Research/Quality Improvement Project

A Nurse-Driven Protocol for

Removal of Indwelling Urinary
Catheters across a Multi-Hospital
Academic Healthcare System
Sitha Dy, Bridget Major-Joynes, David Pegues, and Christine Bradway

C
atheter-associated uri-
nary tract infections © 2016 Society of Urologic Nurses and Associates
(CAUTIs) are one of the Dy, S., Major-Joynes, B., Pegues, D., & Bradway, C. (2016). A nurse-driven protocol
most common hospi- for removal of indwelling urinary catheters across a multi-hospital academic
tal-acquired infections in the healthcare system. Urologic Nursing, 36(5), 243-249. doi:10.7257/1053-
United States (U.S.) (Centers for 816X.2016.36.5.243
Disease Control and Prevention Catheter-associated urinary tract infections (CAUTIs) are one of the most com-
mon hospital-acquired infections in the United States. Because of persistently
high CAUTI rates despite evidence-based interventions, we designed and imple-
[CDC], 2015), and strategies

mented a performance improvement nurse-driven removal protocol for indwelling

aimed at CAUTI prevention are a

urinary catheters. Post-implementation, both catheter utilization and CAUTIs

global priority (World Health

decreased significantly at the one hospital with the highest baseline rates; at the
Organization [WHO], n.d.). In fis-
two hospitals with low baseline rates, the impact of the protocol varied. This proj-
cal year (FY) 2013, one acute care
ect highlights important steps in developing and implementing a nurse-driven
hospital within our healthcare
removal protocol across a multi-hospital academic healthcare system.
system had one of the highest
CAUTI rates in the state of
Pennsylvania. A prior clinical Key Words: Performance improvement, nurse-driven removal protocol
decision support (CDS) interven- (NDRP), catheter-associated urinary tract infection (CAUTI),
tion utilizing evidence-based indwelling urinary catheter (IUC).
electronic alerts to remind
providers regarding timely
However, in spite of this pital #2), and 496 (hospital #3).
removal of indwelling urinary
intervention, CAUTI rates in- Steps in this process, including a
catheters (IUCs) (Ballie et al.,
creased to 3.5 in FY2013. In literature review, development
2014) was associated with a
response, a decision was made and refinement of specific IUC
decline in this hospital’s CAUTI
by executive leadership across orders, a system-wide education
rate from 3.6 infections per 1,000
our healthcare system to imple- and implementation plan, and
device days in FY2010 to 2.5 in
ment a performance improve- impact evaluation, are described
FY2012.
ment nurse-driven removal pro- in this article.
tocol (NDRP) for IUCs. All three
Sitha Dy, MSN, RN-BC, CNS, CCNS, is a
Clinical Nurse Specialist, Hospital of the
urban acute care hospitals with
Literature Review
University of Pennsylvania, Philadelphia, PA.
our academic healthcare system

Bridget Major-Joynes, MSN, RN, CNS, is a

(all in Pennsylvania) were target- Basic practices aimed at

Clinical Nurse Specialist, Hospital of the

ed for the performance improve- CAUTI prevention are recom-
University of Pennsylvania, Philadelphia, PA.
ment project; in 2015, these hos- mended for all acute-care hospi-

David Pegues, MD, is a Professor of

Medicine, Hospital of the University of
Pennsylvania, Philadelphia, PA.
Christine Bradway, PhD, RN, FAAN, is an
Associate Professor of Gerontological
Nursing/University of Pennsylvania School of
Nursing and Hospital of the University of
Pennsylvania, Philadelphia, PA.
pitals had an average daily cen- tals and include infrastructure
sus of 789 (hospital #1), 354 (hos- (e.g., providing guidelines and
Acknowledgements: The authors gratefully acknowledge our colleagues: Diane Newman,
DNP, ANP-BC, FAAN, BCB-PMD; Penn Medicine’s Center for Evidence-Based Practice;
Joanne Resnic, MBA, BSN, RN, Associate Clinical Informatics Officer; and all of the nurses
and interprofessional staff within our healthcare system who work every day to provide excel-
lence in patient care.

