Posted: March 11th, 2023

EBP

Critique a nursing research article on evidence-based practice (ATTACHED BELOW) related to nursing practice or health assessment. The 2–3-page work (not including title and references) will follow APA format. Include the following elements in the work: a summary of the article and the research presented, a critique of the validity of the research, and an analysis of the proposed evidence-based practice based presented in the article. 

Use the following guidelines to assist with writing the work: 1. Provide at least one to two paragraphs summarizing the essential content/ideas of the article and describing the research 2. Include a section describing your view of the article’s balance: Were both sides of the issue addressed? Was there bias involved and if so, slanted towards which side? What is your evidence of this bias or imbalance? 3. Include a section describing your opinion of the article’s quality and your own position: Did the writer do sufficient research? Is the article technically correct and clearly presented and supported? Are there elements of the argument that could have been enhanced with more detail or more argumentation? What would a follow-up article contain to be useful to this one? Did you agree with the article?

1Van Decker SG, et al. BMJ Open Quality 2021;10:e001534. doi:10.1136/bmjoq-2021-001534

Open access

Catheter- associated urinary tract
infection reduction in critical care units:
a bundled care model

Stephanie Grana Van Decker,1 Nicholas Bosch,2 Jaime Murphy2

To cite: Van Decker SG,
Bosch N, Murphy J. Catheter-
associated urinary tract
infection reduction in critical
care units: a bundled care
model. BMJ Open Quality
2021;10:e001534. doi:10.1136/
bmjoq-2021-001534

Received 20 April 2021
Accepted 26 November 2021

1Department of Internal
Medicine, Boston Medical
Center, Boston, Massachusetts,
USA
2Department of Pulmonary,
Allergy, Sleep, and Critical
Care Medicine, Boston Medical
Center, Boston, Massachusetts,
USA

Correspondence to
Dr Stephanie Grana Van Decker;
svandec@ gmail. com

Quality improvement programme

© Author(s) (or their
employer(s)) 2021. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.

ABSTRACT
Catheter- associated urinary tract infections (CAUTIs)
represent approximately 9% of all hospital acquired
infections, and approximately 65%–70% of CAUTIs are
believed to be preventable. In the spring of 2013, Boston
Medical Center (BMC) began an initiative to decrease
CAUTI rates within its intensive care units (ICUs). A CAUTI
taskforce convened and reviewed process maps and
gap analyses. Based on Centers for Disease Control and
Prevention (CDC) and Institute for Healthcare Improvement
(IHI) guidelines, and delineated by the Healthcare Infection
Control Practices Advisory Committee 2009 guidelines,
all BMC ICUs sequentially implemented plan–do–study–
act cycles based on which measures were most easily
adaptable and believed to have the highest impact
on CAUTI rates. Implementation of five care bundles
spanned 5 years and included (1) processes for insertion
and maintenance of foley catheters; (2) indications for
indwelling foley catheters; (3) appropriate testing for
CAUTIs; (4) alternatives to indwelling devices; and (5)
sterilisation techniques. Daily rounds by unit nursing
supervisors and inclusion of foley catheter necessity on
daily ICU checklists held staff accountable on a daily
basis. With these interventions, the total number of CAUTIs
at BMC decreased from 53 in 2013 to 9 in 2017 (83%
reduction) with a 33.8% reduction in indwelling foley
catheter utilisation during the same time period. Adapted
protocols showed success in decreasing the CAUTI rate
and indwelling foley catheter usage in all of the BMC
ICU’s. While all interventions had favourable and additive
trends towards decreasing the CAUTI rate, the CAUTI
awareness education, insertion and removal protocols and
implementation of PureWick female incontinence devices
had clear and significant effects on decreasing CAUTI
rates. Our project provides a framework for improving HAIs
using rapid cycle testing and U- chart data monitoring.
Targeted education efforts and standardised checklists and
protocols adapted sequentially are low- cost and high yield
efforts that may decrease CAUTIs in ICU settings.

