ANSWER
Appropriate Indications
In 2009, the Centers for Disease Control and Prevention’s (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC) recommended a list of appropriate and inappropriate indications for indwelling urinary catheter placement.15 The list was based on a critical review of the available medical literature. Because of the lack of high-quality studies examining indications for urinary catheterization, the recommended indications for catheter use primarily represented expert consensus opinion.
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In May 2015, refined guidelines for urinary catheter use were published in a special supplement to Annals of Internal Medicine, “The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients.” 16 Four coauthors of these published guidelines were faculty members of the national AHRQ-funded On the CUSP: Stop CAUTI project. The authors developed the guidelines through work with a 15-member expert panel using the RAND/UCLA Appropriateness Method,17 which combines a review of available literature with input by an expert panel to assess whether the expected benefits of a medical procedure outweigh potential harms. Refinements of the HICPAC guidelines based on the Ann Arbor Criteria are included below for appropriate and inappropriate indications and possible alternatives to indwelling transurethral urinary catheters (commonly known as Foley catheters).

Appropriate indications for indwelling urinary catheters are summarized below:

Acute urinary retention or obstruction—Indwelling urinary catheters (IUCs) are indicated for managing acute urinary retention without bladder outlet obstruction, such as medication-related urinary retention or sensitive neurogenic bladder. IUCs are also shown for some types of acute urinary retention with bladder outlet obstruction, such as an exacerbation of benign prostatic hypertrophy; however, urology consultation should be considered for the most appropriate catheter type and expert placement in cases of acute prostatitis and urethral trauma. Indwelling urinary catheters are suitable for managing gross hematuria with blood clots in the urine to prevent obstruction related to the nuggets. An IUC may also be applicable to drive chronic urinary retention with bladder outlet obstruction. Patients with chronic urinary retention without bladder outlet obstruction, such as neurogenic bladders, are often best handled by non-indwelling methods such as intermittent straight catheterization.
Accurate measurement of urinary output in critically ill patients—Indwelling urinary catheters are the only method to measure hourly urine output when needed to manage critical illnesses such as hemodynamic instability, frequent titration of life-supportive therapy such as intravenous drips requiring close titration (e.g., vasopressors or inotropes), and certain essential technologies of care to support respiratory and cardiac failure. Indwelling urinary catheters may also be appropriate to measure daily urine output if required to provide medical treatment and cannot be assessed by alternative strategies such as urinal/bedpan, external catheter, or physical examination methods to assess volume status. However, routine use of catheters in the intensive care unit (ICU) without indication is inappropriate. ICU patients who are hemodynamically stable often do not require urinary catheters and are appropriate candidates for alternate means of collecting or measuring urine output (see Consider Alternatives to Indwelling Urinary Catheters subsection below).
Perioperative use in selected surgeries—According to the 2009 HICPAC guideline, urinary catheters are indicated perioperatively for established surgical procedures. Catheters are shown when surgery is expected to be prolonged, when a patient will require large-volume infusions or diuretics during surgery, or when there is a need for intraoperative urinary output monitoring. Catheters are also indicated for urologic surgeries or other surgeries on the genitourinary tract contiguous structures. Catheters placed for surgery duration should be removed in the post-anesthesia care unit. Urinary catheters should not be used routinely for patients receiving epidural anesthesia or analgesia.18 Among these patients, the risk of acute urinary retention can be reduced by promptly discontinuing the epidural medication and using bladder scanners to monitor for acute urinary retention in the immediate postoperative period (see Consider Alternatives to Indwelling Urinary Catheters subsection below).
Assistance with the healing of stage III or IV perineal and sacral wounds in incontinent patients—This is a relative indication for urinary catheter use when there is concern that urinary incontinence is leading to worsening skin integrity in areas where skin breakdown already exists. For example, indwelling urinary catheters can be appropriate for stage III, IV, or unstageable pressure ulcers or similarly severe wounds that cannot be kept clear of urinary incontinence despite wound care and other urinary management strategies. Urinary catheters should not be used as a substitute for skin care, skin barriers, and other methods to manage incontinence and limit skin breakdown. An indwelling urinary catheter may be needed when turning a patient causes hemodynamic or respiratory instability, in cases of strict prolonged immobility (such as an unstable pelvic or spine fracture) or rigid temporary stiffness, or when the patient’s weight exceeds 300 pounds due to severe edema or obesity, and the patient’s weight impairs nursing care. A catheter may be needed when nurses do not have resources such as lift teams and mechanical lifts to help turn a heavy patient frequently to provide the necessary skin care.
Hospice/comfort/palliative care—This is a good indication for catheter use in end-of-life care when it facilitates meeting patient and family goals in a dying patient or helps with patient comfort. However, all indwelling urinary catheters can cause discomfort during placement and use, and not all patients or families desire urinary catheters.
Necessary immobilization for trauma or surgery—Indwelling urinary catheters may be used when patients require strict prolonged immobilization following specific types of trauma or surgery. Examples include instability in the thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures, and acute hip fractures when there is a risk of displacement with movement before surgical repair.
Other appropriate indications, based on the Ann Arbor Criteria, include the following:

Single 24-hour urine sample for diagnostic testing that other urine collection strategies, such as urinal, bedside commode, bedpan, external catheter, or intermittent straight catheter, cannot obtain.
Indwelling urinary catheters may be appropriate to reduce the need for movement in the patient with acute severe pain when other urine management strategies are complex, such as a critical, unrepaired hip fracture; however, catheter use should be reconsidered once acute pain is better controlled.
Clinical conditions for which intermittent straight catheters or external catheters would be appropriate, but placement by an experienced nurse or physician is difficult.
In a patient for whom bladder emptying was inadequate with non-indwelling strategies.
Inappropriate Indications
Urinary catheters should not be placed in the following situations:

Urine output monitoring that can be obtained by means other than an indwelling urinary catheter—Many patients currently receive urinary catheters to monitor urine output as part of routine care when admitted for specific conditions such as heart failure or renal failure. When urine output monitoring is needed to provide care, but the hourly measurement is not required, alternatives to indwelling catheters should be prioritized. Some potential solutions are using male, female, or unisex urinals, graduated collection containers (“hats”) in the commode, and accurate daily weights. For patients with congestive heart failure, consider involving the patients and family members. Providing patients and family members with educational materials on documenting urine output and daily weight may assist in this process. It may be helpful to provide information for assessing urine output after discharge from home.

Exceptions: The benefits of urinary catheters may outweigh potential harms in cases where hourly measurement of urine volume is required to provide treatment (such as management of hemodynamic instability, severe electrolyte imbalance, or hourly titration of fluids, drips, or life-supportive therapy that occurs outside the ICU). Catheters may also be used when daily urine volume measurement is required to provide treatment and cannot be assessed by other strategies.
Incontinence without a sacral or perineal pressure sore—Urinary catheters should not be routinely placed to manage urinary incontinence in patients for whom skin care can be provided. Remember that patients with preexisting incontinence manage their incontinence before admission. Nursing homes rarely use urinary catheters to manage urinary incontinence, even though this is a common comorbidity for nursing home residents. Mechanisms to keep the skin intact need to be instituted on admission. Some potential solutions for the management of incontinence include using skin barrier creams for skin protection, high-absorbency briefs or pads that wick moisture away from the skin, and scheduled voiding by using a bedpan or frequent assistance to the bedside commode. Check for any wet bed linen, and change linens if wet when the patient is being turned in bed. In addition, external (“condom”) catheters may be an alternative to manage urinary incontinence in cooperative male patients without urinary retention or obstruction.

