Running head: DECREASING CAUTI WITH REMINDER SYSTEM

Decreasing the Risk of CAUTI with the Use of a Reminder System

Kacy McMurry
University of South Florida

DECREASING CAUTI WITH REMINDER SYSTEM

Abstract
Hospital care associated infections cause close to two million infections and cause
close to 100,000 deaths every year, with catheter associated UTI being the most common
infection (Bruminhent et al. 2010). The evidence-based project proposed in this paper
was to determine if the use of a reminder system would decrease the dwell time and the
incidence of catheter associated UTIs on inpatient units. Using the search engines of
PubMed and CINHAL, three peer reviewed, randomized controlled trials were found and
used for this evidence based project. Key terms used to find theses sources included
CAUTI, UTI, reminder system, and catherization. In conclusion, it was found that using
some sort of a reminder system, whether it be sticker based, pre-written stop orders, or
requiring nurses to reevaluate urinary catheter use after a specific time, was successful in
decreasing both the dwell time of urinary catheters as well as decreasing the number of
occurrences of CAUTIs.

DECREASING CAUTI WITH REMINDER SYSTEM

Decreasing CAUTI with the Use of a Reminder System

Health care associated infections make up about 1.7 million infections and are the
cause of almost 100,000 deaths every year in hospitalized patients (Bruminhent, Keegan,
Lakhani, Roberts, & Passalacqua 2010). This means that these infections can be
prevented if care is completed appropriately and follow the appropriate healthcare
guidelines. Catheter associated UTIs are the most common infection that occurs out of
the health care associated infections. The risk for a catheter associated UTI increases
every single day by 5 percent every day that a catheter is left in place (Bruminhent,
Keegan, Lakhani, Roberts, & Passalacqua 2010). Not only are these infections deathly,
but they are costly to the hospital as well. The PICOT question proposed is: In adults on
an inpatient unit, how does using a criteria based reminder system compared with no
reminder system affect duration of urinary catherization and incidence of CAUTI over six
months? The infrastructure needed to support this project would include the doctors who
would be putting in the stop orders and overseeing the patients care as well as the floor
nurses that would be evaluating the patients need for the urinary catheter. These key
people along with following evidence based practice guidelines will set the foundation
for this evidence-based project.
Literature Search
To find resources for this evidence based practice project, both PubMed and
CINAL were used as search engines. Some of the key terms used to find the sources were
CAUTI, UTI, catherization, and reminder system. To specify sources even further, the
sources were limited to ones that were peer reviewed and randomized control trials.

DECREASING CAUTI WITH REMINDER SYSTEM

Literature Review
Bruminhent, Keegan, Lakhani, Roberts, & Passalacqua (2010) conducted a study
made up of 400 patients that were admitted to the hospital for at least 48 hours in an
inpatient unit. The only patients involved in this study were ones with indwelling urinary
catheters. Data were tracked by using both the electronic medical records and nursing
documentation notes. The intervention consisted of putting a sticker on the patients file
saying that they had a urinary catheter in place, reminding the patients doctors to put in
orders to discharge the catheters. The floor nurses had the duty of monitoring the
intervention of the stickers and the determining if removal of the urinary catheter was
appropriate at least one day a week. The appropriate indications for urinary catherization
came from HICPAC and other relevant research studies. If an indication for urinary
catherization was cured or fixed, the urinary catheter was to be removed right away. The
data from the study shows that the incidence of catheter associated UTIs decreased by
61.3% 6 months post intervention (p= .008). It also shows that it decreased
inappropriately catherized patients (p<.001). Strengths of this study include: similar
patient demographics, randomization, and measurement guidelines. Weakness of this
study include: only one day was required a week for monitoring the intervention by
nurses, when it could be more frequent. The strengths outweigh the weaknesses in this
study; therefore this study would be valid. This study will be included because it shows
that a reminder system for ending catherization decreases the chance of CAUTI
(Bruminhent, et. al. 2010). Refer to the literature table for a review of the article.