PROBLEM
Healthcare- associated infections (HAIs) are a
significant cause of morbidity and mortality
in hospitalised patients in the USA.1 Catheter-
associated urinary tract infections (CAUTIs),
urinary tract infections that occur in the
context of an indwelling foley catheter, repre-
sent approximately 9% of all HAIs,2 and are
associated with increased morbidity, mortality

and cost in intensive care units (ICUs).3–5
Given that 65%–70% of CAUTIs may be
preventable,6 they are the target of ongoing
national7 and international5 8 preventable
harm initiatives to improve patient safety and
cut costs in the healthcare delivery system. In
an effort to reduce the rate of ICU CAUTIs
at our hospital, we serially implemented
bundled CAUTI- prevention tools and meas-
ured the effect of the implementation on
CAUTI rates in the ICU. In this manuscript,
we describe our experiences using bundled
CAUTI- prevention tools in a tertiary care,
inner city, safety net, medical centre.

BACKGROUND
Boston Medical Center (BMC) is a 487- bed
safety- net hospital in Boston, Massachu-
setts.9 10 In accordance with the Centers for
Medicare and Medicaid Services Hospital
Inpatient Quality Reporting mandate, BMC
reports CAUTI rates to the National Health-
care Safety Network (NHSN). The NHSN
provides hospitals with real- time data on their
HAI performance through various measures
including the Standardized Infection Ratio
(SIR),11 an adjusted index allowing HAI rate
comparison between US hospitals.12 In the
spring of 2013, the SIR for CAUTIs among
BMC ICUs was 65% greater than predicted.
Consequently, BMC formed a multidiscipli-
nary CAUTI task force to implement data-
proven CAUTI- reduction techniques based
on current best practices and guidelines, and
monitored effects of the interventions longi-
tudinally. The formation of the Executive
Critical Care Committee in 2011 by hospital
leadership established the groundwork for
collaboration between all the BMC ICUs
and among the key disciplines involved in
ICU decision- making, including pharmacy,
nursing and physicians. The CAUTI taskforce
aimed to reduce CAUTIs by 10%–20% and
to reduce the BMC SIR for CAUTIs to the
national average.

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2 Van Decker SG, et al. BMJ Open Quality 2021;10:e001534. doi:10.1136/bmjoq-2021-001534

Open access

BASELINE MEASUREMENT
CAUTIs were defined according to the published CDC
definition ((1) use of an indwelling foley for more
than two consecutive days, (2) catheter in place on day
of or day prior to event, (3) two or more symptoms
concerning for CAUTI and (4) urine culture with no
more than two species of organism of which at least
one is a bacterium of ≥105 CFU/mL).13 CAUTIs were
captured in real time using medical chart surveillance.
CAUTI rate, rather than SIR, is readily trackable at
BMC in real time, and thus was chosen as the best
measure to monitor the CAUTI reduction tools used.
In addition, during the intervention, NHSN changed
the definitions of CAUTIs resulting in challenges using
SIR and NHSN percentiles to compare preinterven-
tion and postintervention data. Prior to the planned
interventions, the baseline ICU CAUTI rate was 5.86
per 1000 ICU patient- days with a corresponding SIR
of 1.65.

DESIGN
The CAUTI taskforce is composed of key stakeholders
including representatives from the infection preven-
tion department, quality and patient safety depart-
ment, ICU nurse managers, ICU nurse educators,
urologists and intensivists. We plotted the current
workflow for foley catheter management and CAUTI
identification using process maps, which we then used
to perform gap analyses. Gap analyses identified that

BMC processes diverged from national guidelines,
especially with regard to infection prevention tactics
and CAUTI identification. Subsequently, the CAUTI
taskforce created driver diagrams based on clinician
expertise to delineate key strategies for improvement
in CAUTI rates and conducted preventability analyses
on identified CAUTIs (figures 1 and 2).

Based on CDC and IHI guidelines, and delineated
by the Healthcare Infection Control Practices Advisory
Committee 2009 guidelines,14 we implemented new prac-
tices sequentially in plan–do–study–act (PDSA) cycles
starting with measures that we deemed most easily adapt-
able and most likely positively impact CAUTI rates. The
CAUTI taskforce drafted interventions based on available
guidelines and then distributed intervention protocols to
stakeholders via email listserv, ICU paper postings, depart-
mental meetings and institutional intranet postings. In
preparation for implementation, nurses completed simu-
lation and web- based training programmes. In collab-
oration with the institutional Information Technology
Department, the CAUTI taskforce developed electronic
best practice advisories (BPAs) within the Epic electronic
medical record.