Exceptions: The use of an indwelling urinary catheter may be appropriate to manage incontinence in patients with morbid obesity or severe edema for whom available resources are inadequate for standard turning protocols.
Prolonged postoperative use—Urinary catheters should be promptly discontinued within 24 hours or less after surgery unless there is an appropriate indication for continued postoperative catheter use (e.g., structural repair of the urethra or adjacent structures, acute urinary retention per bladder scanner, etc.).
Other potentially inappropriate uses of urinary catheters include the following:
Patients being transferred within or from an acute care facility—Any handoff transition when a patient moves from one unit to another is an opportunity for the off-going and oncoming staff to review together whether the patient indicates continued use of an indwelling urinary catheter. In particular, transfer from the ICU or emergency department to an acute-care setting frequently triggers an opportunity to remove a urinary catheter.
Morbid obesity or immobility—Morbid obesity or immobility alone is not an appropriate indication for urinary catheter placement. Patients who are morbidly obese have functioned without a urinary catheter before admission. The combination of immobility and morbid obesity may lead to inappropriate urinary catheter use. However, this may lead to more immobility, with the urinary catheter being a “one-point restraint.” Some potential solutions include scheduled toileting every 2 hours, using a bedpan or urinal, or assisting the patient out of bed to a toilet or appropriately sized bedside commode.
Confusion or dementia—Confusion or dementia is not an appropriate indication for urinary catheter placement. See Consider Alternatives to Indwelling Urinary Catheters subsection below.
Patient and family request—Patient and family request is not a sufficient reason for placing a urinary catheter. Explain to the patient and family the risk of infection, trauma, and immobility related to using the urinary catheter. Consider providing them with educational materials on the dangers of CAUTI. For example, suppose a patient is on diuretics and does not want to move out of bed multiple times. In that case, a catheter should not be used as a substitute for urine collection otherwise available by urinal, bedpan, or toilet. Education is key! Explain to the patient the increased risks of using a urinary catheter and the resulting immobility: urine infection, skin breakdown (pressure ulcers), and deep venous thrombosis. An exception would be for patients receiving end-of-life or palliative care and in whom a catheter would facilitate meeting quality-of-life goals (appropriate indication #5 described above).
Other inappropriate uses for indwelling urinary catheters, based on the Ann Arbor Criteria, include the following:

Attempting to reduce the risk of falls by minimizing the need to get up to urinate
Postvoid residual urine volume assessment
Random or 24-hour urine sample collection when collection by another strategy is feasible
When a patient is ordered for “bed rest” without a strict immobility requirement
Attempting to prevent UTI in patients with fecal incontinence or diarrhea
Management of frequent, painful urination in patients with UTI
Indwelling urinary catheter use is not effective in reducing falls or reducing the risk of UTI in patients with fecal incontinence or diarrhea.

Consider Alternatives to Indwelling Urinary Catheters
Consider alternatives to an indwelling urinary catheter based on a patient’s care needs. All alternative devices and procedures provide a much lower risk of infectious complications, such as urinary tract infections. Additionally, these alternative methods can reduce or eliminate noninfectious complications associated with indwelling urethral catheters, such as discomfort and immobility.

Identify alternatives to indwelling urinary catheters with consideration of the target populations. Involve the Supply Chain/Materials Management Department in the search for other options. Samples of products can be obtained so that staff can conduct a trial to identify which products work best with the patient population. Product representatives can provide staff guidance and instruction on using their devices correctly. The team should complete product evaluations so that this information can be used to determine the best alternative product(s). When products have been procured, consider defining appropriate indications for use and sharing that information with staff.

Before placing an indwelling catheter, consider if these alternatives would be more appropriate:

Bedside commode, urinal, incontinence garments for both sexes, and external condom catheter for males —Use these tools to manage incontinence. Additional planning and personnel resources may be required to ensure that patients are regularly prompted and assisted with voiding or assessed for incontinence. Consider involving staff from other departments to assist unit staff with scheduled voiding/toileting, such as respiratory, physical, or occupational therapists.
Bladder scanner—Use this tool to assess and confirm urinary retention before placing a catheter to address suspected urinary retention to reduce unnecessary catheterization when the bladder’s volume is not the cause of the patient’s symptoms. Portable bladder scanners use ultrasound, a noninvasive way to determine the volume of urine remaining in the bladder after voiding (i.e., postvoid residual), to inform whether a urinary catheterization is needed. For example, portable bladder ultrasounds are helpful in medical, surgical, or rehabilitation units to determine whether a patient has sufficient urinary retention to justify catheterization. Nurse-driven protocols and handheld bladder scanners have been shown to reduce the risk of CAUTI.19
Straight catheter—A straight catheter can be used for one-time, intermittent, or chronic voiding needs. Intermittent catheterization is most often used in patients with neurogenic bladder or spinal cord injury and lessens the risk of urinary tract infection compared to chronic indwelling urinary catheters. Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction. When the patient returns to the community, intermittent catheterization enhances patient privacy and dignity and facilitates the return to activities of daily living. It is essential to perform intermittent catheterization at regularly scheduled intervals to avoid overdistending the bladder. Among hospitalized patients, one-time or periodic catheterization is often used with a portable bladder scanner ultrasound.

Intermittent straight catheterization (ISC) is appropriate for the following indications:
Acute urinary retention without bladder outlet obstruction if the bladder can be emptied adequately by ISC every 4 hours or less often.
Acute urinary retention with bladder outlet obstruction due to noninfectious, nontraumatic diagnosis such as benign prostatic hypertrophy
Chronic urinary retention with or without bladder outlet obstruction
Stage III or IV or unstageable pressure ulcer, or similarly severe wounds of other types that cannot be kept clear of urinary incontinence despite wound care and different urinary management strategies, if ISC is adequate to manage the type of incontinence
Urinary incontinence that is treated and can be controlled by ISC
Urine volume measurements (not hourly) or sample collections in patients using ISC for urinary retention/obstruction or overflow incontinence
Random urine sample collection, if impossible by other collection strategies
Management of urination in patients with strict temporary immobility if ISC does not require excessive movement
Postvoid residual urine volume assessment if bladder scanner is unavailable or inadequate and more detail than suprapubic fullness is needed
ISCs are inappropriate when the hourly measurement of urine volume is required to provide treatment or for random urine sample collection if the collection is possible by other collection strategies.

External “condom” catheter—This is appropriate for cooperative men without urinary retention or obstruction who are not expected to frequently manipulate the urinary catheter due to behavior issues such as delirium. External catheters are helpful, especially for managing incontinence in cooperative elderly male patients with dementia who remain underutilized.20 In a randomized clinical trial among 75 male patients at a Veterans Affairs medical center, condom catheters reduced the cumulative risk of urinary tract infection or death. They were better tolerated than indwelling urinary catheters.21 When using condom catheters, it is essential to choose an appropriate size to improve fit and adherence, which limits the risk of urine leakage or penile trauma. Utilize the help of the central supply manager to obtain samples of new/improved condom catheters on the marketplace and trial them on the unit. Engage the input of frontline staff to determine which products to add to the hospital and department Central Supply stock.

External catheters are appropriate for the following indications:
Stage III or IV or unstageable pressure ulcers or similarly severe wounds of other types that cannot be kept clear of urinary incontinence despite wound care and different urinary management strategies
Moderate to severe incontinence-associated dermatitis that cannot be controlled clear of urine despite different urinary management strategies
Urinary incontinence in patients for whom nurses find it challenging to provide skin care despite different urinary management strategies and available resources, such as lift teams and mechanical lift devices
Daily (not hourly) measurement of urine volume that is required to provide treatment and that cannot be assessed by other volume and urine collection strategies
Single 24-hour or random urine sample for diagnostic testing that cannot be obtained by different urine collection strategies
Reduction in acute, severe pain with movement when other urine management strategies are difficult
The patient requested an external catheter to manage urinary incontinence while hospitalized
Improvement in comfort when urine collection by outer catheter addresses patient and family goals in a dying patient
Although the risk of urinary tract infection is reduced with the use of condom catheters as opposed to indwelling catheters, condom catheters do carry some risk of disease. External catheters are inappropriate in the following cases:22

