The South Carolina Hospital Association is making several CAUTI: Catheter-Associated Urinary Tract Infection

educational materials available for our member hospitals. Below are some examples hospitals have shared with us.

Lake City Community Hospital: Unnecessary Foley Object

Lake City Community gave out the attached brochure, one page flyer, and 10 question T/F quiz to all staff on the unit
during their CAUTI educational effort.

8 door prize baskets were awarded via a random drawing among team members who completed and turned in the quiz.
The quiz was graded, and employees also received in-service credit for participating as an added incentive.

Note the fun alien theme!

Qsource

Qsource (a nonprofit, healthcare quality improvement and information technology consultancy) created a photo
opportunity for hospital staff. Each team member was encouraged to develop their own unique messaging and express
themselves in action shots. Because the staff actively participated in the design and implementation, the positive
response was overwhelming.

Having a co-worker give the reminder is more effective than one coming from a stranger!

The photo posters are very easy to make and inexpensive to produce.
If your hospital or organization has CAUTI prevention tools you would like to share, please contact Rosemary Thompson
at rthompson@scha.org.
 Th e CAUTI Ti m es: Alternatives to Foley Catheterization
Let's Review the Alternatives To A Foley is NOT the Answer for
Foley Caths!!!
Incontinence!

Hourly Rounding: Ensure your Patient's bathroom needs Incontinence Care: Use the Proper Products to Reduce
RSFH Models: Roper 7 Buxton
are met by developing a Toileting Schedule! Skin Breakdown!

Intermittent Caths Reduce Thanks for Choosing a

Infection. SIGN ME UP!!! Condom Cath!

Urinary Retention Protocol: Utilize Bladder Scanners at Intermittent Caths: Reduce Catheter Associated Condom Caths: Use a Condom Cath in Men to Reduce
Regular Intervals to determine Urinary Retention. Infections!!! Infections associated with Indwelling Catheters!

Extra, Extra: Get Th at Fol ey OUT!!!

 Foley Necessity???

RSFH Models:
St. Francis ICU

Not an Accessory!!!
Necessity: Accessory:
•Acute Urinary Retention/ •Patient Request
Bladder Outlet Obstruction
•Need for Accurate Urine Output •Convenience
Measurements in Critically ill Patients
•To Assist in Healing of Sacral/Perineal •Patient Confusion
Wounds in Incontinent Patients
•Patient Requires Prolonged •Nurse Preference
Immobilization
•To Improve Comfort for End of Life Care •Incontinence
 On the CUSP:
Stop Catheter Associated Urinary Tract Infections (CAUTI) Project

TRUE/FALSE QUIZ: Please answer each question by writing in “True” or “False”

1. __________ One of the goals of the project is to improve patient safety and outcome.

2. __________ 300,000 patients develop hospital-acquired Urinary Tract Infections (UTIs) per
year.

3. __________ 80% of hospital-acquired UTIs are associated with indwelling urinary catheters.

4. __________ 5% of hospitalized patients are catheterized.

5. __________ The risk of developing a Catheter Associated Urinary Tract Infection (CAUTI)
increases by 2% each day the urinary catheter remains in place.

6. __________ Perineal or sacral wounds in the incontinent patient is an appropriate indication

for a urinary catheter to assist in healing.

7. __________ If a patient has a “chronic” foley on admission, the need for continued use should
still be assessed during the hospitalization and upon subsequent admissions.

8. __________ About half of the patients with a urinary catheter do not have a valid indication for
placement.

9. __________ Adverse urinary catheter outcomes include increases in infections, length of stay,
cost, patient discomfort and antibiotic usage.

10. __________ There are specific actions that can be taken to manage the incontinent patient
without requiring catheterization.

Name: ______________________________

Department: ______________________________

Watch Out for UFOs!

(Unnecessary Foley Objects)
 Urinary Catheters
Outcomes: Promptly
Infections  Project Team Members:
{LIS T HERE} Remove
Patient Length of Stay 

Cost  Foley
Patient Discomfort 
{HOS PITAL LOGO} Catheters
Antibiotic Usage 

Patient Management for

Incontinence:
Turn patient every 2 hours
to cleanse area and change Questions?
A Focus
linens
Call: _____
On
Use quilted pad under
patient
or ______
Patient
Utilize skin barrier creams
Safety
Start toilet training
program: offer bedpan or
commode with assist every 2
(Adapted Nov. 2008 from brochure by Infection Prevention
hours Mohamad G Fakih, MD, MPH) and Control Initiative
 Guidelines for Urinary Indications for
Urinary Catheters:
Catheter Need Urinary Tract Obstruction:
blood clots; enlarged prostate;
burethral problems

Is there a Neurogenic Bladder: retention

Foley NO of urine
Catheter
in place?
Urologic studies or surgery;
perioperative use in selected cases

Stage III or IV sacral decubiti in the

incontinent patient (to assist in healing
Urinary Catheters: YES
Hospice/Comfort/Palliative Care
600,000 patients develop hospital patient
acquired urinary tract infections (UTIs)
every year. Output monitoring only on the most
YES
seriously ill patients (those with the
80% of these infections are from a Does the
acuity of an ICU patient)
urinary catheter. pati ent meet
cri teri a for
Chronic on admission (continued
About half of the patients with a a Foley?
need should be assessed upon each
urinary catheter do not have a valid
admission & during hospitalization)
indication for placement.
Required immobilization for trauma
Each day the urinary catheter
or surgery
remains in place the risk of urinary NO
infection (CAUTI) increases 5% per
day. Urinary Catheters are not
Remove Foley Indicated for:
prostate; urethral strictures
Incontinence Convenience
**With MD’s order** Neurogenic Bladder
Patient Requests

Urine Specimen Collection

Output monitoring (in general)

 LAKE CITY COMMUNITY HOSPITAL
On the CUSP:
“Stop Catheter Associated Urinary Tract Infections” Project
Goals:
 Decrease Catheter Associated Urinary Tract Infections (CAUTI), which
will in turn improve patient outcomes and decrease length of stay.
 Improve Patient Safety and Outcome.
(UNNECESSARY FOLEY OBJECT)

Background:
 600,000 patients develop hospital-acquired UTIs per year.
IS THAT FOLEY A “UFO”?

 80% of these are associated with indwelling urinary catheters.

 10 – 15% of hospitalized patients are catheterized.
 Approximately half of the patients with a urinary catheter do not have a
valid indication for placement.
 Each day the urinary catheter remains, the risk of the CAUTI increases 5%.

Specific Goals:
 Reeducate nurses and physicians re. the indications for the urinary catheter
use.
 Reduce the unnecessary use of urinary catheters (particularly indwelling
urinary catheters in in-patients).
 Reduce the risk of hospital-acquired urinary tract infections.