Given the planned sequential implementation and
varied stakeholders involved, the CAUTI taskforce created
a Microsoft Outlook distribution group, (‘DG- CAUTI’),
where clinicians and support staff could email sugges-
tions for improvement of piloted interventions, ask ques-
tions regarding the ongoing CAUTI- reduction efforts

Figure 1 CAUTI driver diagram. Driver diagram depicting primary aim of CAUTI task force as well as proposed primary and
secondary drivers targeted to achieve this aim. Depicted are interventions implimented as part of the CAUTI bundle as well
as those that were reviewed and fall outside of the purview of this intervention. CHG, chlorhexidine gluconate. TTM, targeted
temperature management; NM, nurse manager; MD, physician; HO, house officer; CM, case management; SIR, standard
infection ratio.

3Van Decker SG, et al. BMJ Open Quality 2021;10:e001534. doi:10.1136/bmjoq-2021-001534

Open access

and where CAUTI taskforce members could clarify device
use and protocols.

STRATEGY
The CAUTI taskforce used the PDSA cycle framework to
serially implement initiatives aimed at reducing CAUTI
rates. We plotted CAUTI rates monthly and evaluated
the impact of each PDSA cycle using a standard run
chart. Once we had a sufficient number of data points
(ie, 20) we switched to a statistical process control
chart (SPC). SPC charts are preferable to run charts as
they have upper and lower control limits which more
readily allow for discrimination of special causes from
common cause variation. A U- chart, a specific type
of SPC chart, was used because it accurately analyses
data in which it is possible for an individual patient to
have more than one defect per unit (ie, more than one
CAUTI per episode of foley catheter) and to account
for variable subgroup size (ie, variance in patient
volume each month).

PDSA cycle 1: didactic and simulation-based education
initiative to increase awareness of CAUTIs and standardised
foley catheter insertion and maintenance protocols
(September 2014; project month 0)
The CAUTI task force created nursing and physician
education courses targeting preventability of CAUTIs and
appropriate insertion and maintenance techniques of
indwelling foley catheters. Designated department quality
leaders in surgical specialties and ICU nurse managers
scheduled formal education on foley catheter insertion
and maintenance for staff. Materials used during these
trainings closely paralleled the Healthcare Infection
Control Practices Advisory Committee 2009 guidelines14

and were distributed in May 2014 with the goal of official
implementation by September 2014. Physicians and nurses
completed foley catheter insertion and maintenance
in- person simulation training. Additionally, nursing staff
completed mandatory relevant online modules through
the hospital nursing education portal, received retraining
on foley catheter insertion processes at an annual compe-
tency day, and received 1:1 or small group bedside educa-
tion according to standard ICU practices.

PDSA cycle 2: evidence-based foley catheter use (January
2016, project month 16)
The CAUTI taskforce created and published a list of
hospital- approved indications for indwelling urinary
devices, which they based on national guidelines14 and had
reviewed by the urology department for their specialty-
specific indications for bladder management. We posted
the indications and appropriate foley catheter insertion
and maintenance techniques, titled ‘Bladder Manage-
ment Protocol’, on the local intranet for ease of access.
Nursing managers and department leaders encouraged
providers and staff to remove foley catheters when no
longer meeting indications. To support this effort, nurse
managers used an EMR- generated daily foley catheter
report to identify patients with indwelling catheters and
review if they met criteria to retain them. Feedback via
the DG- CAUTI listserv as well as to nurse managers and
CAUTI taskforce members facilitated continuous refine-
ment of acceptable indications for foley catheter use in
critically ill patients.

PDSA cycle 3: urinalysis (UA) with reflex to culture (January
2016, project month 16)
Too often, patients are identified as having a CAUTI if
they have an indwelling foley catheter, fever and positive

Figure 2 Catheter- associated urinary tract infection (CAUTI) preventability analysis (PA). Process by which the CAUTI
taskforce identified CAUTIs is depicted. Root cause analyses subsequently undertaken to develop designed interventions. HAI,
healthcare- associated infection.