An uncooperative patient is expected to frequently manipulate catheters because of such behavior issues as delirium and dementia.
Any type of urinary retention (acute or chronic, with or without bladder outlet obstruction)
Hourly measurement of urine volume is required to provide treatment
Urinary incontinence in patients with intact skin when nurses can turn/provide skin care with available resources and when the patient has not requested the external catheter
Routine use in ICU without an appropriate indication
To attempt to reduce the risk of falls by minimizing the need to get up to urinate
Postvoid residual urine volume assessment
Twenty-four-hour or random sample collection, if the group is possible, by noncatheter strategies.
For the convenience of urinary management in the patient during transport for tests and procedures
Patient or family request when there are no expected difficulties managing urine by commode, urinal, or bedpan in nondying patient
To prevent urinary tract infection in patients with fecal incontinence or diarrhea or to manage frequent, painful urination in patients with urinary tract infection.
Engaging Patients and Families
If a patient (or the patient’s family) requests that a urinary catheter be placed, communicate to them the risks involved with catheter use, including urinary tract infection. One effective way to gain the support of patients and their family members in CAUTI prevention efforts is to include patients and families in unit education efforts. Consider editing CAUTI education materials to reduce jargon and frame the content to reflect the patient/family perspective. Emphasize the role of patients and families as partners in care. Another approach is to talk with patients and their family members during rounds about the team’s efforts to reduce CAUTIs. Listen to their concerns and suggestions and report your findings at team meetings.

Proper Catheter Insertion and Maintenance
Properly Trained Clinicians
Ensure that only staff members trained in aseptic technique for catheter insertion are given responsibility for catheter placement. The trained staff should have their proficiency documented before independent catheter insertions. Consider using two staff members to perform all catheter insertions. The second staff member can function as a “helper,” assisting with patient positioning or as a runner if more supplies are needed during catheter placement. Involve frontline staff in assessing compliance with the maintenance of the aseptic technique during insertions using a checklist.

Aseptic Insertion
Techniques for catheterization of female and male patients vary. The New England Journal of Medicine has published two widely referenced articles with accompanying instructional videos on catheterization of females and males.23, 24 Evaluate your facility’s the policy/procedure for placement of indwelling urinary catheters to ensure that the policy follows evidence-based practice. If the policy does adhere to the evidence base, then ensure that the policy is followed consistently. Use audits and observations of training and ensure that collected data are reported back to staff doing this procedure.

Appropriate Maintenance
Implement a policy/procedure for the care of patients’ urinary needs that delineates catheter care and maintenance guidelines.

Catheter maintenance requires knowledge of proper aseptic technique and the mechanics of drainage. Staff should be aware of the following considerations:

If there are breaks in the aseptic technique, disconnection of drainage tubing from the catheter, or malfunctioning the catheter and drainage system, replace the catheter and the drainage system.
Make sure urinary flow is not obstructed. Ensure the catheter tubing is not kinked.
Drainage bags should always be placed below the level of the patient’s bladder to facilitate drainage and prevent stasis of urine.
Urine in drainage bags should be emptied at least once each shift and before any unit transfer (e.g., going to radiology) using a container designated for that patient only. Care must be taken to keep the outlet valve from becoming contaminated.
Follow standard precautions by using gloves and proper hand hygiene before and after handling the drainage device.
Do not change catheters or urinary drainage systems routinely to prevent CAUTI. Consider changing the urinary system in case of infection, obstruction, or a break or leak of the closed system.
Do not remove the seals between the catheter and the drainage tubing or disconnect the closed system.
Avoid irrigation. If catheter obstruction is determined and the catheter remains indicated, replace the catheter and drainage system.
When obtaining a urine sample from the system, disinfect the sampling port and allow the disinfectant to dry before accessing the port.
Frequently washing the meatus with povidone-iodine or soap is not associated with a lower infection risk. Frequent meatal cleaning may be associated with an increased risk of CAUTI. The CDC recommends routine perineal hygiene using soap and water during daily bathing.
Only healthcare workers, family members, or patients who know the correct technique of aseptic insertion and maintenance of the catheter should handle catheters. Healthcare workers and others who take care of catheters should be given periodic education (e.g., annual instruction on insertion and maintenance with competency testing), stressing the correct techniques and potential complications of urinary catheterization.