Prevention of CAUTI:
Follow criteria indicated for a urinary catheter:
1. Urinary Tract Obstruction: blood clots; enlarged prostate; urethral problems
2. Neurogenic Bladder: retention of urine
3. Urologic studies or surgery; perioperative use in selected cases
4. Perineal or sacral wounds in the incontinent patient (to assist in healing)
5. Hospice/Comfort/Palliative Care patient
6. Output monitoring only on the most seriously ill patients (those with acuity of an ICU
patient)
7. Chronic on admission (Continued need should be assessed upon admission & during
hospitalization)
8. Required immobilization for trauma or surgery

Promptly Remove Unnecessary Foley Catheters

Questions? Call ____________

(Adapted Nov. 2008 from poster by Mohamad G Fakih, MD, MPH)

 EFFECTIVE DATE: December 15, 2010

SUPERSEDES: N/A

POLICY TITLE: Indwelling Urinary Catheter

Insertion and Care REVIEW DATE: December 2013

Infection Prevention
POLICY NUMBER: 305-IC-709 REVIEW and Control Committee
RESPONSIBILITY: Quality Council

DEPARTMENT: Global
APPROVED BY: Chief Executive Officer
CATEGORY: Infection Prevention & Control Chief of Staff
Chairman, Infection
Prevention & Control Comm.

SIGNATURE(S):
Chief Executive Officer

Chief of Staff

________________________
Chairman, Infection
Prevention & Control Comm.

PURPOSE

Urinary Tract Infections (UTI) have been shown to occur more frequently than other infections associated with
healthcare, accounting for 36% of all Healthcare Acquired Infections in the United States. Most healthcare associated
UTIs are associated with an indwelling urinary catheter. The risk of acquiring a UTI depends on the method of
catheterization, duration of catheter use, the quality of catheter care, and host susceptibility. Studies have shown a
strong and direct correlation between catheter use greater than six days and Catheter Associated Urinary Tract
Infection (CAUTI) occurrence. In the same study, it was also reported that bacteriuria is nearly universal by day 30 of
catheterization.

SCOPE/ACCOUNTAB ILITY

All healthcare providers, hospital personnel hired or contract who insert and maintain urinary catheters.

POLICY

The necessity for the appropriate insertion and management of urinary catheters has been emphasized by the Institute
of Healthcare Improvement, Association for Professionals in Infection Control and Epidemiology, and the Center for
Disease Control to reduce and prevent the occurrence of catheter associated infections. More than 30 million Foley
catheters are inserted annually in the United States, and these catheterization procedures probably contribute to 1
million CAUTIs.

PROCEDURE

I. Insert catheters only for appropri ate indications and leave in place only as long as needed.
POLICY TITLE: Indwelling Urinary Catheter Insertion and Care
POLICY NUMBER: 305-IC-709
PAGE 2 OF 3
 Minimize urinary catheter use and duration of use in all patients, particularly those at higher risk for CAUTI
or mortality from catheterization such as women, the elderly, and patients with impaired immunity.
 Avoid the use of urinary catheters in patients and nursing home residents for the management of
incontinence.
 Use urinary catheters in operative patients only as necessary, rather than routinely.
 For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as
possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued
use documented.
 Avoid using indwelling urinary catheters for patients in chronic renal failure who are on dialysis and don’t
make urine.

II. Proper Techniques for Urinary Catheter Insertion

A. Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or
site.
B. Ensure that only properly trained persons who know the correct technique of aseptic catheter insertion and
maintenance are given this responsibility.
C. Insert urinary catheters using aseptic technique and sterile equipment .
 Use sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning,
and a single-use packet of lubricant jelly for insertion. Refer to “Clinical Nursing Skills sixth edition” (or
current edition as indicated) by Smith, Duell, and Martin located on each floor for the appropriate
insertion procedure found on page 713 -725.
 Once a new urinary catheter has been placed for the first time obtain a urine sample and send it to the lab
for a baseline UA. This will help to establish whether the patient has a Urinary Tract Infection prior to
insertion of the catheter. A physician’s order must be obtained for the UA.
D. Properly secure the indwelling catheter after insertion to prevent movement and urethral traction .
E. Unless otherwise clinically indicated, consider using the smallest bore catheter possible, consistent with good
drainage, to minimize bladder neck and urethral trauma.
F. If intermittent catheterization is used, perform it at regular intervals to prevent bladder over distension.

III. Protocol for obtaining Urine Specimens from patients who are admitted to the hospital with indwelling
urinary catheters already in place.
 If the patient arrived to the hospital with an indwelling catheter already in place from the nursing home
or LTAC and the physician orders a routine UA or UA for Culture and Sensitivity the following steps
should be taken:
1. Discontinue the old indwelling urinary catheter.
2. Follow steps A-F in section II of this policy for proper techniques for urinary catheter insertion and
insert a new indwelling urinary catheter.
3. Obtain a sterile urine specimen and send it to the lab as specified by the physician’s orders.

IV. Proper Techniques for Urinary Catheter Maintenance

A. Following aseptic insertion of the urinary catheter, maintain a closed drainage system.
 If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system
using aseptic technique and sterile equipment.
 Use Urinary catheter systems with pre-connected, sealed catheter tubing junctions.

B. Maintain unobstructed urine flow.

 Keep the catheter and collecting tube free from kinking.
 Keep the Collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.
 Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid
splashing, and prevent contact of the drainage spigot with the non -sterile collecting container.
C. Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of
the catheter or collecting system.
POLICY TITLE: Indwelling Urinary Catheter Insertion and Care
POLICY NUMBER: 305-IC-709
PAGE 3 OF 3
D. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rat her, it is
suggested to change catheters and drainage bags based on clinical indications such as infection obstruction, or
when the closed system is compromised.
E. Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine
hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate.
F. Unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery) bladder
irrigation is not recommended. If obstruction is anticipated, closed continuous irrigation is suggested to
prevent obstruction.
 If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the
catheter.
G. Routine irrigation of the bladder with antimicrobials is not recommended.
H. Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended .
I. Clamping indwelling catheters prior to removal is not necessary.

Specimen Collection

J. Obtain urine samples aseptically.

 If a small volume of fresh urine is needed for examination (i.e., urinalysis or culture), aspirate the urine
from the needleless sampling port with a sterile syringe/cannula adapter after cleansing the port with a
disinfectant.
 Obtain large volumes of urine for special analyses aseptically from the drainage bag .

Daily Assessment of the Need to Continue Urinary Catheters

During rounds, each patient should be assessed for the presence of a urinary catheter. The reason for use is reviewed.
If there is no indication, nurses are instructed to contact physicians to obtain an order to discontinue the catheter.

The following is a List of Reasons for Urinary Catheters to remain in:

 Abdominal/Pelvic or Colorectal Surgery (questionable after 48 hou rs)

 Renal/Urology or Gastric Bypass surgery
 Accurate I & O for patients who are hemodynamically unstable or on strict hourly urine outputs
 Skin breakdown (decubitus ulcers)
 24 hour urine collection
 Chemically paralyzed and sedated
 Epidural Catheter
 Inability to void/urinary retention
 Pelvic fracture/Crush injury
 Head injury

REFERENCES

APIC “Guide to the Elimination of Catheter-Associated Urinary Tract Infections(CAUTIs) 2008

HICPAC “Guideline for the Prevention of Catheter-Associated Urinary Tract Infections” 2009

APIC (ASSOCIAT ION FOR PROFESSIONALS IN INFECT ION CONTROL AND EPIDEMIOLOGY )
HICPAC (HEALT HCARE INFECTION CONTROL PRACTICES ADVISORY COMMITTEE) A COMMITTEE FROM THE CENTERS FOR
DISEASE CONT ROL.