UROLOGIC NURSING / September-October 2016 / Volume 36 Number 5 243

systems for documentation; ap-
propriate personnel, supplies, and
training); surveillance, including
standardized criteria and a process
for providing feedback; ongoing
education and assessment of pro-
vider competencies; and appropri-
ate insertion and management of
IUCs (Yokoe et al., 2014). Special
approaches to prevent CAUTIs
(Yokoe et al., 2014), such as proto-
col development for management
of post-operative urinary reten-
tion, systematic reporting and
analysis of IUC use and adverse
effects, and implementation of an
organization-wide program to
identify and remove IUCs when
no longer necessary, are also rec-
ommended. Nurse-directed inter-
ventions have been highlighted as
an important component of com-
prehensive CAUTI prevention ef-
forts (Bernard, Hunter, & Moore,
2012; Fink et al., 2012; Oman et
al., 2012; Saint et al., 2009, 2013;
Underwood, 2015; Yokoe et al.,
2014).
Three studies describe IUC
management and CAUTI preven-
tion strategies focused on either
North American data (Fink et al.,
2012) or a statewide (Saint et al.,
2009) followed by national com-
parative (Saint et al., 2013)
approach. Fink and colleagues
(2012) employed an electronic
survey method to collect and
examine IUC practices for CAUTI
prevention in 75 acute care hos-
pitals in the U.S. and Canada
where the Nurses Improving Care
of Healthsystem Elderly (http://
www.nicheprogram.org/) geri-
atric nursing program was imple-
mented as a standard of care.
Although this study provides
detailed information on nursing
care practices focused on IUC
care and CAUTI prevention, and
many facilities reported having
some type of IUC or CAUTI-pre-
vention strategy(ies) in place,
considerable variation was iden-
tified in all areas (e.g., equipment,
training, management, documen-
tation). For example, although
recommended as a standard of
care, 44% of the facilities sur-
veyed had no strategy in place to
address early IUC removal. Re-
commendations include em-
244
phasis on the nursing role in
leading efforts to implement and
standardize evidence-based tech-
niques and policies, including
annual training and staff educa-
tion specific to IUC insertion and
maintenance techniques.
In 2007, the state of Michigan
launched the “Keystone Bladder
Bundle Initiative” as a compre-
hensive strategy for reducing
CAUTIs (Saint et al., 2009). This
was followed by a mail survey to
compare Michigan data (n = 78
Michigan hospitals) with data
from a sample of hospitals across
the U.S. (N = 392 non-Michigan
hospitals) of CAUTI-prevention
practices and CAUTI-specific
infection rates (Saint et al., 2013).
Key practices and measures in
the Bladder Bundle include a
NDRP and additional practice
recommendations primarily ini-
tiated and performed by nurses
(e.g., portable bladder ultrasound
monitoring; IUC reminders and
removal prompts; IUC care and
consideration of alternatives to
IUC placement) (Saint et al.,
2009). When compared with
other U.S. hospitals, Michigan
hospitals reported more frequent
use of CAUTI prevention prac-
tices, including reminders or
nurse-directed IUC stop-orders
(p < 0.001) (Saint et al., 2013). In
addition, during a one-year peri-
od, Michigan hospitals reported
a 25% decrease in CAUTI rates,
while non-Michigan hospitals
reported only a 6% reduction
during that same time period
(Saint et al., 2013).
Oman and colleagues (2012)
described hospital-wide yet indi-
vidualized (unit-based) nurse-
directed interventions that incor-
porated other members of the
interprofessional healthcare team,
competency-based nursing staff
education, appropriate selection
and use of products (e.g., IUCs,
bedside commodes, catheter tub-
ing securement devices), regular
catheter care nursing rounds, and
patient and family involvement
in the development of English
and Spanish language education-
al materials. As an integral part
of the process, almost all (96%)
nursing staff completed training
UROLOGIC NURSING / September-October 2016 / Volume 36 Number 5
modules and in-service training
on the use of a portable bladder
ultrasound device (95% of staff
on selected units). Although
overall impact on CAUTI rates
varied among units, the number
of catheter days decreased on
two units (surgery and medicine;
p = 0.018 and p = 0.076, respec-
tively), and discontinuation of
silver alloy IUCs as a choice of
device for use (which, prior to
the study, were being used as the
primary IUC device) resulted in
a $52,000/year savings. The
authors highlight the importance
of considering a unit-based
(rather than hospital-wide) pro-
gram, particularly if hospital-
wide approaches achieve only
partial rather than all desired
outcomes (Oman et al., 2012).
In a more recent publication,
Underwood (2015) detailed a
unit-specific (Neurosurgical and
Neurological Intensive Care Unit)
quality improvement (QI)/safety
program to address CAUTIs and
IUC utilization. A multi-faceted
approach, titled the Compre-
hensive Unit-Based Safety Pro-
gram (CUSP), included staff edu-
cation focused on proper tech-
niques for IUC insertion and doc-
umentation, optimal IUC care,
guidelines for considering and
obtaining urinalysis, urine cul-
ture and sensitivity, and IUC
removal, and nursing staff’s com-
mitment to and responsibility for
following established guidelines
and adhering to educational stan-
dards. Retrospective data were
collected to compare the impact
of CUSP interventions. Imple-
mentation of new QI initiatives
resulted in a significant decrease
in total catheter days (p = 0.001),
number of catheter days per
month (p = 0.001), and overall
catheter utilization (p = 0.001).
CAUTI rates did not change sig-
nificantly (pre- vs. CUSP: 21 vs.
17; p = 0.95). Recommendations
stress the importance of nursing
leadership, IUC guidelines and
standards, and ongoing strategies
to educate and empower health-
care providers in delivering
excellent patient care.
These studies suggest that
nurse-directed strategies are an
 Table 1.
Project Timeline for Indwelling Urinary Catheter (IUC) Nurse Directed Removal Protocol (NDRP)