Prompt Catheter Removal
Nurses and physicians should be aware of urinary catheter use indications and continually monitor the patient’s ongoing need for a catheter. Nurses evaluating their patient’s catheter use and finding no current clue should contact the physician to discontinue the catheter or independently remove it if their hospital has a nurse-driven removal protocol. Physicians should promptly order the discontinuation of catheters that are no longer needed if the hospital does not have a nurse-driven removal protocol.

One prominent reason for inappropriate catheter use is a lack of awareness among clinicians of current catheter use. In a study published in 2000, 18 percent of medical students, 22 percent of interns, 28 percent of residents, and 35 percent of attending physicians were unaware that the patients for whom they were responsible had an indwelling catheter.25

Reminders and Stop Orders
Reminders that a urinary catheter is in use and stop orders are low-cost/high-impact methods for reducing the duration of catheter use. Reminders can be written, verbal, or electronic (e.g., computer order entry) and may include appropriate indications for continued catheter use and alternatives to indwelling catheters. Reminders are handy at the time of transition of care when nurse-to-nurse communication can prompt the removal of catheters that are no longer indicated. Automatic stop orders produce the removal of urinary catheters based on a specified time (e.g., within 24 hours of surgery) or clinical criteria. In a systematic review of 14 urinary catheter reminder systems studies, daily reminders and automatic stop orders reduced the overall risk of CAUTI by 48 percent and the average duration of catheter use by 2.6 days. Yet, these measures were not associated with an increased rate of catheter reinsertion compared with standard care.26

Nurse-Driven Protocol for Catheter Removal
The role of nursing is critical to reducing the inappropriate use of urinary catheters.27-29 A nurse-driven protocol for removing indwelling urinary catheters has been proven effective in lowering catheter use and preventing CAUTI. A widely used protocol, available as Appendix M, utilizes an algorithm for assessing urinary catheters and discontinuation of catheters that are no longer necessary. This protocol does not require a physician order for the discontinuation of catheters.

Unit team leaders can take steps to encourage the use of a nurse-driven protocol for catheter removal through the following:

Early engagement of the physician champion
Presentation of data before implementation
Approval of the protocol by physician and nursing leadership before implementation
Recognition that physicians and nurses must continue to discuss unusual cases
Education of nursing staff
Involvement of staff on matters related to reducing catheter use
Use of bedside catheter rounds to provide one-on-one coaching about when to remove catheters
Assurance that team is fully supported in removing unnecessary urinary catheters
Sharing and celebration of results with frontline staff
Having physician champions engaged in developing the protocol and process is critical. A winner may be an epidemiologist, infectious disease physician, urologist, chief medical officer, or someone in a physician leadership role. Characteristics to look for when identifying a physician champion can be found in Appendix A. Share information on the outcomes of using the nurse-driven protocol. The results often demonstrate that this approach reduces infections. These data can be used to garner support from the medical staff and usually are most effectively disseminated to physicians by the physician champion. It is also essential to address the noninfectious harms of unnecessary urinary catheters, such as discomfort and immobility related to the urinary catheter. Before implementation, the executive medical committee and nursing leadership should approve the criteria for nurse-driven removal. The nurse-driven catheter removal protocol does not preclude the need for nurses and physicians to discuss individual circumstances.