DECREASING CAUTI WITH REMINDER SYSTEM

Chen, Chi, Chen, Chan, Chou, & Wang (2013) conducted a study that utilized
278 patients in Thailand. The requirements to be included were that they must be an
inpatient for at least two days and must have had a urinary catheter placed at some point
during their stay at the hospital. The intervention in this study involved evaluating a
patients need for a urinary catheter after seven days to see if they met the parameters for
removal, since research shows that risk for CAUTI increases after 7 days. The guidelines
for urinary catheter removal and placement were based on the CDC and the Society for
Healthcare Epidemiology of America/ Infectious Diseases of America. If the indications
for removal were met, the researcher was to speak with the doctor about removal. Use of
urinary catheters decreased by 22% in the intervention group compared to the control
group (p<.001). This study decreased the average dwell time of urinary catheters from 11
days to 7 days. The reminder system decreased CAUTI by 48% (p= .009). Strengths of
this study include: randomization, similar demographics, and guideline parameters.
Weaknesses of this study include: a 7 day wait period before interventions began, and it
was not a double blind study. Although there were weaknesses, the strengths outweigh
these weaknesses, and make for a valid study. This study is being included because it
shows that a reminder system can decrease the chance of CAUTI and dwell time of
urinary catheters (Chen, Chi, Chen, Chan, Chou, & Wang 2013). Refer to the literature
table for a review of the article.
Loeb, Hunt, OHalloran, Carusone, Dafoe, & Walter (2008) conducted a study
that consisted of 692 patients that met the requirement of being inpatients at the hospital
for at least 48 hours and not having a urinary catheter placed 10 days prior to admission.
The study was randomized and split into two different groups. One group was given pre-

DECREASING CAUTI WITH REMINDER SYSTEM

written stop orders and the other was the control group with standard care. The stop order
group was given orders for removing urinary catheters when criteria were met. The mean
dwell time of the stop order group was 3.7 days while the standard care group had a mean
dwell time of 5.4 days (p<0.001). The stop order group, at removal of the urinary
catheters had 19% CAUTIs, while the standard care group had 20% CAUTIs (p= .071).
Although this is not a large difference, there was also not a large difference in dwell time
between the two groups, so more testing would be needed. This study does however show
that stop orders are effective in reducing the inappropriate use of urinary catheters.
Strengths of this study include: randomization, removal guidelines, and a large test group.
Weaknesses of the study include that the study does not show a large improvement with
implementing the change. Although the numbers in this study do not show a large
difference, it is being included because with the implementation of pre-written stop
orders and other interventions, as well as more trials, this method might be reliable
(Loeb, Hunt, OHalloran, Carusone, Dafoe, & Walter 2008). Refer to the literature review
table for a summary of the source.
Synthesis
The three sources used were all peer reviewed and were also randomized
controlled trials that were made up of a control group and an experimental group. All
three resources had a fairly large number of participants. Bruminhent, Keegan, Lakhani,
Roberts, & Passalacqua (2010) used 400 participants, Chen, Chi, Chen, Chan, Chou, &
Wang (2013) used 278 participants, and Loeb, Hunt, OHalloran, Carusone, Dafoe, &
Walter (2008) used 692 participants. Another thing these trials shared, was that the
patients must have been patients for at least 48 hours in the inpatient unit. Both

DECREASING CAUTI WITH REMINDER SYSTEM

Bruminhent et al. (2010) and Chen et al. (2013) had a decrease in CAUTI incidences
(p<.001), while Loeb et al. (2008) did not show a large difference, but did show promise.
With three studies showing pretty positive results, it would support completing this
project as well. The major differences between the trials are the different types of
reminder systems that they used, whether it was using a sticker, putting in stop orders
ahead of time, or having the nurse evaluate patients need of the catheter and reminding
the doctor that it needed to be removed. All three however, required the health care
providers to pay more attention to the patients situation.
Proposed Practice Change
By looking at the synthesis as well as the sources, using the intervention of having
a reminder system by using stickers on patients charts and having stop orders will
hopefully decrease the incidence of CAUTI in patients in the inpatient setting. The
doctors and nurses in the test unit will need to be reeducated on the evaluating the
indications and need for the use of a urinary catheter. Evaluating the patients need for the
catheter will be necessary and determine if removal is an option for a patient, but the
guidelines from the CDC, still must be followed. The sticker reminder system, stop
orders from doctors, and evaluating the need for a urinary catheter will all help to
decrease the rate of catheter associated urinary tract infections that occur in the hospitals.
These interventions are very cost friendly, and do not take a lot of time to implement, so
it should not be hard to change protocol.
Change Strategy
Several strategies will be used in the implementation of this evidence-based
project to promote staff engagement, which will lead to higher success rates. Strategies