IC POLICY/305-IC-709 INDWELLING URINARY CATHETER INSERTION AND CARE (121510) MF:sr


A Review of Strategies to
Decrease the Duration of Indwelling
Urethral Catheters and Potentially
Reduce the Incidence of Catheter-
Associated Urinary Tract Infections
Michael S. Bernard, Kathleen F. Hunter, and Katherine N. Moore
I
ndwelling urinary catheters
are widely used in hospital-
ized patients and can be an
appropriate means of thera-
peutic management under specif-
ic circumstances. However, many
indwelling urinary catheters are
used without clear indications
(Gokula, Hickner, & Smith, 2004;
Jain, Parada, David, & Smith,
1995), thus putting patients at an
unnecessary risk for complica-
tions during their hospitaliza-
tion. Catheter-associated compli-
cations include physical and
psychological discomfort to the
patient, bladder calculi, renal
inflammation, and most fre-
quently, catheter-associated uri-
nary tract infections (CAUTI)
(Gokula, Smith, & Hickner,
2007). The development of
CAUTI in older adults can result
in falls, delirium, and immobility
(Hazelett, Tsai, Gareri, & Allen,
2006).
Michael S. Bernard, MN, RN(EC), NP-
Adult, is a Nurse Practitioner, VON 360
Degree Nurse Practitioner-Led Clinic,
Peterborough, Ontario, Canada.
Kathleen F. Hunter, PhD, RN, NP GNC(C),
is an Assistant Professor, University of
Alberta, Edmonton, Alberta, Canada.
Katherine N. Moore, PhD, RN, CCCN,
is a Professor, University of Alberta,
Edmonton, Alberta, Canada.
UROLOGIC NURSING / January-February 2012 / Volume 32 Number 1
Research
© 2012 Society of Urologic Nurses and Associates
Bernard, M.S., Hunter, K.F., & Moore, K.N. (2012). A review of strategies to
decrease the duration of indwelling urethral catheters and potentially reduce
the incidence of catheter-associated urinary tract infections. Urologic
Nursing, 32(1), 29-37.
The use of indwelling urinary catheters in hospitalized patients presents an
increased risk of the development of complications, including catheter-associat-
ed urinary tract infection (CAUTI). With regard to the risk of developing a CAUTI,
the greatest factor is the length of time the catheter is in situ. The aim of this arti-
cle is to review the evidence on the prevention of CAUTI, particularly ways to
ensure timely removal of indwelling catheters. Published studies evaluating inter-
ventions to reduce the duration of catheterization and CAUTI in hospitalized
patients were retrieved. The research identified two types of strategies to reduce
the duration of indwelling urinary catheters and the incidence of CAUTI: nurse-
led interventions and informatics-led interventions, which included two subtypes:
computerized interventions and chart reminders. Current evidence supports the
use of nurse-led and informatics-led interventions to reduce the length of
catheterizations and subsequently the incidence of CAUTI.
Key Words: Catheter-associated urinary tract infection (CAUTI),
indwelling urinary catheters, informatics, hospital-acquired
infections, bacteremia.
Urinary tract infections (UTIs) However, in the U.S., concern over
account for at least 35% of all hos- care costs resulting from a largely
pital-acquired infections (Hart, preventable problem has resulted
2008), with 80% of those being in changes to the Centers for
attributed to the use of indwelling Medicare & Medicaid Services’
catheters (Gokula et al., 2007). In (CMS) reimbursement system,
addition to the impact on quality with hospitals no longer receiving
of life, CAUTIs place a financial additional payment for CAUTIs
burden on the health care system that were not present at the time of
in terms of treatment and in- admission (Wald & Kramer, 2007).
creased length of stay. The exact In addition to financial cost,
cost of CAUTI is difficult to calcu- CAUTIs affect patient well-being.
late due to changes in clinical and In a systematic review that exam-
billing practices (Saint, 2000). ined the clinical and economic
29
 Research Summary
Introduction
Prevention of catheter-associated urinary tract infections
(CAUTIs) has become a major focus of health care providers,
accrediting agencies, and reimbursement sources.
Purpose
Evaluate current literature for research-based strategies
to decrease the length of time of catheter placement, the
effects of strategies on the duration and removal of catheters,
and the incidence of CAUTI.
Methods
A search of electronic databases using key words yield-
ed 53 abstracts that were appraised. Only 9 research stud-
ies focused on reducing the duration of catheter use and
CAUTI incidence.
Findings
The available evidence supports nurse-led or informat-
ics-led interventions for reducing the length of catheteriza-
tions and incidence of CAUTI. However, no specific interven-
tion was clearly superior than the others.
Conclusions
More evidence, particularly through randomized con-
trolled trials, to determine the best method of ensuring time-
ly removal of indwelling urinary catheters in all settings is
required.
Level of Evidence – V
(Melnyk & Fineout-Overholt, 2011)

consequences of bacteriuria from
catheters, 3.6% of those with
symptomatic UTI also developed
bacteremia, and mortality from
bacteremia can be as high as 10%
(Saint, 2000). Although morbidi-
ty and mortality rates are rela-
tively low from CAUTIs com-
pared to other hospital-acquired
infections, the use of urinary
catheters in hospitalized patients
leads to a large cumulative risk
burden for mortality (Gould
et al., 2009). Potentially serious
complications associated with
indwelling urethral catheters and
the possible development of
CAUTI warrant efforts to restrict
the use of these devices by hav-
ing clear indications for insertion
and discontinuation.
Indications for Indwelling Urinary
Catheter Use
Indications for short-term
catheterization (less than 30 days)
have been described by several
authors (Gokula et al., 2007;
Gould et al., 2009; Hooton et al.,
2010; Nazarko, 2008). These
include a) urinary retention,
b) obstruction to the urinary tract,
c) close monitoring of the urine
output of critically ill patients,
d) urinary incontinence that poses
a risk to the patient because of
Stage 3 or greater ulcer to the
sacral area, and e) comfort care for
terminally ill patients. Despite
such recommendations and
guidelines, catheters are often
placed for inappropriate or poorly
documented reasons (Gokula
et al., 2004; Jain et al., 1995;
Munasinghe, Yazdani, Siddique,
& Hafeez, 2001; Raffaele, Bianco,
Aiello, & Pavia, 2008). Among
hospitalized patients, the rate of
unnecessary urethral catheteriza-
tion has been reported between
21% and 50% (Gardam, Amihod,
Orenstein, Consolacion, & Miller,
1998; Gokula et al., 2004; Jain
et al., 1995; Saint, 2000). The
majority of inappropriately
placed catheters are initiated and
inserted in the emergency depart-
ment (Gokula et al., 2007;
Munasinghe et al., 2001). Urinary
catheters are inserted without a
physician order in as many as
one-third of patients, and even if
an order is recorded, no docu-
mented rationale is provided. The
lack of documented rationale was
identified several years ago
(Gardam et al., 1998) and remains
an ongoing problem (Gokula et al.,
2004, 2007).
Individuals 65 years of age or
older are at increased risk for unnec-
essary catheterization (Gokula et al.,
2007; Holroyd-Leduc et al., 2007;
Saint, 2000), a concern given their
high risk of developing complica-
tions, particularly infection. No
recent research has been published
on decision making related to the
use of indwelling catheterization,
but historically, the increased use
in older adults has been an attempt
to manage bladder emptying in
those with cognitive impairment,
incontinence, and decreased func-
tion in carrying out activities of
daily living (Hampton, 2006;
Hazelett et al., 2006) or conven-
ience to staff (Jain et al., 1995;
Saint, Lipsky, Baker, McDonald, &
Ossenkop, 1999). Anecdotal evi-
dence and case studies suggest that
these reasons may continue in
some settings.
Whatever the reason for inser-
tion, assessment of the continued
need for an indwelling catheter is
often overlooked, and catheters
then remain in situ without prop-
er indications (Jain et al., 1995;
Rabkin et al., 1998). Dingwall
and McLafferty (2006) reported
that although nursing staff have
knowledge about proper and
improper indications for urinary
catheters and associated risk,
they continue to use indwelling
urinary catheters for reasons of
personal preference and do not
assess their continual use. Even
with the best nursing care for
those with indwelling urinary
catheters, each day presents an
increasing risk for infection,
ranging from 3% to 10% (Hooten
et al, 2010; Saint, Lipsky, &
Goold, 2002). Strategies should
be developed to ensure that
catheters are used only when
indicated and only for as long as
they are needed. Thus, the pur-
pose of this review was to evalu-
ate the current literature for
research-based strategies to re-
duce catheter insertion time
and to review the effects of these
strategies on the duration of
catheterization and incidence of
CAUTIs.