January–
June-July February March April May June
Activity 2013 2014 2014 2014 2014 2014
Center for Evidenced-Based Practice report completion X
Clinical decision support development of project team, X X X
policy, protocols and build elements
Create online education materials – nursing staff X X
Standard protocol and policies across healthcare system X X
IUC order set clean up (N = 191 order sets) X X X
Identification of “NDRP Default On” units X X
Create clinician awareness and information materials X X
Active provider education X X
Finalize build elements and testing X X
Determine evaluation criteria X
Launch April 28
Evaluate with focus on units with “NDRP as Default” X X X
Deploy “NDRP as Default” system-wide June 2

important component for reduc-
ing unnecessary IUC utilization
on a unit, hospital, and national
level. In our healthcare system,
all three acute care hospitals
were involved in efforts to pro-
vide IUC care and prevent
CAUTIs. Policies and procedures
among the three acute care hospi-
tals were similar but not stan-
dardized, and we had limited
data on the effectiveness or uti-
lization of these strategies. Our
objective was to standardize and
then evaluate IUC care and
CAUTI prevention across the
acute care facilities in our health-
care system.
Purpose/Aims
The overall purpose of this
project was to implement a
NDRP for IUC in three acute care
hospitals within our academic
healthcare system. Specifically
we aimed to: 1) reduce IUC uti-
lization rates and 2) reduce
CAUTI rates.
Performance Improvement Methods
First, a multidisciplinary work-
group came together and worked
with our healthcare system’s
Center for Evidence-Based Prac-
tice to perform a systematic evi-
dence review of IUC care and
CAUTI prevention strategies
(unpublished in-house docu-
ment; Penn Medicine’s Center for
Evidence-Based Practice). Next,
our group worked together to
assess our current IUC ordering
and removal process and identify
requirements to build a nurse-dri-
ven IUC removal decision sup-
port tool, and ongoing nurse
monitoring and removal docu-
mentation. A target date for
deployment was determined, fol-
lowed by additional essential
steps to address the healthcare
system’s needs and meet the proj-
ect timeline (see Table 1). Edu-
cation and awareness were keys
to adoption, and much of this was
accomplished by leveraging exist-
ing unit-based and system com-
mittees as well as healthcare sys-
tem-wide education online.
Education provided for nursing
included the development and
deployment of an interactive self-
learning module, unit-based edu-
cational in-services, clinical
nurse specialist (CNS) day and
night rounds, and the appoint-
ment of a unit-based clinical
nurse “Champion” resource.
A pilot was deployed at the
end of April 2014 in several units
for which NDPR Default On was
the pre-selected option for all
IUC removal processes. Within
the pilot units, providers would
be required to unselect the NDRP
if either of the two remaining
options were desired. The re-
maining options included 1)
Time and Condition, and 2)
Provider Will Assess. First, the
provider could select the specific
time or a specific condition that
needed to be met before the IUC
could be removed. Once time or
condition was met, the nurse
could independently remove the
IUC. Then, the provider would
assess IUC need daily and enter a
removal order when deemed
appropriate. At the end of the
pilot period (June 2014), a full-
scale deployment was imple-
mented, and the NDRP became
the default option for IUC
removal in all three of the acute
care hospitals within the health-
care system (see Figure 1).
Data Collection and Analysis
To determine utilization of
the NDRP, we measured NDRP
“adoption rates” (defined as the