DECREASING CAUTI WITH REMINDER SYSTEM

such as web learning programs (ex. Mindlab programs at TGH), educational pamphlets,
and team meetings will help the staff to feel like part of the project and realize how
important preventing CAUTIs are. Without the staff, the project would be unsuccessful,
and total support of the project will help to insure the best results. The EBP model that is
used to incorporate this into the hospital setting is the Iowa model (Melnyk, FineoutOverholt, 2011), which is the model that is used at Tampa General Hospital. This model
was chosen because it promotes decision-making that will directly affect patient care and
is easy to use.
Roll Out Plan
-

Step 1
(Month 1)
January 2015

Step 2
(Months 2-5)
Febuary-May 2015

Problem focused triggers

1. Risk management data
2. Process improvement data
3. Financial data
4. Identification of clinical
problem
- Knowledge focused triggers
1. New research or other literature
researched
2. National guidelines or standards
3. Philosophies of care
4. Questions from ISC
(Create PICOT question, search evidence,
critical appraisal of evidence)
-Pilot the change in practice
1. Select outcomes to achieve
2. Collect baseline data
3. Design EBP guidelines
4. Implement EBP on units
5. Evaluate project and outcomes
6. Modify the practice guideline
(Integrate the evidence into practice)

DECREASING CAUTI WITH REMINDER SYSTEM

Monitor and analyze structure,

process, and outcome data.
Step 3
1. Environment
2. Staff
(Month 6)
3. Cost
4. Patient and family
June 2015
(Evaluate outcomes of changing practice,
disseminate the outcomes)
More specifically for the roll out plan for this project, the risks and benefits will
need to be measured, and since this project is working to lower the risks of CAUTIs that
occur at the hospital the benefits will outweigh the risks since it will not be increasing
CAUTIs in the hospital. Financially, this project will be quite affordable and save the
hospital a significant amount of money in the end. CAUTIs are a real problem in the
hospital, so this project is worth doing. There are other evidence-based projects that have
been completed with this issue, but more evidence is still needed, and the previous
studies show it to be promising. The proposed project and changes are state in the
sections above and these sections would help to describe what would happen in step two,
or where data collection will occur. Once collecting the data is completed, it then it can
be evaluated and disseminated into the community and the hospital setting as well as
published in journals so that other health care professionals can use the research to their
advantage.
Project Evaluation
Data that will be collected during this project will include the dwell time of the
urinary catheter as well as if a catheter associated UTI occurs or not in patients that are in
the inpatient unit for at least 48 hours that did not have a UTI or urinary catheter placed
two weeks prior to admission to the hospital. An important number to look at will be if
the shorter dwell times affect the amount of catheter associated UTIs occurring. The

DECREASING CAUTI WITH REMINDER SYSTEM

10

intervention will be considered successful if the participants that receive the intervention
have a decreased amount of catheter associated urinary tract infections and shorter dwell
times compared to the control group who did not receive the intervention. The
intervention will be considered a failure if there is no decrease in number of incidences of
CAUTI and the dwell times remain the same as the control group, even with the
intervention of the stop orders in place. The floor nurses will be in charge of collecting
the data for the evidence-based project. They will be evaluating the patients need for
urinary catherization based off standard guidelines as well as determining if a catheter
associated UTI has developed or not.
Dissemination of EBP
To disseminate the findings of this project in the hospital as well as locally in the
community, posters, educational handouts, and online educational programs will be made
and distributed through the community. These educational materials will show the
findings from the evidence based project and show that the new interventions help
promote a higher patient care quality. Another way to help spread the information to the
hospital staff would be to hold meetings with the providers and nurses
that will be doing the evaluating of the paitents need for the urinary catheter and whether
or not they have developed a CAUTI. These meetings will allow the projects success to
be seen and healthcare providers will see the benefits of the new protocol. If staff
members are not educated on the findings, then the benefits will not be known and
projects such as this will not be utilized by the hospital, as they should be. Since the
findings of this project were positive and conducive of using some sort of stop order, the
project should be published in a public journal or article, so that other health care

DECREASING CAUTI WITH REMINDER SYSTEM

11

facilities can improve their health care policies. This will also allow for further
experiments to occur, and even better interventions can be established, promoting an even
higher level of patient care standards. Overall, support in the community will allow for a
more successful project and the new protocols will be understood with disseminating this
project.

