doi: 10.1111/ijun.

12113 RESEARCH PAPER

A nurse-driven process for timely

removal of urinary catheters
Juriyah Yatim, Kok-Seng Wong, Moi-Lin Ling, Siok-Bee Tan, Kwee-Yuen Tan and Marilyn
Hockenberry

ABSTRACT
Catheter-associated urinary tract infection (CAUTI) comprises 30–40% of all health care-acquired infections,
and 70–80% of these infections are related with use of indwelling urinary catheters. This quality improvement
(QI) project was initiated to evaluate the effectiveness of a nurse-driven urinary catheter removal process in
reducing the duration of urinary catheter usage in a general medical ward in Singapore. A pre- and post-study
design was adopted. The pre-implementation data included urinary catheter utilization ratio and CAUTI rates.
Over a 6-months period, nurses used a nurse-driven urinary catheter removal process to improve rates of
timely removal of catheter. Data collected included nurses’ compliance with the process and clinical outcomes,
such as urinary catheter utilization ratio and CAUTI rates before and after implementation. Compliance with
the use of the nurse-driven process by staff was 89%. The urinary catheter utilization ratio revealed a raise
from 0·12 before implementation to 0·18 after implementation. However, CAUTI rates decreased from 4 to 0 per
1000 catheter-days, indicating a marginally significant difference between the pre and post-implementation rates
(p = 0.06), using Fisher’s exact test. The nurse-driven process decision support tool for optimizing appropriate
catheter usage had the potential of reducing a patient’s risk of acquiring CAUTI.
Key words: Catheter-associated urinary tract infection • Indwelling catheter • Intervention studies •
Nurse protocol • Urinary catheterization

BACKGROUND include fever, urgency, frequency, dysuria, suprapu-

Prolonged catheterization is the primary risk factor
for catheter-associated urinary tract infection (CAUTI),
the most frequent type of health care-acquired infec-
tion (HAI) in acute care settings. CAUTI comprises
30–40% of all HAIs, and 70–80% of these infections
are related with the use of indwelling urinary catheters
(Bagshaw and Laupland 2006). CAUTI symptoms may
Authors: J Yatim, DNP, APN–Assistant Director, Nursing (Advanced
Practice Nurse). Singapore General Hospital, Singapore, Singapore; W
Kok-Seng, MBBS, M Med (Int. Med.), FAMS, FRCP (London), FRACP
(Hon)–Clinical Head. Internal Medicine, Singapore General Hospital,
Singapore, Singapore; L Moi-Lin, MBBS, FRCPA, CPHQ, MBA–Director.
Infection Control, Singapore General Hospital, Singapore, Singapore; T
Siok-Bee, PhD, APN–Deputy Director. Nursing (Advanced Practice Nurse).
Singapore General Hospital, Singapore, Singapore; T Kwee-Yuen, BHSN,
RN–Senior Nurse Clinician. Infection Control, Singapore General Hospital,
Singapore, Singapore; M Hockenberry, PhD, RN, PNP-BC, FAAN–Bessie
Baker Professor of Nursing. Duke University School of Nursing, Durham,
NC, USA
Address for correspondence: J Yatim, Speciality Nursing, Nursing
Division, Singapore General Hospital, Outram Road, Singapore 169608,
Singapore
E-mail: juriyah.yatim@sgh.com.sg
bic tenderness and a positive urine culture with no
more than two species of organisms. Approximately
449, 000 CAUTIs occur in US hospitals each year at a
cost of up to US$450 million (Scott 2009). Although uri-
nary tract infections associated with alternative urinary
drainage systems are considered device-associated,
CAUTI rates reported to the National Healthcare Safety
Network (NHSN) refer exclusively to infections associ-
ated with indwelling urinary catheters (Centers for Dis-
ease Control and Prevention 2009).
Duration of urinary catheterization is the predomi-
nant risk factor for CAUTI. Hence, preventive mea-
sures directed at limiting placement, along with early
removal of urinary catheters, have the greatest impact
on decreasing CAUTI rates (Chenoweth et al. 2014).
The body of evidence indicates that a variety of inde-
pendent variables encourage early removal of urinary
catheters and significantly reduce both CAUTI rates
and catheter-days with minimal risk (Magers 2013).
For example, in their meta-analysis, Meddings et al.
(2010) concluded that urinary catheter reminders and
stop-orders reduced CAUTI rates by 52% (p < 0.001)