4 Van Decker SG, et al. BMJ Open Quality 2021;10:e001534. doi:10.1136/bmjoq-2021-001534

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urine culture with or without reportable symptoms.13 The
literature demonstrates that a negative UA has an excel-
lent negative predictive value for CAUTI in ICUs as well
as prevent unwarranted antibiotic exposure in critically
ill patients.15–17 Thus, the CAUTI taskforce created a BPA
to encourage practitioners who ordered concurrent UA
and urine culture to change their order to UA only and
those who attempted to order urine cultures without a
recent UA (<24 hours) to cancel the culture order and
instead opt for UA alone. The goal being to reduce the
number of urine cultures sent on non- infectious UAs.
Opt- out criteria for cancelling the simultaneous urine
culture include neutropenia and septic shock. In order
to reduce the likelihood of false positive culture results
due to the presence of biofilms on indwelling foley cathe-
ters,17 patients with a positive UA had a new foley catheter
placed prior to urine culture collection.

PDSA cycle 4: PureWick female incontinence device
(January 2017, project month 28)
Professional organisations advocate for increased use of
external urinary collection devices to prevent CAUTIs.18
Among male inpatients, external collection devices are
associated with a lower incidence of symptomatic UTIs
and bacteriuria than with indwelling devices.19 More
recently, companies have developed external urinary
collection devices for women.20 Recent reports suggest
PureWicks provide a non- invasive method to manage
female urinary incontinence, measure urinary output and
reduce skin breakdown from urinary incontinence.21 22
Despite the early stages of this technology, BMC leader-
ship felt it imperative to be on the forefront of the move-
ment towards non- invasive urinary incontinence manage-
ment, given the promising experiences of other institu-
tions. The CAUTI taskforce implemented a protocol for
the use of the PureWick external catheter among female
ICU patients requiring strict output documentation, had
an indwelling foley catheter for longer than 3 days, or
those on bedrest and at risk for pressure injuries. The
protocol implementation used simulation and online
modules consistent with the methods outlined in cycle 1.

PDSA cycle 5: chlorhexidine gluconate (CHG) bathing (June
2017, project month 33)
CHG baths reduce drug- resistant infections and blood
stream infections from the various life- support equip-
ment used in ICUs.23–25 Independent, but complimentary
to the efforts of the CAUTI taskforce, separate hospital
groups tasked to evaluate and reduce the number of
catheter- associated central line infections trialled CHG
baths for all ICU patients. Education for nursing staff on
how to perform CHG baths used simulation and online
module tools consistent with the methods outlined in
Cycle 1. While the initial reduction in CAUTI rates with
CHG baths showed promise, we halted the practice for
2 weeks in December 2017 following a notable elevation
in CAUTI rate. Investigation by the CAUTI taskforce
found the special cause variation correlated with the

several logistical difficulties, including compatibility of
wipes with hospital infrastructure, coinciding with the
holiday season, when BMC typically sees a slight increase
in CAUTI. Once identified and remediated, the CAUTI
taskforce re- initiated CHG baths and noted a continued
downtrend in CAUTI rates as compared with prior to this
practice’s implementation.

RESULTS
With the above listed interventions, the total number of
CAUTIs at BMC decreased from 53 in 2013 to 9 in 2017
(83% reduction) and a 33.8% reduction in indwelling
foley catheter utilisation from the fourth quarter of 2015
to the fourth quarter of 2017. BMC had a mean CAUTI
rate of 5.86 per 1000 ICU patient- days prior to the above
listed interventions.