UROLOGIC NURSING / September-October 2016 / Volume 36 Number 5 245


Indwelling Urinary Catheter (IUC) Order Set: Nurse-Driven Removal Protocol (NDRP)
proportion of provider orders
where NDRP was selected as the
removal option each month) fol-
lowing implementation of the
NDRP in May 2014. To assess the
clinical impact of the NDRP, we
compared CAUTI rates and IUC
device utilization for the 12-
month baseline period (May
2013-April 2014) to the 12-month
NDRP implementation period
(June 2014-May 2015) for each
hospital and for the healthcare
system combined. CAUTI rates
were calculated using device day
and patient day denominators
(Wright, Kharasch, Beaumont,
Peterson, & Robicsek, 2011). Data
from May 2014 were excluded
from these analyses. The Stat Calc
program in EpiInfo 7 (https://
www. cdc . gov/ epi info/ user-
guide/StatCalc/introduction.
html), a free statistical and epi-
demiology software program from
the CDC, was used to calculate the
rate ratios, 95% confidence inter-
246
Figure 1.
vals, and p values for IUC device
utilization and CAUTI rates. We
adjusted CAUTI rates by exclud-
ing cases of CAUTI pre-2015 that
met CDC CAUTI Surveillance
Criteria 2a (urine culture with
1,000 to 100,000 colony forming
units per mL of a pathogen) or
urine cultures growing greater
than 100,000 Candida or yeast.
These exclusions reflect changes
to the CDC CAUTI surveillance
definition effective January 2015
(CDC, 2015).
Results
Adoption of the NDRP in-
creased rapidly following the go-
live date and was selected for
40% to 60% of all IUC removal
orders depending on the hospital
(even after the go-live date,
providers had options, such as
Time and Condition or Provider
Will Assess, and could choose
these options based on clinical
UROLOGIC NURSING / September-October 2016 / Volume 36 Number 5
judgment and individual patient-
related factors) (see Figure 2). For
the healthcare system, NDRP was
associated with no significant
change in IUC utilization (see
Table 2) and with a 19% reduc-
tion in CAUTI rates per 1,000
IUC days compared to the base-
line period (p = 0.13) (see Table
3). The impact of the NDRP was
greatest at hospital #1, where IUC
utilization was reduced 6% and
CAUTI rate per 1,000 IUC days
was reduced 28% from baseline.
The reduction in the CAUTI rate
at hospital #1 was greater still
using the patient day rather than
device day denominator for com-
parison to baseline (relative
reduction: 32% vs. 28%). Of
note, hospital #1 had the highest
baseline CAUTI rates and highest
overall adoption of the NDRP.
IUC utilization and CAUTI rates
both increased significantly at
hospital #2 following implemen-
tation of the NDRP. At hospital
 Figure 2.
Adoption Rates of the Nurse-Directed Removal Protocol (NDRP),
managers, unit-based CNSs, rep-

June 2014-May 2015

resentatives from the health sys-
tem’s Clinical Information Sys-
tems and Center for Evidence-
1.0
Based Practice departments), we
re-educated nursing staff in three

0.8
acute care hospitals regarding the
assessment, placement, manage-
NDRP Adoption (%)

ment, and early removal of IUCs.