30 UROLOGIC NURSING / January-February 2012 / Volume 32 Number 1

Methods
A search of the electronic
databases MEDLINE, CINAHL,
Cochrane Database, Google, and
Google Scholar was conducted.
Grey literature (abstracts from
conferences or presentations)
was also sought for the years
2000 to 2010 using Google
Scholar.
Search terms were indwel-
ling urinary catheter*, Foley
catheter*, and urinary catheter*,
UTI, added UTI*, bacturia,
pyuria, CAUTI*, catheter ac-
quired urinary tract infection,
acute care, acute-care, tertiary
care, tertiary-care, and hospital-
ized. Fifty-three abstracts were
appraised, and only research
studies that addressed acute-care
patients, the timely removal of
catheters (removal once no
longer indicated), and the out-
come measures of duration of
indwelling urinary catheter and
incidence of CAUTIs were
included. Of the 53 abstracts
reviewed, 9 were relevant to the
research questions.
Evidence Base for Strategies
To Decrease Indwelling
Catheter Use
Nine studies were found that
focused on reducing the duration
of catheter use, and subsequent-
ly, the incidence of CAUTIs (see
Table 1). Most of these studies
involved reminder systems to
trigger the review for continued
use of indwelling urinary
catheters. Two key interventions
were noted: nurse-led (Crouzet
et al., 2007; Elpern et al., 2009;
Fakih et al., 2008; Huang et al.,
2004; Robinson et al., 2007) and
informatics-led with two sub-
types – computerized reminders
(Apisarnthanarak et al., 2007;
Cornia, Amory, Fraser, Saint, &
Lipsky, 2003; Topal et al., 2005)
and chart reminders (Loeb et al.,
2008).
Nurse-led interventions. Nurse-
led interventions utilize nursing
staff (charge nurse, clinical nurse
specialist, or staff nurses) to assess,
after a set period of time, whether
an indwelling urinary catheter is
still indicated for the patient. This
leads to a decision to discontinue
or continue the catheter through
collaborative discussion with the
physician or use of a standing
order. Elpern et al. (2009) em-
ployed a quasi-experimental de-
sign in a medical intensive care
unit (ICU) at Rush Medical Center
(Chicago), including all patients
admitted with an indwelling uri-
nary catheter or with an in-
dwelling urinary catheter insert-
ed during their stay. The initial
phase of the intervention was the
identification of patients with an
indwelling urinary catheter by a
member of the nursing staff. On a
daily basis, in consultation with
the staff nurses and with the
physician, the investigators
determined whether there were
appropriate indications for the
continuation of the patients’
catheters as defined in a litera-
ture review on the indications for
use. Data were collected over a
six-month period with outcome
measures, days of catheter use,
and rates of CAUTI. The prospec-
tive data were compared to retro-
spective data from the 11-month
pre-study initiation. Results indi-
cated that the active intervention
of daily consultation and review
of the need for a catheter signifi-
cantly reduced the number of
indwelling urinary catheter days
per month as well as the number
of CAUTIs.
Taiwanese researchers Huang
et al. (2004) also investigated a
nurse-led intervention to discon-
tinue indwelling urinary cath-
eters. Participants were recruited
from five ICUs: cardiovascular,
coronary care, surgery, neuro-
surgery, and medicine. A 12-
month observational period was
followed by a 12-month interven-
tion period. Those with in-
dwelling urinary catheters were
identified through the computer-
ized order entry system. All
patients who had indwelling uri-
nary catheters were included in
the study. Indications for inser-
tion and continuation of the
catheters were defined; the pri-
mary intervention was a daily
reminder to physicians by nurs-
ing staff to remove catheters five
days after insertion. Overall,
there was a consistent decrease
in the duration of catheters in
situ from 7.0 +1.1 days to 4.6 +
0.7 days and a statistically signif-
icant reduction in incidence of
CAUTI from 11.5 + 3.1 to 8.3 +
2.5 per 1000 catheters days.
A French research group
(Crouzet et al., 2007) conducted a
quasi-experimental study of a
nurse-led intervention in several
non-critical acute care units
(neurosurgery, cardiovascular
surgery, orthopedic surgery, neu-
rology, and geriatrics). All
patients who had undergone uri-
nary catheterization in hospital
were included. The study took
place over six months, with a
three-month observational phase
and a three-month intervention
phase. During the observational
phase, CAUTIs occurred on
days 5 and 6 of catheterization;
thus, the target day for removal
was day 4. Although there was
no overall reduction in length of
time that the catheters were in
situ (8.4 vs. 6.7 days), there was a
statistically significant reduction
in CAUTI (12.8 vs. 1.8). The
authors attribute the improve-
ment to increased surveillance as
well as decreased catheter days.
Fakih et al. (2008) used a
quasi-experimental design that
made use of pre-existing, nurse-
led multidisciplinary rounds and
involved 10 nursing units over
three phases (pre-intervention,
intervention, and post-interven-
tion). Each unit served as a con-
trol and as part of the interven-
tion for one period of time.
Nursing staff were given educa-
tion on indications for urinary
catheters based on recommenda-
tions of the Centers for Disease
Control and Prevention (CDC)
(Gould et al., 2009). If no indica-
tions existed for catheterization
during the daily rounds, the
nurses contacted the physician
for an order to discontinue the
catheter. There was a statistically
significant reduction in the num-
ber of urethral catheterization
days and the percentage of
unnecessary catheter days in the
intervention phase of the study.
Unfortunately, the authors report
that once the study was complet-

UROLOGIC NURSING / January-February 2012 / Volume 32 Number 1 31

 Table 1.