We mapped CAUTI rates and intervention time using
a U- chart (figure 3). The data plotted showed a signifi-
cant decrease in CAUTI rate associated with the CAUTI
awareness campaign and with the new foley catheter
insertion and maintenance protocols implemented in
September 2014. These educational efforts decreased
the mean CAUTI rate to 3.25 per 1000 ICU patient- days,
suggesting the creation of a new sustainable system.
Subsequently, the concurrent implementation of the
‘Bladder Management Protocol’ and UA with reflex to
culture resulted in decreased CAUTI rates, however, did
not manage to create a new system as evidenced by the
U- chart. The CAUTI rate in the quarter preceding imple-
mentation of these processes was 2.48 (fourth quarter
2015) and following these interventions was 2.24 in the
first quarter of 2016. The implementation of PureWick
catheter resulted in a significant downward shift in the
mean CAUTI rate to 1.62 suggesting the creation of a
new system with intrinsically lower CAUTI rate. The CHG
bathing protocol initiation correlated with a downtrend
in CAUTI rates with a preimplementation rate of 1.27
in the second quarter of 2017 and postimplementation
rate of 0.61 in the fourth quarter of 2017. The hospital
encountered several challenges in the implementation of
this intervention and noted special cause variation in the
U- chart that required cessation of practice for 2 weeks in
January 2018 for investigation. Eventually we reinstituted
the practice with continued improvement of CAUTI rate
reduction.

DISCUSSION
Our multi- disciplinary CAUTI taskforce reviewed insti-
tutional policies, documented deficiencies, and initiated
rapid cycle testing in the form of PDSA cycles to improve
CAUTI rates. PDSA cycles built off each other, with new
interventions implemented as soon as the CAUTI task-
force finalised the protocols. Protocols showed success in
decreasing the CAUTI rate and indwelling foley catheter
usage in all of the BMC ICU’s. While all interventions had
favourable and additive trends towards decreasing the
CAUTI rate, the CAUTI awareness education, insertion

5Van Decker SG, et al. BMJ Open Quality 2021;10:e001534. doi:10.1136/bmjoq-2021-001534

Open access

and removal protocols, and implementation of Pure-
Wick female incontinence devices had clear and signif-
icant effects on decreasing CAUTI rates. Our project
provides a framework for improving HAIs using rapid
cycle testing and U- chart data monitoring. We identified
and confirmed several CAUTI- reduction methods that
successfully reduce CAUTI rates in ICUs.

Our findings mirror those of several other institutions
who aimed to reduce CAUTI rates in both ICUs and
on medical and surgical floors with bundled care initia-
tives.26–35 We concur with the previous studies that clear
foley catheter indication guidelines, insertion and peri-
care processes, and appropriate testing can effectively yield
lower CAUTI rates. Institutional prioritisation of CAUTI
reduction and continued education of frontline staff
on approved protocols remain excellent ways to reduce
infection rates. This is the first published study using
U- charts to track and display CAUTI reduction effects, as
compared with run charts and alternative control charts.
We believe U- charts most informatively portray the trend
of CAUTI rate as well as allow for interpretation of special
cause effect. We demonstrated significant improvement
in CAUTI rates with the implementation of PureWick
catheters, which to date have been sparsely studied.36–38
Further studies investigating the effects of external
urinary collection devices for female patients, including
PureWicks, is warranted. Despite reaching our intended
outcomes, which included reduction in foley use and
decreased CAUTI rates, we did not specifically design our
intervention to quantitatively assess staff knowledge or
the impact of our educational efforts on staff behaviour.
Thus, we cannot exclude that the improvement in CAUTI
rates were due to other factors. Unexpected hurdles
included the implementation of the CHG bath protocol.

Trial of any new devices or wipes should go through a
hospital’s standardised instrument trialling process.

BMC’s success stemmed in part to the leadership of
the Executive Critical Care Committee and the standard-
isation of processes among all BMC’s ICUs. Thus, the
generalisability of BMC’s results are in a sense limited
by this committee, as institutions without similar cross-
departmental buy- in may be less likely to reproduce these
results. The culture at BMC, stimulated by the Executive
Critical Care Committee, focuses on strong interprofes-
sional collaboration. This culture stimulates an open
dialogue and culture of safety across all the ICUs.