Education about evidence-based practices to prevent CAUTI (e.g., nurse-driven protocol) is one of the first actions the CAUTI prevention team can use to begin the CAUTI prevention journey with the staff. Provide education on the approved indications for the use of urinary catheters, and distribute posters, name tag cards, and other tools listing the symptoms. Use case scenarios to teach the best use of the nurse-driven protocol for removing catheters. Create an acute urinary retention protocol to govern nursing decisions if a patient cannot void after removing an indwelling urinary catheter. A sample protocol is as follows:

Prompted voiding every 4–6 hours (up to bathroom or bedside commode, urinal, or bedpan only if unable to get out of bed).
Check postvoid residual (PVR) with a bladder scan every 4–6 hours after prompted or spontaneous voiding (where a bladder scan is available).
Intermittent straight catheterization every 4–6 hours if PVR on the scanner is more significant than 300 mL or the patient cannot initiate prompted or spontaneous voiding.
Discontinue scanning if PVR results are less than 100 mL for three consecutive scans.
Notify the physician of failure of prompted or spontaneous voiding after 24 hours.
Involving staff in matters related to reducing catheter use increases ownership of the CAUTI prevention effort. Including bedside staff at the inception allows them to gain ownership and buy-in to embed the new practices into their daily work.

Consider using a train-the-trainer format for staff education around the proper use and removal of urinary catheters. Peer-to-peer education increases buy-in. Support staff in designing and piloting new systems to decrease the use of catheters and CAUTI, such as performing daily safety huddles to decide which catheterized patients no longer have an approved indication for an indwelling urinary catheter.

Involve bedside or frontline staff in assessing the hospital’s supply and unit’s supply of urinary equipment and in testing new equipment used to care for the urinary needs of the unit’s patients (e.g., incontinence equipment: female urinals, superabsorbent pads, barrier creams, condom catheters made of silicone in different sizes). Provide bedside staff with an evaluation tool to record their perceptions of new processes and equipment and provide feedback to frontline staff on the evaluation results. Inform staff of the decisions made using their input and all considerations included when making new equipment purchases (e.g., safety and efficacy published, cost comparisons, ease of use).

Teach about appropriate care for acute urinary retention that may occur. Check the adequacy of the supply of bladder scanners on the unit and ensure staff understanding of how best to use them. A sample bladder scan policy is available in Appendix C. If the unit supply area has new equipment for incontinent patients without catheter use, ensure that staff is proficient in using this equipment. Using new equipment to care for incontinent patients requires that the team be given time to adjust. Change can be challenging, and there is a learning curve to mastering new items, such as a female urinal.

Ensure staff members are fully supported in removing unnecessary urinary catheters. All nurses who remove a patient’s catheter based on the nurse-driven protocol should be supported by their charge nurse, nurse manager, and the CUSP-CAUTI team’s physician champion. Recognize staff for changes in their behavior. Consider giving “Catheter Removal Star of the Month” awards to those who excel at appropriately choosing to remove catheters that are no longer needed quickly. Hold staff accountable if they are reluctant to try new care systems for catheterized patients. Plan for the succession of CAUTI team members and physician champions (e.g., term limits with automatic transfer of team leader and physician champion role every year).

Sharing process (catheter use and appropriateness) and outcome (CAUTI rate) data with frontline staff is an effective motivator and is critical to sustaining project gains over time. Post a graph in the nurse’s station illustrating progress in decreasing catheter days to motivate and encourage staff to continue to improve. Reward staff for their work in reducing unnecessary urinary catheters. Consider hosting a pizza party or other event that includes the hospital leaders thanking the staff for embracing the new processes of care and demonstrating a reduction in CAUTI. Managers, physician leaders, and administrators should appreciate teams that set goals, make progress toward goals, and then reach their CAUTI prevention goals. Patients and their families may also be interested and appreciative. Plan for celebrations along the journey to thank the staff for their extraordinary patient safety culture improvements.