0.6
Education of ordering providers
resulted in the selection of the
NDRP for 40% to 60% of all IUC
0.4 orders, and enhanced the deci-
sion-making skill and autonomy

0.2
of the nurse providing direct
patient care in assessing the daily
need for an IUC. In addition,
0.0
while providers did not choose

-05 -07 -09 -11 -01 -03 -05 -07 -09 -11 -02 -04
the NDPR 100% of the time, we
13 013 013 013 014 014 014 014 014 014 015 015
20 2 2 2 2 2 2 2 2 2 2 2
believe this reflects that in day-to-
day practice, alternatives such as
Month Time and Condition and Provider

Hospital #1 Hospital #2 Hospital #3

#3, where adoption of the NDRP
was lowest, IUC utilization and
CAUTI rates remained essential-
ly unchanged.
Discussion
The goal of this performance
improvement project was to
implement a NDRP for IUC in
three acute care hospitals within
our healthcare system, and in so
doing, reduce IUC utilization and
CAUTI rates. Management and
ongoing care of an IUC is within
the purview of nursing practice
and plays an important role in
reducing the risk of both infec-
tious and non-infectious compli-
cations associated with IUC use
(Saint et al., 2013; Underwood,
2015; Yoke et al., 2014). Similar
to descriptions of others pub-
lished in recent years (Carter,
Reitmeier, & Goodloe, 2014;
Oman et al., 2012; Saint et al.,
2009), our NDRP focused on a
multi-faceted, evidence-based,
interprofessional approach. Thus,
by examining current, best evi-
dence and then building a pro-
cess that included engagement of
an interprofessional team (e.g.,
staff nurses, physicians, nurse
Will Assess are also important
options that take into account
individual patient needs and the
provider’s clinical judgment.
The NDRP was associated
with negligible reduction (0.5%)
in the overall IUC device utiliza-
tion ratio for our three hospital
healthcare system, but with wide
variation at the level of individ-
ual hospitals, ranging from a rel-
ative 6% decrease to 18% in-
crease in IUC device use. These
results are consistent with previ-
ously published studies and per-
formance improvement projects,
where overall results varied
among hospital units (Oman et
al., 2012) and across individual
hospitals nationwide (Fink et al.,
2012). The observed differences

Table 2.
Indwelling Urinary Catheter (IUC) Use by Hospital and Overall Healthcare System (HCS)
Device
IUC Patient Utilization Rate Ratio
Hospital Period Days Days Ratio (95% Confidence Interval) p-Value
#1 Baseline period 40,442 216,668 0.187 0.94 (0.93-0.95) < 0.001
Performance period 37,440 213,663 0.175
#2 Baseline period 11,646 61,959 0.187 1.18 (1.15-1.20) < 0.001
Performance period 14,984 67,732 0.221
#3 Baseline period 13,144 85,525 0.154 0.98 (0.96-1.01) 0.16
Performance period 12,709 84,019 0.151
HCS Baseline period 65,232 364,152 0.179 0.995 (0.98-1.05) 0.32
Performance period 65,133 365,414 0.178

Note: Baseline Period, May 2013-April 2014; Performance period, June 2014-May 2015

UROLOGIC NURSING / September-October 2016 / Volume 36 Number 5 247

 Table 3.
Catheter-Associated Urinary Tract Infection (CAUTI) Rates per 1,000 Indwelling Urinary Catheter (IUC)
Device Days and 1,000 Patient Days by Hospital and Overall Healthcare System (HCS)

CAUTI
CAUTI Rate/1,000 Rate Ratio (95%
Hospital Period Count IUC Days Device Days Confidence Interval) p-Value
#1 Baseline period 91 40,442 2.25 0.72 (0.52-1.00) 0.05
Performance period 61 37,440 1.63
#2 Baseline period 2 11,646 0.17 4.27 (0.95-19.28) 0.04
Performance period 11 14,984 0.73
#3 Baseline period 15 13,144 1.14 1.03 (0.51-2.11) 0.92
Performance period 15 12,709 1.18
HCS total Baseline period 108 65,232 1.65 0.81 (0.61-1.07) 0.13
Performance period 87 65,133 1.33
CAUTI
CAUTI Patient Rate/1,000 Rate Ratio
Hospital Period Count Days Patient Days (95% confidence Interval) p-Value
#1 Baseline period 91 216,668 0.42 0.68 (0.49-0.94) 0.02
Performance period 61 213,663 0.28
#2 Baseline period 2 61,959 0.032 5.03 (1.12-22.70) 0.02
Performance period 11 67,732 0.16
#3 Baseline period 15 85,525 0.18 1.02 (0.50-2.08) 0.96
Performance period 15 84,019 0.18
HCS total Baseline period 108 364,152 0.30 0.80 (0.61-1.06) 0.13
Performance period 87 365,414 0.24