CONCLUSION
Over the course of 4 years, rapid cycle testing of evidence-
based interventions focused on education and proto-
colisation of indwelling foley catheter management and
CAUTI diagnosis with PDSA cycles improved CAUTI
rates at BMC. These interventions achieved a sustained
reduction in CAUTIs at BMC and reduced the foley
catheter utilisation rate. Strong inter- ICU and inter-
professional collaboration to standardise and optimise
processes among the ICUs was critical to the success of
our CAUTI quality improvement programme. Further
studies are needed to compare external urinary collec-
tion devices for females and each practice setting will
need to investigate site- specific requirements with regard
to CHG bathing given our challenges as described above.
However, despite the obstacles, BMC faced in targeted
education efforts and standardised checklists and proto-
cols adapted sequentially are low- cost and high- yield
efforts that may decrease CAUTIs in ICU settings.

Figure 3 Boston Medical Center (BMC) CAUTI rate per 1000 patient- days October 2013 to December 2018. U- chart depicting
CAUTI rate decline in response to rapid cycle testing of CAUTI bundle with a significant decrease in rate of CAUTIs with the
CAUTI awareness campaign and with the new indwelling foley catheter insertion and maintenance protocols implemented in
September 2014 as well as implementation of PureWick catheter. CHG, chlorhexidine gluconate; ICU, intensive care unit; UCL,
upper control limit; UTI, urinary tract infection; IP; inpatient.

6 Van Decker SG, et al. BMJ Open Quality 2021;10:e001534. doi:10.1136/bmjoq-2021-001534

Open access

Acknowledgements Thank you to Deeksha Ahluwalia, MPH for providing
statistical support and figure design of key figures included in the manuscript.

Collaborators Deeksha Ahluwalia, MPH

Contributors JM played an integral role in the study design, assisted stakeholders
with evaluation of evidence- based practices and implementation of chosen
practices, contributed to editing of manuscript and provided statistical and study
design expertise. JM is the guarantor of this publication. NB provided statistical
expertise and study design expertise and was critical to the editing of manuscript.
SGVD performed data analysis and wrote and edited manuscript. All authors
contributed to and approved the final manuscript.

Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not- for- profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication Not applicable.

Ethics approval This study does not involve human participants.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement Data are available upon request.

Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

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• Catheter-­associated urinary tract infection reduction in critical care units: a bundled care model

Abstract

Problem

Background

Baseline measurement

Design

Strategy

PDSA cycle 1: didactic and simulation-based education initiative to increase awareness of CAUTIs and standardised foley catheter insertion and maintenance protocols (September 2014; project month 0)

PDSA cycle 2: evidence-based foley catheter use (January 2016, project month 16)

PDSA cycle 3: urinalysis (UA) with reflex to culture (January 2016, project month 16)

PDSA cycle 4: PureWick female incontinence device (January 2017, project month 28)

PDSA cycle 5: chlorhexidine gluconate (CHG) bathing (June 2017, project month 33)

Results

Discussion

Conclusion

References

Running head: GUIDED IMAGERY AND PROGRESSIVE MUSCLE RELAXATION

2

1

Evidence-Based Practice Article Critique

In this paper, I will be critiquing an evidence based article about Catheter Associated Urinary Tract Infections (CAUTI). CAUTIs are one of many Hospital Acquired Infections (HAI) that are common in critical care units where many patients are chemically sedated and ventilated. HAIs must be treated by hospitals usually with no cost to the patient or insurance company. In this article, a CAUTI bundle was implemented in Boston Medical Centers (BMC) Intensive Care Units (ICUs). Through a near 5-year time frame they implemented 5 key CAUTI bundles. This was started in 2013 and lasted through the end of 2017. The use of CAUTI prevention bundles was introduced by administrators and enforced by unit nursing supervisors.

The following care bundles implemented included, Foley catheter insertion techniques and maintenance, indications for introducing Foley catheters, appropriate testing for CAUTIs, the use of alternatives to indwelling catheters, and sterilization techniques. Daily ICU checklists included determining if Foley catheters are to remain in place.

References

Van Decker, S. G., Bosch, N., & Murphy, J. (2021). Catheter-associated urinary tract infection reduction in critical care units: a bundled care model. 
BMJ open quality, 
10(4), e001534. https://doi.org/10.1136/bmjoq-2021-001534