© 2016 John Wiley & Sons Ltd. and BAUN Int J of Urol Nurs 2016; Vol 10 No 3: 167–172 167
 Timely removal of urinary catheters
and resulted in 2·61 fewer days of catheterization per
patient in the intervention versus control groups.
The introduction of evidence-based, nurse-driven
daily checklists for initiation and continuance of urinary
catheters were shown to decrease CAUTI rate across
five ICUs from 2·8 to 1·5/1 000 d, and reduction in num-
ber of urinary catheter days from 402 to 380 (p = 0·047)
(Fuchs et al. 2011). Catheter usage (per patient popu-
lation) was decreased by greater than 17% after the
introduction of a nurse-led urinary catheter removal
protocol known as ‘HOUDINI,’ an acronym used to list
the indications for continued use of a urinary catheter,
namely: H – haematuria, O – obstruction, U – urology
surgery, D – decubitis ulcer (grade 3 or 4) or per-
ineal wound in incontinent patient, I – input and out-
put measurement for patient management or hemo-
dynamic instability, N – nursing end-of-life care and
I – immobility due to physical constraint (Adams et al.
2012). In a more recent study, whereby nurse-driven
catheter removal protocol was part of a multifaceted
strategy to improve outcomes, Purvis et al. (2014)
demonstrated a reduction in CAUTI rate from 4·7 to 2·3,
as well as decreased catheter utilization.
Based on the collective evidence, the literature sup-
ports a nurse-led process to evaluate the continu-
ing need for a catheter and to encourage its prompt
removal where warranted, led by the clinical issue
question, ‘Will nursing assessment for early removal of
indwelling catheters decrease the number of catheter
device days and the incidence of CAUTI?’ However,
the use of nurse-led protocols is still relatively new
in our local setting. Henceforth, this current project
was conducted to evaluate the implementation of
a nurse-driven urinary catheter removal process in
reducing the duration of urinary catheter usage in a
general medical ward in Singapore.
PROJECT AIM
The aim of this quality improvement (QI) project was
to evaluate the effectiveness of a nurse-driven uri-
nary catheter removal process in reducing the duration
of urinary catheter usage and CAUTI rate (per 1000
catheter days) in a general medical ward.
METHODS
Setting
Singapore General Hospital is the largest, acute
tertiary care hospital in Singapore, with a capacity
of 1700 beds. The identified general medical ward
where the intervention was piloted has a capacity of
75 beds and admits individuals with various medical
conditions.
168
Study design and sample
A pre-post study QI project design was used
to compare catheter days and CAUTI rates pre
(9 months) and post (6 months) implementation of the
nurse-driven process.
All patients with indwelling urinary catheters or those
that have a catheter placed during hospitalization were
eligible for review and were included in the project.
Patients who had a condom catheter, arrived from
home or an extended care facility with a chronic uri-
nary catheter, had a nephrostomy tube, suprapubic
catheter or who were practising intermittent catheter-
ization was excluded from evaluation. Center for Dis-
ease Control (CDC)’s definition for CAUTI was used to
identify patients who develop CAUTI.
Implementing the nurse-driven process
We adapted Adams et al.’s (2012) ‘HOUDINI’ urinary
catheter removal process for use in this project. Reg-
istered nurses (RN) were empowered to make inde-
pendent assessments of the continued need for an
indwelling catheter based on the ‘HOUDINI’ process.
The ward RN evaluated the patient upon insertion of
the urinary catheter and on a daily basis (see Figure 1).
If a patient with a urinary catheter did not meet one of
the seven criteria indicated by the acronym HOUDINI,
RN had the autonomy to remove the device without a
physician order.
Staffs were encouraged to think ‘HOUDINI’ each
time a patient’s urinary catheter status was assessed.
After the catheter was removed, the RN assessed the
patient for voiding within 6 h. Bedside bladder ultra-
sound scanners were used to assess patients who
could not void after removal of catheter (Figure 1). If uri-
nary retention was documented, an indwelling urinary
catheter was placed.
An education programme for all nursing staff, nurs-
ing assistants and physicians was conducted before
implementation of this nurse-driven process. Atten-
dance rate for the programme was 80%. ‘Let’s Zero
CAUTI!’ was used as tagline to create awareness dur-
ing the implementation period. Over a 3-week period,
training took place at staff meetings, unit practice coun-
cil meetings, as well as in-service one-on-one consul-
tations with unit nurses. Posters illustrating key points
were created and used as visual aids when conducting
staff education in the ward. In this pilot ward, posters
were placed at every nursing station. To ensure con-
sistency in the daily use of the HOUDINI process, the
researcher observed the use of the process by the
ward’s nursing staff; feedback and clarification were
provided on the spot as required.
A ‘Daily Review HOUDINI Protocol’ stamp was also
developed to remind the physicians and nursing staff
© 2016 John Wiley & Sons Ltd. and BAUN
 Timely removal of urinary catheters

