Catheter-Associated Urinary Tract Infection Reduction in a Pediatric Safety Engagement Network - Beyond the Abstract

Catheter-associated urinary tract infections (CAUTIs) are a major cause of harm in hospitalized children. While CAUTI prevention insertion and maintenance bundles have been developed, implemented, and validated in adult populations, their applicability to pediatric populations has been unclear because validation studies in children have been limited to small populations with a short duration of follow up. Our report in Pediatrics describes the CAUTI prevention efforts of the Children’s Hospitals’ Solution for Patient Safety (SPS), a pediatric safety engagement network consisting of over 135 children’s hospitals.1,2

SPS content experts evaluated best practices in CAUTI prevention to develop and implement insertion bundles and maintenance bundles suitable for use in children. The consensus was that CAUTI prevention bundles developed for implementation in adults were largely applicable for pediatric use. The pediatric insertion bundle includes two standard elements supported by high- to moderate-quality evidence: 1) use the aseptic technique on insertion and 2) avoid unnecessary catheterization. The pediatric maintenance bundle includes five standard elements: 1) maintain a closed system, 2) maintain hygiene, 3) keep bag below the level of the bladder, 4) maintain unobstructed flow, and 5) remove the catheter when no longer needed. In addition, the maintenance bundle includes one strongly recommended element, supported by low-quality evidence, to secure the catheter. SPS instructional videos describe the proper steps for compliance with the urinary catheter insertion and maintenance bundles.3,4

We used an open start time engagement approach, in which bundles were trialed in initial hospitals. Subsequent hospitals began data collection and were encouraged to implement process measures concurrently on enrollment. SPS facilitated network-wide learning sessions and reviewed hospital run charts for special cause variation. The reporting period spans seven years (2011 through 2017), during which the number of children’s hospitals participating in the CAUTI prevention effort increased from 26 to 128. 

The primary outcome was network CAUTI rate per 1000 CLD. We captured 2,555 CAUTIs and 1,574,216 urinary catheter line days (CLD). After the introduction of the prevention bundles, CAUTI rates across the network decreased by 61.6%, from 2.55 to 0.98 infections per 1000 CLD. We did not observe a decrease in device use during the study period, but the use rate in this pediatric population was 0.06 CLDs per patient-day, which is substantially lower than published adult rates of 0.30 and 0.15 in critical care and non-critical care units, respectively.5

An unanticipated event that occurred during the trial was the 2015 Centers for Disease Control and Prevention CAUTI definition change, which excluded cultures with yeasts or molds and those with < 105 colony-forming units per milliliter.6 The timing of the change posed a challenge for our initiative, and efforts were taken to ensure that all hospitals adopted the new definition concurrently. Although our data collection methods did not allow us to recalculate baseline CAUTI rates, we observed declines in CAUTI rates and center-line shifts on our monthly control charts both before and after the definition changes, supporting the argument that bundle implementation contributed to a decline in CAUTIs. 

Written by: Charles B. Foster, MD, Center for Pediatric Infectious Diseases, Cleveland Clinic Children’s, Cleveland, Ohio, and Rachel E. Wenthe, RN, bCook Children’s Health Care system, Fort Worth, Texas


  1. Foster, Charles B., Kathy Ackerman, Vera Hupertz, Laurie Mustin, Joann Sanders, Patricia Sisson, and Rachel E. Wenthe. "Catheter-Associated Urinary Tract Infection Reduction in a Pediatric Safety Engagement Network." Pediatrics 146, no. 4 (2020).
  2. Lyren, Anne, Richard J. Brilli, Karen Zieker, Miguel Marino, Stephen Muething, and Paul J. Sharek. "Children’s hospitals’ solutions for patient safety collaborative impact on hospital-acquired harm." Pediatrics 140, no. 3 (2017).
  3. Children's Hospitals' Solutions for Patient Safety. SPS CAUTI Insertion Bundle Video. at (Accessed 9/15/2020, at
  4. Children's Hospitals' Solutions for Patient Safety. SPS CAUTI Maintenance Bundle Video. (Accessed 9/15/2020, at
  5. Dudeck, Margaret A., Jonathan R. Edwards, Katherine Allen-Bridson, Cindy Gross, Paul J. Malpiedi, Kelly D. Peterson, Daniel A. Pollock, Lindsey M. Weiner, and Dawn M. Sievert. "National Healthcare Safety Network report, data summary for 2013, device-associated module." American journal of infection control 43, no. 3 (2015): 206-221.
  6. Centers for Disease Control and Prevention. FAQs: NHSN CAUTI Definition & Rebaseline. (Accessed 9/15/2020, at
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