Resource Library-Decatur Memorial Hospital Significantly Reduces Hospital Acquired Catheter Associated Urinary Tract Infections

Video Transcription

Video Summary

Stacy Taylor, Director of Professional Nursing Practice at Decatur Memorial Hospital, describes a hospital-wide quality improvement project that significantly reduced catheter-associated urinary tract infections (CAUTIs). She explains the high human and financial toll of healthcare-associated infections, sharing a personal story about her grandfather’s preventable infection complications to underscore the stakes.<br /><br />After COVID-era increases in catheter use and CAUTIs, a newly formed Nursing Performance and Outcomes Council selected CAUTI prevention as a priority and used the Plan-Do-Check-Act (PDCA) model. Data review showed 10 CAUTIs (SIR 1.677 vs. target 0.810), all occurring more than four days after insertion—pointing to maintenance, not insertion, problems. Root-cause analysis identified inconsistent bathing/perineal care and lack of standardized policy.<br /><br />An evidence review supported daily 2% chlorhexidine (CHG) bathing (replacing soap-and-water baths) and CHG perineal/foley care twice daily and as needed. Policies, job aids, product standardization, training, and unit-level real-time monitoring were implemented, with troubleshooting around EHR changes, supply levels, warmer availability, and CHG sensitivity concerns.<br /><br />Go-live occurred in Feb 2023, resulting in zero CAUTIs for eight months and only one CAUTI over the following 16 months, beating benchmarks. The team also saw concurrent CLABSI reductions, suggesting broader benefits of improved CHG bathing compliance.

Asset Caption

Speaker: Stacey Taylor, MSN, RN

The session will include an overview of a successful PDCA project to reduce CAUTI rates led by the hospitals nursing council. Tools used to understand root causes included 5 Why Analysis and a Driver Diagram. Best practice interventions supported by literature and how they were successfully implemented and sustained will be shared. After interventions, the average CAUTI Standard Infection Ratio (SIR) decreased from 1.10 to 0.18 with 0 CAUTIS in 12 out the 13 months post intervention.

Meta Tag

Competency Tag PPI1

Competency Tag Description Implement standard performance and process improvement (PPI) methods into individual, team and project work activities

Domain Tag Performance and Process Improvement

Keywords

catheter-associated urinary tract infections (CAUTI) reduction

hospital-wide quality improvement project

Plan-Do-Check-Act (PDCA) model

chlorhexidine (CHG) bathing protocol

perineal and Foley catheter care standardization

Nursing Performance and Outcomes Council

root-cause analysis and maintenance bundle

healthcare-associated infection prevention benchmarks