32
Studies that Focused on the Duration of Catheter Use with Nursing-Led Interventions

Author/Year Methods Participants Interventions Outcomes Comments

Elpern et al., 2009 Quasi-experimental design.
11-month observational
period compared against a
6-month intervention period.
All participants in the MICU
at an acute care hospital in
Chicago who had an
indwelling urinary catheter
during their unit stay were
included.
Patients with an indwelling
urinary catheter identified on
a daily basis. Indications for
use in patients identified with
staff nurses. Patients with
inappropriate indications
indentified by staff nurses
and co-investigations
discussed with physician.
CAUTI incidence reduced
from 4.7/100 catheter days
to zero (p = 0.01).
Duration reduced from 311.7
days per month to 238.6
days per month (p < 0.001).
Discussion of statistics used
in analysis was not present.
CIs were not present making
the reliability of the results
hard to determine.

Fakih et al., 2008 Quasi-experimental design. All patients with an Nurses educated on the CAUTI not measured. CAUTI not reported;
indwelling urinary catheter indications for appropriate however, due to the
Three phases: Pre-inter- admitted to the units catheter use based on CDC Duration reduced from 203 established link between
vention measuring over five identified by a charge nurse guidelines. If indication was urinary catheter days per duration and rate of CAUTI,
days, intervention measuring during daily rounds; 4963 not present for indentified 1000 patient days to 162 this study still may provide a
over 10 days, and post- patient-days observed. patients during rounds, then urinary catheter days per level of evidence in the
intervention measuring over nurses contacted doctors for 1000 patient days reduction of CAUTI through
four weeks. In each phase, an order to discontinue the (p = 0.002). their intervention.
two units were studied indwelling urinary catheter.
concurrently, with the other No significant reduction of
two units serving as a duration between pre- and
control done over five post-intervention periods
periods across 10 units. (p = 0.32).

Crouzet et al., 2007 Prospective, non-
randomized, time-
sequenced design.
Three-month prospective
observational phase
followed by a three-month
prospective intervention
phase.
All patients undergoing
urinary catheterization were
included in the study.
Patients with urinary
catheters on admission were
excluded from the study.
Staff nurses reminded
physicians to remove any
unnecessary indwelling
urinary catheters after four
days of being in situ and on
a daily basis thereafter.
CAUTI rate decreased from
10.6 per 100 patient days to
1.1 per 100 patient days
(p = 0.003).
CAUTI incidence reduced
from 12.3 to 1.8 per 1000
catheters days (p = 0.03).
Duration decreased from a
mean of 8.4 days to 6.7 days
However this was not
significant (p = 0.14).
Unnecessary, catheterization
was not clearly defined.
Between individual units, the
duration decreased
significantly on only two out
of the five units. Collectively,
there was no significant
reduction in the duration of
indwelling urinary catheter.

continued on next page

UROLOGIC NURSING / January-February 2012 / Volume 32 Number 1

 ed, on a subsequent visit to the site, there was a

intervention is not described.

Unnecessary catheterization
regression to pre-intervention practice in the post-
intervention phase. This emphasizes the need for
on-going support of staff in practice changes.
The frequency of the
Comments

was not described.

Robinson et al. (2007) used a mixed retrospec-
tive and prospective study design. Patient records
for a two-week period were reviewed retrospec-
tively to identify those who had had indwelling
urinary catheters. For many patients in this study,
no appropriate reason could be identified, and
many developed CAUTIs. In the two-week
Studies that Focused on the Duration of Catheter Use with Nursing-Led Interventions (continued)

prospective arm, the charge nurses identified

Patients who developed UTI

CAUTI incidence decreased

intervention decreased from

from 11.5 ± 3.1 to 8.3 ± 2.5

patients without a clear indication for a catheter.

Duration of catheterization
Number of days catheters

from a mean of 8.57 (1 to

decreased from 7.0 + 1.1

36) to 4.5 (1 to 13) days.
were in place decreased

The authors concluded that the charge nurses’

per 1000 catheter days

days to 4.6 + 0.7 days

active interventions in requesting discontinuation
Outcomes

symptoms after the

of unneeded catheters resulted in a 67% reduc-

tion in the number of days of catheter use and a
40% to 13.3%.

26% reduction in the number of CAUTIs when

(p = 0.009).

(p < 0.001).
compared to the results from the retrospective
arm.
Informatics-led interventions. Informatics-led
interventions make use of technological informa-
tion systems, including computerized, order-entry
catheters if they had no clear
for discontinuation of urinary

Daily reminders to physician

indwelling urinary catheters.
The charge nurse identified

obtain an order for removal

Nurses requested an order

indication based on a past

patients with inappropriate

systems that automatically prompt health care

after five days of insertion
from the nursing staff to

practitioners to take action with regard to a speci-

literature review on the
Interventions

fied and defined intervention. Two studies were

that were no longer
indications for use.

found that described two types of order-entry sys-

tems. The first was a computerized order-entry
and charting system that prompted health care
necessary.

workers to assess and reassess the indications for

Table 1.

the use of indwelling urinary catheters (Topol et

al., 2003). The second involved recording the use
of catheters in a computerized database, similar to
indwelling urinary catheter or

medication entry orders with automatic stop

All patients admitted with an
catheters in place or placed

who had a catheter placed,

orders (Apisarnthanarak et al., 2007; Cornia et al.,

Patients who had urinary

during the study periods.

on a medical unit and a

2003).
Participants

Computerized interventions. Topal et al.

(2005) used the computerized order-entry and
charting system in four general medicine units at
surgical unit.

an acute care hospital in Connecticut. They used

a quasi-experimental design over three collection
cycles, pre-intervention and intervention at two
points, each of which was 53 days in duration. In
each cycle, the researchers measured and record-
observational period through
two-week prospective study.

nonrandomized intervention

ed the use of antimicrobials, the incidence of

chart review followed by a
assessment followed by a

CAUTIs, and the duration of catheterization. The

Mixed retrospective and

12-month retrospective

intervention phase included two separate strate-

12-month prospective
prospective design.
Methods

gies. The first was to enter the indications for the

Two-week needs

catheter being ordered into a computerized sys-

Time-sequence

tem in the emergency department and then send-

ing these orders with the indications to the admit-
ting doctors. The admitting doctors were then
period.
study.

prompted to choose one of three orders for the

continuation of the indwelling urinary catheter:
a) to discontinue the catheter, b) to maintain the
Robinson et al., 2007

catheter for an additional 48 hours, and c) to leave

Huang et al., 2004

the catheter in place. The second strategy was to

Author/Year

allow the nurses to discontinue catheters that no

longer had an indication based on their assess-
ment and a standing order. Nursing staff received
education sessions on the indications for
indwelling urinary catheters use, alternatives, and