Note: Baseline Period, May 2013-April 2014; Performance period, June 2014-May 2015

were seen despite moderate and
sustained selection of the NDRP
by ordering providers at each of
the hospitals. An order for NDRP
will not result in earlier removal
of an IUC if the patient continues
to have an appropriate indication
for catheter use or the criteria for
removal are not accurately
assessed and acted upon. It is
likely that factors other than the
implementation of the NDRP
contributed to some differences
in device utilization, including
changes in case-mix index,
staffing ratios, length of stay, and
admission volumes over time. In
addition, when we examined
specific units, we found that
twice daily electronic documen-
tation of IUC indication use was
substantially higher in the inten-
sive care units compared to
acute-care unit locations, sug-
gesting that staffing ratios may be
an additional factor impacting
NDRP implementation (Olson-
Sitki, Kirkbride, & Forbes, 2015).
The NDRP was associated
with a non-significant 19%
reduction in overall CAUTI rates,
with 21 fewer CAUTIs observed
compared to the baseline period.
This overall reduction was due
exclusively to the 28% reduction
in CAUTI rates per 1,000 IUC
days at hospital #1, where there
were 30 fewer CAUTIs compared
to baseline (61 vs. 91). Given the
very low burden of CAUTIs at
hospital #2, with only two
CAUTIs reported during the
baseline period, the four-fold
increase in CAUTI rates observed
during the NDRP implementa-
tion period may reflect regres-
sion to the mean or be due to
other factors, including increased
device utilization. Use of device
days as a denominator may
underestimate reductions in
CAUTI risk associated with earli-
er catheter removal if the inter-
vention results in only sicker
patients at greater risk of CAUTI
still having catheters (Wright et
al., 2011). Therefore, we used a
patient days denominator in
addition to the IUC device days
denominator to risk adjust
CAUTI rates; we observed a
slightly greater 21% reduction
CAUTI rates across the health
system and 32% reduction at
hospital #1.
To facilitate comparison over
time, we adjusted our CAUTI data
for changes in the National
Healthcare Safety Network CAUTI
surveillance definitions that took
effect in January 2015 (CDC,
2015). These changes included
exclusion of low colony count
urine cultures and Candida
species from CAUTI criteria, and
were implemented to account for
differences in microbiology labo-
ratory practices across the U.S.

248 UROLOGIC NURSING / September-October 2016 / Volume 36 Number 5

 Our study provides an important contribution to the literature on
CAUTIs and specific nursing interventions to optimize care and
address prevention strategies.
and evidence of limited clinical
significance of Candiduria, re-
spectively. Without this adjust-
ment, there were approximately
45% more CAUTI cases during
the baseline period, and it is pos-
sible that the impact of the NDRP
may have been greater than that
reported herein.
Limitations
This performance improve-
ment project highlights impor-
tant steps in developing and
implementing a NDRP for IUCs
across a multi-hospital health-
care system. Our study has sever-
al important limitations. We
focused our educational efforts
on the pre-implementation phase
and did not formally assess
provider barriers to the use of the
NDRP or other active IUC re-
moval options once the order set
was implemented. This approach
may have contributed to subopti-
mal selection of and adherence to
the NDRP over time. We were
also not able to assess other
human and systems factors that
potentially impact the decision
to leave an IUC in place or to
assess differences in patient char-
acteristics or other care practices
that may have influenced the risk
of CAUTI. Despite inclusion of
three acute care hospitals across
a large healthcare system, results
may not be generalizable to other
settings or healthcare systems.
Nevertheless, our study provides
an important contribution to the
literature on CAUTIs and specif-
ic nursing interventions to opti-
mize care and address preven-
tion strategies.
UROLOGIC NURSING / September-October 2016 / Volume 36 Number 5
Summary and Conclusions
Keys to the success of this
project included 1) a solid multi-
disciplinary team, including
nursing, physician providers,
information systems staff, system
education teams, infection pre-
ventionists, evidence analysts,
and data scientists; 2) strong sup-
port of executive leadership; and
3) engagement of physicians,
nursing staff, and others in-
volved in patient care on individ-
ual care units. Next steps include
expanding this initiative to
include additional acute care
hospitals that have more recently
joined our healthcare system and
exploring barriers to early adop-
tion of the NDRP.
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