Removal of Urinary Catheter

Nurse Driven Urinary Catheter Removal Process

“HOUDINI” NURSING PROCESS

Urinary NO No action necessary.

Catheter in Continue to assess urinary output.
Place? Avoid catheter placement.

YES

Does patient meet

YES
Criteria to leave Continue to assess on a DAILY basis
catheter in?
Follow HOUDINI

Follow this protocol unless patient falls into one of these categories:

H Haematuria, gross

O Obstruction, urinary/ catheterized by Urologist

U Urologic surgery/ urology patient/ abdominal/ gynaecological or perineal surgery

D Decubitus ulcer – open sacral or perineal wound in incontinent patient

I Intake & Output for hourly management or haemodynamic instability

N Nursing end-of-life care/ comfort care

I Immobility due to physical constraints (i.e., unstable fracture, bedbound, uncommunicative)

Patient has
NONE of the
criteria listed
above?

ACTION: Remove catheter and assess for voiding within 6 hours

If patient has not voided within 6 hours…
Bladder scanner available: No bladder scanner available in unit:
1. If bladder scan shows <150 ml, contact physician, provide condition 1. Palpate bladder for distention, assess patient’s comfort level;
report and obtain orders. straight catheterize patient as determined by assessment.
2. If scan >150 m, but <300 ml and patient is not uncomfortable, re-assess
2 hours later.
3. If scan shows >300 ml, straight (in and out) catheterize patient; record
amount and catheter size.
4. Repeat process after 6 hours; straight catheterize patient if necessary
and document.

Figure 1 HOUDINI nursing process.

of the need to evaluate indications for the catheter on
a daily basis (Figure 2).
Fidelity measures were collected throughout the
project to determine whether or not the intervention
was implemented and used as outlined. Nurses were
responsible for completion of the tool and the ward’s
nurse champions assessed fidelity on a daily basis
for the duration of project. Criteria for success, eval-
uated by the fidelity measures, were set at 85%
adherence or above. For all fidelity measures below
80%, the principal investigator undertook re-education
of staff.