UROLOGIC NURSING / January-February 2012 / Volume 32 Number 1 33

bladder scanning after removal to
ensure that patients were not in
retention. The interventions
resulted in a 42% reduction in
the duration of catheterization,
and follow up at one year
revealed a 79% reduction in the
duration of catheterization.
Cornia et al. (2003) utilized a
quasi-experimental design to
determine the effect of a comput-
erized reminder system on the
length of catheterization. The
study focused on patients admit-
ted to medical and cardiovascu-
lar wards at a city hospital in
Seattle. They conducted the
study on two floors, each of
which contained a set of wards.
One floor and its wards served as
the intervention group, and the
other served as the control group.
The intervention included a
computerized order-entry system
that required the physician to
indicate the rationale for initiat-
ing catheters and after three days,
added daily reminders to deter-
mine whether the catheters were
still warranted. On the control
ward, catheters were initiated as
written orders, with no reminder
system. The number of days of
catheterization between the two
intervention and control units, as
well as the number of UTIs, were
compared after the first day of
catheterization. The authors
reported a statistically significant
reduction in the number of
catheterization days from 8 to 5
compared to the control ward.
However, they did not find a sig-
nificant reduction in the rate of
CAUTI. A lack of blinding on the
control unit (knowing they were
part of a research study) may
have changed practice so that
infection rates were reduced.
In an inner-city hospital in
Thailand, Apirsarnthanarak et al.
(2007) tested the computerized
order-entry system to reduce
indwelling urinary catheter use.
The authors used pre- and post-
measures to evaluate the efficacy
of a program that focused on nurs-
es’ reminders to physicians to
order the removal of unnecessary
catheters. The intervention was a
daily reminder to the nurses on
the computerized order-entry sys-
34
tem to identify patients with
catheters that had been in place for
more than three days and then to
notify the attending physicians if
catheters were not indicated. The
nurses had been previously edu-
cated on what constituted appro-
priate indications based on the
authors’ review of the literature.
The primary outcome measure
was the development of CAUTI,
which the authors compared at
two points in time: pre-interven-
tion and intervention. There was a
significant reduction in the num-
ber of catheter-utilization days,
with a mean reduction from 11 to
3 days, as well as a significant
reduction in CAUTIs (see Table 2).
Chart reminders. In a ran-
domized controlled trial in three
acute care hospitals in Ontario,
where all patients had in-
dwelling urinary catheters, Loeb
et al. (2008) utilized automatic
stop orders through the medica-
tion order-entry system. Subjects
were assigned either to a group
with automatic stop orders or to a
control group for which the cur-
rent practice was maintained.
The intervention consisted of an
automatic pre-written stop order
in the intervention group’s charts
to discontinue the use of the
catheter if there was no longer an
indication for its use. Nursing
staff were required to select an
indication if they wished to
maintain the indwelling urinary
catheter. The indications for use
included urinary obstruction,
neurogenic bladder, urinary re-
tention, urological surgery, fluid
challenge for acute renal failure,
open sacral wound for inconti-
nent patients, and urinary incon-
tinence in terminally ill patients.
There was a significant reduction
in the number of days of catheter
use and a significant decrease in
the number of CAUTIs in the
intervention group (see Table 3).
Discussion
The purpose of this review
was to discuss the current
research on strategies for timely
removal of indwelling urethral
catheters and to assess the strate-
gies on effectiveness and impact
UROLOGIC NURSING / January-February 2012 / Volume 32 Number 1
on incidence of CAUTI. Only nine
studies were found that addressed
the topic. The available evidence
supports nurse-led or chart
reminders to stimulate consistent
daily assessment of the continu-
ing need for a catheter and to
remove it as soon as possible.
Among the current studies, only
one (Loeb et al., 2008) was a ran-
domized controlled trial. The
experimental design was possible
because of the unique computer-
ized charting system in the study
setting, which allowed the easy
identification and randomization
of their participants. In the other
studies, randomization into two
groups was not feasible because
the nature of the interventions
made it possible to carry them out
only in an entire hospital unit.
Another factor that reduced
the quality of the studies – ex-
cluding those of Apisarnthanarak
et al. (2007), Cornia et al. (2003),
and Loeb et al. (2008) – was the
lack of reported confidence inter-
vals (CIs), which made it difficult
to judge the precision of the sta-
tistics, making the results less
reliable as predictors of the effec-
tiveness of the interventions.
The studies took place across
several settings: critical care
(Apisarnthanarak et al., 2007;
Elpern et al., 2009; Loeb et al.,
2008), medicine (Cornia et al.,
2003; Fakih et al., 2008; Huang
et al., 2004; Topal et al., 2005), and
surgical units (Crouzet et al., 2007;
Robinson et al., 2007). Four coun-
tries were represented: Canada
(Loeb et al., 2008), France (Crouzet
et al., 2007), the United States
(Cornia et al., 2003; Elpern et al.,
2009; Fakih et al., 2008; Huang
et al., 2004; Robinson et al., 2007;
Topal et al., 2005), and Thailand
(Apisarnthanarak et al., 2007). The
potential differences in health care
practices and education in these
settings could affect the generaliz-
ability of the results. Moreover, all
interventions, whether nurse-led
or informatics-led, demonstrated a
significant reduction in the dura-
tion of catheterization. However,
practice change may be limited to
particular settings because of
resource issues. For example, to be
implemented, an intervention that
 Table 2.
Informatics-Led Interventions: Computerized Reminders
Author/Year Methods Participants Interventions
Apisarnthanarak et al., Quasi-experimental design All patients admitted with A nurse-generated daily
2007 without a control. an indwelling urinary reminder to physicians three
10-month preintervention catheter or who had a days after initiation of an
period (control) followed catheter placed. indwelling urinary catheter via
by a 12-month the computerized order-entry
interventional period. system to remove catheters
that were no longer indicated.
Topal et al., 2005 Quasi-experimental All patients admitted with Two-part intervention. First,
design. an indwelling urinary patients who had catheters
Three collection cycles: catheter or who had a initiated in the emergency had
One pre-intervention cycle catheter placed. the indications for initiation of
and two intervention their indwelling urinary catheter
cycles separated by a entered into the computerized
order entry system. The
UROLOGIC NURSING / January-February 2012 / Volume 32 Number 1
year.
admitting physician then had
the choice to enter into the
computerized system to either
discontinue the catheter, leave
it in chronically, or continue it
for an additional 48 hours.
The second part of the
intervention entailed allowing
nurses to independently
discontinue catheters based on
education sessions offered to
them on the proper indication
for the continuation of
catheters.
Cornia, Amory, Fraser, Quasi-experimental design All patients admitted with Intervention group utilized a
Saint, & Lipsky, 2003 with a control. a catheter or who had a computerized order-entry
Set up across two time catheter placed while on system that required the
periods between two the unit. physician to indicate the
floors of medical units. rational for the utilization of the
catheter and provided a
Allowing for each floor to
serve as a control and an reminder after three days every
day if the catheter was still
intervention.
indicated.
35
Outcomes Comments
CAUTI rate decreased from Study completed in a
a mean rate of 21.5 non–North American
infections per 1000 catheter- setting, which may limit
days to 5.2 infections per generalizability to other
1000 catheter days settings.
(p < 0.001).
The duration of urinary
catheterization decreased
from a mean of 11 days to 3
days (p < 0.001).
Period 1: CAUTI rate was A significant decrease in
not significant with a CAUTI and reduction in
decrease from 10 episodes duration was found over an
per 1000 catheter-days to 9 extended period of time but
episodes per 1000 catheter- not initially.
days (p = 0.054). The first part of the
Duration of catheter use was intervention that utilizes the
reduced 42% from 892 to computerized order-entry
521 days (p < 0.001). system focuses on every
second day assessments
Period 2: CAUTI rate
decreased from 10 episodes as opposed to daily
assessments.
per 1000 catheter-days to
two episodes per 1000
catheter-days (p < 0.001).
Duration of catheter use was
reduced 79% from 892 to
184 days (p < 0.001).
No significant difference in
CAUTI rate between the two
groups (p = 0.71).
Duration mean decreased
from 8 ± 5 to 5 ± 3
(95% CI 0 to 5; p = 0.03).

