Reports From the Field

The Impact of Two-Person Indwelling Urinary Catheter Insertion in the Emergency Department Using Technical and Socioadaptive Interventions



From Tampa General Hospital, Tampa, FL.


• Objective: To decrease insertion-related catheter-associated urinary tract infections (CAUTIs) attributed to the emergency department (ED) as well as facility-wide within a large teaching hospital.

• Methods: Recommendations from the Agency for Healthcare Research and Quality (AHRQ) toolkit for reducing CAUTIs in hospital units were used to implement both technical and socioadaptive changes focused on prevention of insertion-related CAUTIs in the ED through a trial that required 2 licensed personnel for insertion of all urinary catheters. The process would include a safety time-out to confirm catheter appropriateness and review of the proper steps for insertion as a means to encompass and hardwire both the technical and socioadaptive aspects of the Comprehensive Unit-based Safety Project methodology into ED practice.

• Results: There was a 75% decrease in CAUTI rates following the intervention (P = 0.05). This reduction was sustained for at least 1 year following implementation.

• Conclusion: Using AHRQ recommendations to implement socioadaptive and technical changes through 2-person insertion of urinary catheters yielded a significant and sustainable decrease in insertion-related CAUTI rates and utilization of indwelling urinary catheters in the ED at Tampa General Hospital.

Key words: catheter-associated urinary tract infections; infection prevention; quality improvement; change model.

Each year an estimated 721,800 health care–associated infections occur in U.S. acute care hospitals, resulting in approximately 75,000 deaths [1]. Catheter-associated urinary tract infections (CAUTIs) account for an estimated 449,334 of health care–associated infections s annually [2]. The direct medical cost per CAUTI ranges from $749 to $1007, resulting in direct costs to U.S. facilities of over $340 million annually [2]. Although CAUTIs are one of the most common health care–associated infections, the literature has shown that following well established prevention guidelines can greatly reduce their incidence.

Since most health care–associated infections are preventable and cause unnecessary patient harm, there is pressure from regulatory bodies to prevent such events during a patient’s hospitalization. Prevention of CAUTIs is a Joint Commission National Patient Safety Goal, and as of 2008 the Centers for Medicare and Medicaid Services (CMS) does not reimburse hospitals for the cost of additional care as a result of a CAUTI. Additionally, facility CAUTI data is included in the CMS value-based purchasing program, which can withhold payments to hospitals based on performance, as well as the inpatient quality reporting program, which requires public reporting of CAUTI to receive a higher annual payment.

Even before the external pressures of regulatory bodies, Tampa General Hospital has strived to protect patients by preventing infections through implementing best practices via multidisciplinary committees to maximize impact. Tampa General Hospital, a private not-for-profit level 1 trauma center located in downtown Tampa, Florida, is a teaching facility affiliated with the University of South Florida Morsani College of Medicine. It is licensed for more than 1000 beds and serves 12 surrounding counties with a population in excess of 4 million.


CAUTI data had been collected in all of the intensive care units at the hospital for several years, benchmarked against national unit-specific rates, with feedback provided to committees and the hospital board. However, in 2006, a multidisciplinary committee chaired by the chief operating officer known as Committee Targeting Zero (CTZ) was formed to review best practices and analyze all device-associated infection rates in an effort to reduce hospital-acquired infections. To target reduction of the CAUTI rate, a Foley stabilization device and renewed focus on hand hygiene were implemented, and CAUTI rates were reduced by over 50% by the end of 2007.

When CAUTI rates began to climb in 2008, additional interventions were implemented under the direction of CTZ, including a literature review for CAUTI prevention for any new or novel prevention strategies, reporting of each CAUTI to leadership of the attributed unit at the time of identification, ongoing surveillance of the appropriateness of indwelling urinary catheters at the unit level with feedback to CTZ, and mandatory education focused on infection of CAUTI and proper insertion for all staff inserting indwelling urinary catheters. Additionally, in 2009 an evaluation of an antibiotic-coated Foley catheter was implemented to further decrease rates, resulting in a statistically significant 42% reduction in the CAUTI rate as compared to 2008. Other prevention strategies instituted between 2010 and 2012 included increased availability of condom catheters, a closed system urine culture collection kit, and computer-based learning module for all staff inserting indwelling urinary catheters.

In 2013, the hospital included CAUTI prevention as part of a facility-wide initiative to decrease patient harm. A CAUTI committee led by senior leadership was convened to address CAUTI rates that exceeded national benchmarks. The multidisciplinary team began as a subcommittee of CTZ and was chaired by the chief nursing officer with the support of the chief operations officer and included representation from the infection prevention department and nursing unit leadership. After reviewing the Healthcare Infection Control Practices Advisory Committee’s (HICPAC) guideline for prevention of CAUTIs [3], the committee focused its efforts on appropriate indications for insertion and timely removal, aseptic insertion, and proper maintenance of indwelling urinary catheters.

The key accomplishments of the CAUTI committee during 2014 included development of a comprehensive genitourinary management policy, incorporation of CAUTI prevention into new employee orientation for all patient care staff, aseptic indwelling urinary catheter insertion competency check-off with return demonstration (teachback methodology) for all nursing staff, and reinforcement of insertion criteria and daily assessment for necessity with documentation of indications, and removal via nurse-driven protocol when necessary. Additionally, a requirement to document indications for ordering urine cultures and a pop-up reminder in the electronic medical record for patients with an indwelling urinary catheter requiring indications to continue, both targeted towards physicians and advanced practice providers, were implemented.

In conjunction with the technical changes, additional strategies were executed with the intent of facilitating a culture of patient safety and reinforcing the aforementioned technical changes. In 2014, the hospital implemented Franklin Covey’s “The Speed of Trust” methodology [4] and its associated 13 behaviors hospital-wide. Additionally, several of the inpatient units participated in a quality improvement project with either the Florida Hospital Engagement Network (HEN) [5] or the Agency for Healthcare Research and Quality (AHRQ) Comprehensive Unit-based Safety Program (CUSP) [6] national project. Physician engagement and education was accomplished through a white paper written by the infection prevention department, summarizing the current state of CAUTI within the facility and highlighting strategies to reduce infection, including evidence-based guidelines on ordering urine cultures.

In an attempt to target ongoing improvement strategies, CAUTIs were categorized as either insertion-related, occurring within 7 days of insertion, or maintenance-related, occurring greater than 7 days of insertion; the date of insertion was considered day 1. A review of the facility CAUTI data demonstrated that an opportunity to reduce insertion-related CAUTIs existed and a high volume of urinary catheters were inserted in the emergency department (ED). Therefore, ED leadership agreed to participate in the CUSP initiative for EDs beginning April 2014. The goals of the CUSP initiative include using best practices for CAUTI prevention through the implementation of both technical and socioadaptive changes.

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