DECREASING CAUTI WITH REMINDER SYSTEM

12

References
Bruminhent, J., Keegan, M., Lakhani, A., Roberts, I., & Passalacqua, J (2010).
Effectiveness of simple intervention for prevention of catheter-associated urinary
tract infections in a community teaching hospital. American Journal of Infection
Control, 38(9), 689-693.doi: 10.1016/j.ajic.2010.05.028
Chen, Y., Chi, M., Chen, Y., Chan, Y., Chou, S., & Wang, F (2013). Using a criteria based
reminder to reduce use of indwelling urinary catheters and decrease urinary tract
infections. American Journal of Critical Care, 22(3), 105-114. doi:
http://dx.doi.org/10.4037/ajcc2013464
Loeb, M., Hunt, D., OHalloran, K., Carusone, S., Dafoe, N., & Walter, S (2008). Stop orders
to reduce inappropriate urinary catherization in hospitalized patients: A randomized
controlled trial. Journal of General Internal Medicine. 816-820. Doi: 10.1007/s11606008-0620-2
Melnyk, B., & Overholt, E. (2011). Evidence-based practice in nursing & healthcare:
A guide to best practice (2nd ed.). Philadelphia: Wolters Kluwer/Lippincott Williams
& Wilkins.

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DECREASING CAUTI WITH REMINDER SYSTEM

Table 1
Literature Review
Reference

Aims

Bruminhent, J., Keegan,

M., Lakhani, A.,
Roberts, I., &
Passalacqua, J
(2010).
Effectiveness of
simple
intervention for
prevention of
catheterassociated urinary
tract infections in
a community
teaching hospital.
American Journal
of Infection
Control, 38(9),
689-693.doi:
10.1016/j.ajic.201
0.05.028

To
determine if
a sticker
based
reminder
system
would
decrease
dwell time
and
incidence of
CAUTI.

Chen, Y., Chi, M., Chen,

Y., Chan, Y.,
Chou, S., &
Wang, F (2013).
Using a criteria
based reminder to
reduce use of
indwelling urinary
catheters and
decrease urinary
tract infections.
American Journal
of Critical Care,
22(3), 105-114.
doi:
http://dx.doi.org/1
0.4037/ajcc20134
64

To
determine if
after 7 days,
evaluating
for removal
of the
urinary
catheter will
decrease
CAUTI
incidences.

Design and
Measures
Randomized
control trial.
Measures
based off of
and compared
to HICPAC
standards for
care.

Sample

Outcomes /
statistics
400 patients Significant
were given a difference
sticker on
between the
their file for
control group
a reminder of and the trial
the
group
placement of (p<.001).
a urinary
The amount
catheter.
of CAUTIs
decreased
with the
intervention.

Randomized
control trial.
The measures
are based off
the CDCs
guidelines for
care.

278 patients
were
evaluated by
nurses after 7
days to see if
a urinary
catheter was
still
appropriate.

Significant
difference
between
control and
trial groups
(p<.001).
The amount
of
inappropriate
urinary
catheters
were
decreased as
well as the
incidence of
CAUTIs.

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DECREASING CAUTI WITH REMINDER SYSTEM

Loeb, M., Hunt, D.,

To
OHalloran, K., Carusone, S.,
determine if
Dafoe, N., & Walter, S (2008).
pre-written
Stop orders
stop orders
to reduce inappropriate
decrease
urinary catherization in
dwell time
hospitalized patients: A
and risk of
randomized controlled trial.
CAUTI.
Journal of General Internal
Medicine. 816-820. Doi:
10.1007/s11606008-0620-2

Randomized
control trial
based on
HIDAC
guidelines for
care.

692 patients
were
utilized. Half
were given
pre-written
stop orders,
and the other
half was not.

There was
not a
significance
in the
CAUTI
incidences,
but there was
a significant
difference in
dwell times
decreasing
(p<.001),