Comments
19%, relative risk 0.94 (95%
days (95% CI, -0.64 to -2.05
from -1.69 (95% CI, -1.23 to
CI, 0.66 to 1.33; p = 0.71).
-2.15; p < 0.001) to -1.34
occurrence of 20.2% to
Inappropriate catheter
UTI reduced from an
utilization decreased
Outcomes
days; p < 0.001).
Informatics-Led Interventions: Chart Reminders
indwelling urinary catheter or
no automatic order reminder.
had pre-written stop orders
either to a group were they
Patients were randomized
to the current practice of
discontinuation of their
Interventions
reminding for the
Table 3.
indwelling urinary catheter
inserted for less than 48
hours between three
Participants
All patients with an
hospital sites.
Randomized control trial.
Methods
Author/Year
Loeb et al., 2008
36
depends on a computerized sys-
tem requires the presence of such
a system. Because models of nurs-
ing practice differ, it may not be
reasonable to expect that an inter-
vention that worked in one setting
is necessarily translatable to
another.
There was a lack of consis-
tency in the definition of short-
term catheterization. Two com-
mon definitions were noted: 1 to
14 days (Fernandez & Griffiths,
2006; Joanna Briggs Institute,
2008), or 1 to 30 days (Cochran,
2007; Gould et al., 2009). While
most studies that offer a defini-
tion for short-term use do not
explicitly identify reasoning for
their criterion, CDC guidelines
for the prevention of CAUTI
(Gould et al., 2009) chose 30 days
as a base for short-term catheteri-
zation. This standard is based on
a classic study (Warren, Tenney,
Hoopes, Muncie, & Anthony,
1982) that showed bacteriuria
reach a steady state at 30 days
with an indwelling urinary
catheter, potentially presenting
different risks for short-term ver-
sus long-term catheter use.
The studies reviewed, inde-
pendent of the type of interven-
tion used except for those of
Crouzet et al. (2007) and
Robinson et al. (2007), showed a
significant reduction in the dura-
tion of catheterization with a
planned removal, and only two
(Fakih et al., 2008; Robinson
et al., 2007) of the nine studies
reviewed did not demonstrate a
significant reduction in CAUTI.
These findings, although limited
by the quality of the studies,
demonstrate the potential of
interventions based on the re-
view of indications for cathe-
terization. Even if CAUTI was no
different in any of the studies,
the reduced nursing care time,
the ability of the patient to be
more mobile, and patient comfort
would justify early removal.
These outcomes were not meas-
ured in any of the studies.
Implications for Nursing
Although the studies used
different interventions, they all
UROLOGIC NURSING / January-February 2012 / Volume 32 Number 1
involved registered nurses with
nurse-led interventions or nurses
systematically monitoring pa-
tients and reminding physicians
which patients had indwelling
urethral catheters. The front line
participation of registered nurses
demonstrated their critical role
in reducing complications from
indwelling urinary catheters.
Further research could assess the
benefit of targeted education of
nurses about indwelling urinary
catheters cessation and the effect
that education has on systems to
ensure catheter removal at appro-
priate end points.
For undergraduate nursing
students, this education could be
integrated into their learning of
the catheterization skill. Because
the knowledge base behind the
indications for catheterization is
well established, new nurses
need to think critically about the
indicated need for catheteriza-
tion and the length of their use
when they use their skills to ini-
tiate and maintain a urethral
catheter.
There is a need to under-
stand the transfer of this knowl-
edge into practice. With regard to
nurses who have knowledge
about indications for the use of
indwelling urinary catheters, as
Dingwall and McLafferty (2006)
identified, their knowledge does
not necessarily translate into
practice. A research question
needs to be asked about this phe-
nomenon, for example, “What in
the culture of nursing practice
prevents the translation of
knowledge into practice on the
proper use of indwelling urinary
catheters?”
Conclusion
Indwelling urinary catheteri-
zation is an invasive intervention
with potentially serious out-
comes that can lead to morbidity
and mortality issues in hospital-
ized patients. Although there is a
clinical agreement on the indica-
tions for catheterization in acute
care, more evidence is required
to determine the optimum
method of ensuring timely re-
moval of indwelling urethral
catheters in all settings. The cur-
rent studies identify both nurse-
led and informatics-led interven-
tions as successful in reducing
the length of catheterizations,
and subsequently, the incidence
of CAUTI. Research into the bar-
riers of translating knowledge
about CAUTI into practice may
be important in application of
these interventions.
References
Apisarnthanarak, A., Thongphubeth, K.,
Sirinvaravong, S., Kitkangvan, D.,
Yuekyen, C., Warachan, B., … Fraser,
V.J. (2007). Effectiveness of multifac-
eted hospitalwide quality improve-
ment programs featuring an interven-
tion to remove unnecessary urinary
catheters at a tertiary care center in
Thailand. Infection Control &
Hospital Epidemiology, 28(7), 791-
798.
Cochran, S. (2007). Care of the indwelling
urinary catheter: Is it evidence based?
Journal of Wound Ostomy &
Continence Nursing, 34(3), 282-288.
Cornia, P.B., Amory, J.K., Fraser, S., Saint,
S., & Lipsky, B.A. (2003). Computer-
based order entry decreases duration
of indwelling urinary catheterization
in hospitalized patients. American
Journal of Medicine, 114(5), 404-407.
Crouzet, J., Bertrand, X., Venier, A.G.,
Badoz, M., Husson, C., & Talon, D.
(2007). Control of the duration of uri-
nary catheterization: Impact on
catheter-associated urinary tract infec-
tion. Journal of Hospital Infection,
67(3), 253-257.
Dingwall, L., & McLafferty, E. (2006).
Nurses’ perceptions of indwelling uri-
nary catheters in older people.
Nursing Standard, 21(14-16), 35-42.
Elpern, E.H., Killeen, K., Ketchem, A.,
Wiley, A., Patel, G., & Lateef, O.
(2009). Reducing use of indwelling
urinary catheters and associated uri-