© 2016 John Wiley & Sons Ltd. and BAUN 169

 Timely removal of urinary catheters
HOUDINI Process
Indwelling Urinary Catheter Day: ______. Tick the indication.
Indication Yes
H Haematuria
O Obstruction, urinary/ catheterized by Urologist
U Urology Surgery/ abdominal/ gynaecological or
perineal surgery
D Decubitus Ulcer
I Input and output measurement
N Nursing end of life care
I Immobility: Bedbound/ Uncommunicative
ALL NO’S ARE MET, REMOVE URINARY CATHETER
IF NOT REMOVED, reason: _____________________________
RN Name: ____________________Date/ Time:______________
Figure 2 Daily review HOUDINI process stamp.
Data collection methods
Clinical outcomes
Pre-implementation data consisted of urinary catheter
days/total number of patient-days and the CAUTI rate
of all eligible patients in the study ward from Novem-
ber 2013 through July 2014. This retrospective chart
review was completed by the ward’s Infection Con-
trol nurse and decoded. Post-implementation data was
gathered from the period of September 2014 through
February 2015. Catheter days were calculated by mea-
suring the number of patients using a short-term uri-
nary catheter daily over the course of a month or
expressed as a urinary catheter utilization ratio (that
is, a ratio of total catheter-days to total patient-days).
The rate of CAUTI per 1000 urinary catheter days
was calculated by dividing the number of CAUTIs by
the number of catheter days and multiplying the result
by 1000 (Center for Disease Control and Prevention
2009). These outcomes examined (1) total number of
urinary catheter days per unit per month, and (2) rate
of CAUTI per 1000 catheter days.
Fidelity (compliance with HOUDINI)
The rates of compliance by nurses with the
nurse-driven HOUDINI process were measured after
implementation. Compliance is defined as use of the
nurse-driven process by RN for each day an individual
patient has a urinary catheter. Nurses from the ward
used an audit tool (developed by the author) on a daily
basis to check compliance. A dichotomous (yes/no)
response was used to determine whether the RNs
assessed the patients with indwelling urinary catheter
and used HOUDINI. The following components were
audited: (i) Was the daily review HOUDINI process
stamp used? (ii) Is the catheter still in situ as criteria
indicated in HOUDINI process? (iii) Was the catheter
removed following the HOUDINI process? (iv) If the
170
catheter was removed following the HOUDINI process,
is there any re-catheterization required? Descriptive
statistics was used to describe the percentage of audit
No
checklists received.
Data analysis
Descriptive statistics were used to describe the compli-
ance with the HOUDINI tool completion by the RN staff.
Data for urinary catheter (UC) days and CAUTI rates
were summarized and frequency of CAUTI at pre- and
post-implementation was compared using a Fisher’s
exact test. Differences were regarded as statistically
significant at p < 0·05.
Ethical considerations
Implementation of this study was approved and classi-
fied exempt by our health systems’ Institutional Review
Board (IRB) as well as Duke University IRB.
RESULTS
Clinical outcomes
‘Immobility’ (70·2%), ‘strict monitoring of intake and
output (64·6%) and ‘management of urological symp-
toms’ (23·4%) were the most common indications for
urinary catheters.
Data on clinical outcomes were collected before
and after implementation of the HOUDINI process in
this ward. The urinary catheter utilization ratio demon-
strated an increased from 0·12 before implementation
to 0·18 after implementation (see Figure 3).
CAUTI decreased from 4 to 0 per 1000
catheter-days, revealing a marginally significant
difference between the pre and post-implementation
period (p = 0.06) (see Figure 4).
Fidelity outcomes
Compliance with the use of the daily HOUDINI pro-
cess stamp and assessment of indications for urinary
catheterization by staff during the 6 months monitoring
period was 89%.
DISCUSSION
The results demonstrated a slight increase in urinary
catheter utilization ratio (from 0·12 to 0·18). This was
most likely due to different patient profile in the two
periods.
CAUTI incidents declined from 4 to 0 per
1000 catheter-days, between the pre and
post-implementation (p = 0.06). This was consis-
tent with our ‘Let’s Zero CAUTI!’ tagline. The statistical
significance of these findings was only marginal.
© 2016 John Wiley & Sons Ltd. and BAUN