Antimicrobial Stewardship
Inadvertent increases in antimicrobial use that result from overuse of urine cultures and treatment of asymptomatic bacteriuria can lead to antimicrobial resistance, Clostridium difficile infection, and adverse drug events. Antimicrobial stewardship measures, such as improved processes around urine culturing, are crucial to patient safety. Eliminating unnecessary urinary catheters is the best defense against accidental increases in antimicrobial use. Among patients who do need a urinary catheter, following proper guidelines for urine culturing and understanding the signs and symptoms of CAUTI can reduce antibiotic overuse.30, 31

Avoiding Excessive Urine Cultures
Obtaining urine cultures in patients with indwelling urinary catheters without a valid reason can lead to accidental increases in antimicrobial use.

The following are appropriate conditions for urine culture use:

Evaluation of sepsis without an apparent source (CAUTI is often a diagnosis of exclusion)
Based on local findings suggestive of CAUTI (e.g., pelvic discomfort or flank pain)
Before urologic surgeries where mucosal bleeding is anticipated or transurethral resection of the prostate
Early pregnancy (avoid urinary catheters if possible)
Unacceptable conditions for urine culturing are as follows:

Urine quality: color, smell, sediments, turbidity (these characteristics do not constitute signs of infection)
Screening of urine cultures (whether on admission or before neurologic surgeries)
Standing orders for urinalysis or urine cultures without signs and symptoms of UTI
“PAN” culturing in the absence of sepsis or specific symptoms (mindfulness in evaluating the most likely infection source is critical)
Obtaining urine cultures based on pyuria in an asymptomatic patient
Asymptomatic elderly and diabetic patients (high prevalence of asymptomatic bacteriuria)
Repeat urine culture to document clearing of bacteriuria (no clinical benefit to patients)
To reduce unnecessary urine cultures, evaluate current processes for obtaining urine cultures (e.g., avoid urinalysis or urine cultures as part of standing orders, laboratory triggers to do urine cultures based on urinalysis results, screening urine cultures on admission in an asymptomatic patient—including those arriving with an indwelling urinary catheter). Engage infection preventionists and infectious disease physicians in evaluating reasons given for urine cultures. Avoid having automated orders for urinalysis or urine cultures unless there is an appropriate reason, such as urinary tract infection symptoms. Evaluate practice patterns for certain physician groups, specialties, or units. Ordering cultures should be based on the clinical evaluation of the patients for potential sources of sepsis. Preoperative urine cultures in patients who are not undergoing urologic surgeries are discouraged.32

Educate physicians, midlevel providers, and nurses on when it is appropriate to obtain urine cultures in patients with an indwelling urinary catheter. You may consider implementing institutional guidelines or algorithms. Have periodic audits on urine culture use in intensive care units to look for trends, significantly if CAUTI rates are not dropping with interventions focused on improving insertion and maintenance.

Not Treating Asymptomatic Bacteriuria
The best way to avoid inappropriate antimicrobial use in catheterized patients is to refrain from obtaining a urine culture unless indicated by signs and symptoms of urinary tract infection. When a urine culture is positive in a catheterized patient with no infection symptoms, do not treat that patient with antimicrobials. Guidelines by the Infectious Diseases Society of America strongly discourage using antimicrobials for asymptomatic bacteriuria except for patients undergoing urologic procedures or pregnant.33

One or more of the following symptoms should be present before treating a patient for CAUTI:

Fever, rigors, or sepsis, with no other identified cause
Altered mental status, malaise, or lethargy with no other identified cause
Flank pain
Costovertebral angle tenderness
Acute hematuria
Pelvic discomfort
Dysuria, urgent or frequent urination, or suprapubic pain or tenderness in those whose catheters have been removed.
QUESTION
CAUTI Prevention

create an interview transcript of your responses to the following interview questions:

Tell us about a healthcare program, within your practice ( CAUTI PREVENTION). What are the costs and projected outcomes of this program?

Who is your target population?

What is the role of the nurse in providing input for the design of this healthcare program? Can you provide examples?

What is your role as an advocate for your target population for this healthcare program? Do you have input into design decisions? How else do you impact design?

What is the role of the nurse in healthcare program implementation? How does this role vary between design and implementation of healthcare programs? Can you provide examples?

Who are the members of a healthcare team that you believe are most needed to implement a program? Can you explain why?