this epidemic results in $250 million of
excess health care costs each year.
2. Most UTIs are associated with the ubiquitous IUC, also known as a Foley
3. According to the Infectious Diseases Society of America, 21%–54% of all
IUCs are inappropriately placed and are not medically indicated.
1. Symptomatic UTI. A patient has at least one of the following signs or symp-
toms with no other recognized cause: fever (higher than 38 °C), urgency,
frequency, dysuria, or suprapubic tenderness and positive urine culture (see
2. Asymptomatic bacteriuria. A positive urine culture in a patient who does not
have symptoms referable to the urinary tract; may or may not be catheter-
3. CAUTI. A symptomatic UTI that occurs while a patient has an IUC or
within 48 hours of its removal.
C. Essential Elements
1. The urinary tract is normally a sterile body site. In the presence of an IUC,
microorganisms can gain access to the urinary tract on either the extralu-
minal surface of the IUC or intraluminal surface through breaks in the
2. Once bacteria gain access to the urinary tract, microorganisms can thrive
in a “biofilm” layer on either the extraluminal or intraluminal surface of
3. Because the formation of a biofilm and colonization with bacteria takes
time, most CAUTI occurs after 48 hours of catheterization and increases
approximately 5% per day.
4. The mechanisms described previously provide the rationale for evidence-
based care of IUCs. Four potential opportunities for intervention include
a. Avoid the use of catheters
b. Evidence-based care practices and product selection
c. Timely removal
d. Education and surveillance
IV. ASSESSMENT OF CAUTI
A. The Centers for Disease Control and Prevention (CDC) has developed explicit
surveillance criteria for CAUTI. In brief, the patient must have the following:
1. A positive urine culture (see Table 19.1) sent more than 48 hours after
admission to the health care facility
2. An IUC at the time of or within 48 hours prior to the culture
3. One of the following: suprapubic tenderness, costovertebral angle pain or
tenderness, or a fever higher than 38 °C without another recognized cause;
or a positive blood culture with the same organism as in the urine
a. CAUTIs/1,000 catheter days
a. Catheter days and hospital days
b. Postoperative catheter days and patient days
c. Proportion of catheterized and admitted patients from emergency
department (ED) or operating room (OR)
C. Indications for IUCs can be operationalized using algorithms or protocols.
V. NURSING CARE STRATEGIES
Twenty percent to 69% of CAUTIs are preventable through the application of evi-
dence-based care strategies.
A. Catheter Avoidance
1. Established insertion guidelines for ED and OR
2. Alternative strategies to manage urine output available:
a. Bedside commodes
b. Condom catheters
c. Moisture-wicking incontinence pads
d. Intermittent straight catheterization
e. Bladder scanner for monitoring and assessment
f. Bedpans and urinals that are functional
3. Toileting schedules and frequent nursing rounds
B. Product Selection and Routine Care
1. Catheter material is controversial:
a. Antimicrobial catheter materials have been shown to reduce catheter-
associated bacteriuria (colonization), but impact on prevention of
symptomatic CAUTIs during short-term insertions is unproven.
b. There is insufficient evidence to determine whether selection of a latex
catheter, hydrogel-coated latex catheter, silicone-coated latex catheter,
or all-silicone catheter influences CAUTI risk.
2. Select the smallest size possible (less than 18 French).
3. Use aseptic technique and sterile product during catheter insertion.
4. Routine urethral meatus cleansing with soap and water during bath and
after bowel movement.
5. Secure catheter to leg.
6. Maintain a closed system at all times.
7. Keep drainage bag below level of bladder.
8. Empty the bag when two-third full and before transport.
C. Timely Removal
1. Systems that prompt providers to review the need for the catheter and
encourage early removal. Examples include stop orders and reminder sys-
tems: audit and feedback, nurse-prompted reminders, and nurse-driven
2. Measure of removal: Surgical Care Improvement Project (SCIP), SCIP-9
measure; catheter removal on postoperative Day 1 or 2.
D. Surveillance and Education
1. Measurement of processes and outcomes.
2. Ongoing system evaluation, nursing reeducation, practice reminders, and
public reporting of unit-based CAUTI rate data are strategies to inform the
health care team of current practice outcomes and effectiveness of CAUTI
VI. EVALUATION AND EXPECTED OUTCOMES
A. Plan of Care
1. Assessment that patient meets established insertion criteria
2. Adherence to prompts for early catheter removal
3. Standardized catheter care guidelines followed
1. Dates of insertion and removal
2. Type of catheter (new indwelling, chronic indwelling, reinsertion, change
3. Reason for catheter insertion
4. Justification that catheter is still necessary
5. Post residual void after catheter removal if patient is unable to void in
6–8 hours; bladder volume; intervention.
C. Catheter Utilization
1. Monitor unit-specific CAUTI rates.
2. Monitor average catheter duration (catheter days).
3. Monitor SCIP postoperative catheter removal on catheterization Day 1 or 2.
4. Trend unit-specific IUC usag