Figure 3 Urinary catheter utilization ratio: pre- and post-implementation, mean, upper and lower control limits are illustrated. Reproduced from Adams et al. (2012)
with permission from Journal of Infection Prevention, vol. 13, no. 20, pp. 44–46.
Figure 4 Catheter-associated urinary tract infection (CAUTI) rates November 2013 through February 2015, with mean of 0.7. Reproduced from Adams et al. (2012)
with permission from Journal of Infection Prevention, vol. 13, no. 20, pp. 44–46.
However, a reduction in one CAUTI is still clinically
significant (Meddings et al. 2010).
Several factors can contribute to the reduction
in CAUTI rates and utilization ratio – daily assess-
ment for need of catheter, use of care bundle,
decision-making algorithm and nurse-driven proto-
col (Reilly et al. 2006; Adams, et al. 2012). Our results
were consistent with well-conducted studies and
systematic reviews indicating that catheter-days and
CAUTI rates are nurse-sensitive indicators that can be
controlled through changes in nursing practice.
While the 89% rate of compliance in using the
HOUDINI process was satisfactory, this study did not
examine variables such as overall unit priorities, unit
© 2016 John Wiley & Sons Ltd. and BAUN
Timely removal of urinary catheters
culture, patient types and staff demographics that may
influence the adoption of interventions such as this
nurse-driven process. Further research is needed to
gain a better understanding of these variables and their
impact on compliance rates.
The process measures used in this intervention may
be even more important than the actual clinical results.
According to the nurses’ anecdotal feedback, com-
pliance with HOUDINI increased nurses’ awareness
of the need for daily patient assessment for timely
removal of catheters when the clinical need for them
no longer exists. Our experience with this project
suggested that acceptance and use of care protocols
or algorithms for nursing care by individual nurses and
171
 Timely removal of urinary catheters
units were best achieved with feedback and close com-
munication.
LIMITATIONS
This project had several limitations. First, the project
described the experience of a single site, large acute
tertiary academic teaching hospital; thus, the gener-
alization of our results may be limited to hospitals of
similar size and type. Given the observational nature
of the project, we were unable to establish causality.
Nevertheless, it is reasonable to consider that beyond
fundamental nursing care, an ideal approach to reduc-
ing catheter-days and CAUTI rates is to employ a
nurse-driven process that discourages unnecessary
catheterization and promotes the removal of urethral
catheters as soon as indicated.
ACKNOWLEDGEMENTS
The authors thank Dr Julie Thompson, PhD; HOUDINI
Champions: Cerrada Marizen Baluyut, RN; Yong Ooi
WHAT IS KNOWN ABOUT THIS TOPIC
• CAUTI comprises 30–40% of all HAIs, and 70–80% of these infections are related with use of indwelling urinary catheters. This QI
project was implemented to evaluate the effectiveness of a nurse-driven urinary catheter removal process in reducing the duration of
urinary catheter usage in a general medical ward.
WHAT THIS PAPER ADDS
• The nurse-driven process decision support tool for optimizing appropriate catheter usage was successful in reducing a patient’s risk of
acquiring CAUTI.
REFERENCES
Adams D, Bucior H, Day G, Rimmer JA. (2012). HOUDINI: make
that urinary catheter disappear – nurse-led protocol. Journal
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Bagshaw S, Laupland K. (2006). Epidemiology of intensive care
unit-acquired urinary tract infections. Current Opinion in Infec-
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Centers for Disease Control and Prevention. (2009). Guideline
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172
Peng, BSN, RN; Nurse Manager: Chang Aye Too, RN,
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CONCLUSIONS
It is always challenging for hospitals to ensure
the delivery and provision of safe, quality patient
care. HOUDINI provided a structure for nurse
decision-making, empowering nursing staff to do
the right thing. Key strategies for implementation suc-
cess include a project-planning committee, multimodal
education, organizational support and active use of
provider feedback to improve the adoption process.
IMPLICATIONS FOR NURSING PRACTICE
We intend to embark on disseminating this
nurse-driven HOUDINI process to other inpatient
units in our hospital. We have made available the
beginning framework of incorporating HOUDINI pro-
cess into local nursing practice. Future studies to
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with the HOUDINI process should be conducted.
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