nary tract infections. American
Journal of Critical Care, 18(6), 535-
541.
Fakih, M.G., Dueweke, C., Meisner, S.,
Berriel-Cass, D., Savoy-Moore, R.,
Brach, N., … Saravolatz, L.D. (2008).
Effect of nurse-led multidisciplinary
rounds on reducing the unnecessary
use of urinary catheterization in hos-
pitalized patients. Infection Control &
Hospital Epidemiology, 29(9), 815-
819.
Fernandez, R. S., & Griffiths, R. D. (2006).
Duration of short-term indwelling
catheters – A systematic review of the
evidence. Journal of Wound Ostomy
and Continence Nursing, 33(2), 145-
155.
Gardam, M.A., Amihod, B., Orenstein, P.,
Consolacion, N., & Miller, M.A.
(1998). Overutilization of indwelling
urinary catheters and the develop-
ment of nosocomial urinary tract
infections. Clinical Performance &
Quality Health Care, 6(3), 99-102.
UROLOGIC NURSING / January-February 2012 / Volume 32 Number 1
Gokula, R.R., Hickner, J.A., & Smith, M.A.
(2004). Inappropriate use of urinary
catheters in elderly patients at a mid-
western community teaching hospi-
tal. American Journal of Infection
Control, 32(4), 196-199.
Gokula, R.M., Smith, M.A., & Hickner, J.
(2007). Emergency room staff educa-
tion and use of a urinary catheter indi-
cation sheet improves appropriate use
of Foley catheters. American Journal
of Infection Control, 35(9), 589-593.
Gould, C.V., Umscheid, G.A., Agarwal,
R.K., Kuntz, G., Pegues, D.A., &
Healthcare Infection Control Practices
Advisory Committee. (2009). Guide-
line for prevention of catheter-associ-
ated urinary tract infections 2009.
Retrieved March 19, 2010, from
http://www.cdc.gov.login.ezproxy.
library.ualberta.ca/hicpac/cauti/001_
cauti.html
Hampton, T. (2006). Urinary catheter use
often “inappropriate” in hospitalized
elderly patients. JAMA: Journal of the
American Medical Association,
295(24), 2838.
Hart, S. (2008). Urinary catheterisation.
Nursing Standard, 22(27), 44-48.
Hazelett, S.E., Tsai, M., Gareri, M., & Allen,
K. (2006). The association between
indwelling urinary catheter use in the
elderly and urinary tract infection in
acute care. BMC Geriatrics, 6, 15.
Holroyd-Leduc, J.M., Sen, S., Bertenthal,
D., Sands, L.P., Palmer, R.M.,
Kresevic, D.M., … Landefeld, C.S.
(2007). The relationship of indwelling
urinary catheters to death, length of
hospital stay, functional decline, and
nursing home admission in hospital-
ized older medical patients. Journal of
the American Geriatrics Society,
55(2), 227-233.
Hooton, T.M., Bradley, S.F., Cardenas, D.D.,
Colgan, R., Geerlings, S.E., Rice, J.C.,
… Nicolle L.E. (2010). Diagnosis, pre-
vention, and treatment of catheter-
associated urinary tract infection in
adults: 2009 International Clinical
Practice Guidelines from the
Infectious Diseases Society of
America. Clinical Infectious Diseases,
50(5), 625-663.
Huang, W.C., Wann, S.R., Lin, S.L., Kunin,
C.M., Kung, M.H., Lin, C.H., … Lin,
T.W. (2004). Catheter-associated uri-
nary tract infections in intensive care
units can be reduced by prompting
physicians to remove unnecessary
catheters. Infection Control &
Hospital Epidemiology, 25(11), 974-
978.
Jain, P., Parada, J.P., David, A., & Smith,
L.G. (1995). Overuse of the indwelling
urinary tract catheter in hospitalized
medical patients. Archives of Internal
Medicine, 155(13), 1425-1429.
Joanna Briggs Institute. (2008). Removal of
short-term indwelling urethral
catheters. Nursing Standard, 22(22),
42-45.
Loeb, M., Hunt, D., O’Halloran, K.,
Carusone, S.C., Dafoe, N., & Walter,
S.D. (2008). Stop orders to reduce
inappropriate urinary catheterization
in hospitalized patients: A random-
ized controlled trial. Journal of
General Internal Medicine, 23(6), 816-
820.
Melnyk, B.M., & Fineout-Overholt, E.
(2011). Evidence-based practice in
nursing and healthcare: A guide to
best practice (2nd ed.). Philadelphia:
Lippincott, Williams & Wilkins.
Munasinghe, R. L., Yazdani, H., Siddique,
M., & Hafeez, W. (2001). Appro-
priateness of use of indwelling uri-
nary catheters in patients admitted to
the medical service. Infection Control
& Hospital Epidemiology, 22(10), 647-
649.
Nazarko, L. (2008). Reducing the risk of
catheter-related urinary tract infec-
tion. British Journal of Nursing, 17
(16), 56-58.
Rabkin, D.G., Stifelman, M.D., Birkhoff, J.,
Richardson, K.A., Cohen, D.,
Nowygrod, R., … Hardy, M.A. (1998).
Early catheter removal decreases inci-
dence of urinary tract infections in
renal transplant recipients. Trans-
plantation Proceedings, 30(8), 4314-
4316.
Raffaele, G., Bianco, A., Aiello, M., & Pavia,
M. (2008). Appropriateness of use of
indwelling urinary tract catheters in
hospitalized patients in Italy. Infec-
tion Control & Hospital Epidemiology,
29(3), 279-281.
Robinson, S., Allen, L., Barnes, M.R., Berry,
T.A., Foster, T.A., Friedrich, L.A., …
Weitzel, T. (2007). Development of an
evidence-based protocol for reduction
of indwelling urinary catheter usage.
MEDSURG Nursing, 16(3), 157-161.
Saint, S. (2000). Clinical and economic
consequences of nosocomial catheter-
related bacteriuria. American Journal
of Infection Control, 28(1), 68-75.
Saint, S., Lipsky, B.A., Baker, P.D.,
McDonald, L.L., & Ossenkop, K.
(1999). Urinary catheters: What type
do men and their nurses prefer?
Journal of the American Geriatrics
Society, 47(12), 1453-1457.
Saint, S., Lipsky, B.A., & Goold, S.D. (2002).
Indwelling urinary catheters: A one-
point restraint? Annals of Internal
Medicine, 137(2), 125-127.
Topal, J., Conklin, S., Camp, K., Morris, V.,
Balcezak, T., & Herbert, P. (2005).
Prevention of nosocomial catheter-
associated urinary tract infections
through computerized feedback to
physicians and a nurse-directed pro-
tocol. American Journal of Medical
Quality, 20(3), 121-126.
Wald, H.L., & Kramer, A.M. (2007).
Nonpayment for harms resulting from
medical care: Catheter-associated uri-
nary tract infections. JAMA: Journal of
the American Medical Association,
298, 2782-2784.
Warren, J.W., Tenney, J.H., Hoopes, J.M.,
Muncie, H.L., & Anthony, W.C.
(1982). A prospective microbiologic
study of bacteriuria in patients with
chronic indwelling urethral catheters.
Journal of Infectious Diseases, 146(6),
719-723.
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