Indwelling Catheters

IHI - How-to guide: prevent catheter-associated urinary tract infections

The estimated number of hospital-acquired infections (HAIs) in US hospitals exceeds 1.7 million events annually, leading to an estimated 99,000 deaths. Urinary tract infections account for approximately 40% of all HAIs annually. Fully 80% of these hospital-acquired urinary tract infections are attributable to indwelling urethral catheters. If nursing homes are considered along with acute care hospitals, it is estimated that there are more than one million cases of catheter-associated urinary tract infections (CAUTI) annually.

In the US, up to five million urinary catheters are placed annually. Between 12% and 25% of all hospitalized patients will receive a urinary catheter during their hospital stay, with as many as half not having an appropriate indication. In one study, almost 40% of attending physicians caring for patients with unnecessary urinary catheters were not aware that their patients had a urinary catheter in place.

It is well established that the duration of catheterization is directly related to risk for developing a urinary tract infection. With a catheter in place, the daily risk of developing a urinary tract infection ranges from 3% to 7%. When a catheter remains in place for up to a week, bacteriuria risk increases to 25%; at one month, this risk is nearly 100%. Among those with bacteriuria, 10% will develop symptoms of UTI (fever, dysuria, urgency, frequency, suprapubic tenderness) and up to 3% will further develop bacteremia.




How-to Guide: Prevent Catheter-Associated Urinary Tract Infections. Cambridge, MA: Institute for Healthcare Improvement; 2011. (Available at

IHI - How-to guide: prevent surgical site infections

Surgical site infections are a frequent cause of morbidity following surgical procedures. Surgical site infections have also been shown to increase mortality, re-admission rates, length of stay, and costs for patients who incur them. While nationally the rate of surgical site infection averages between 2 and 3% for clean cases (class I/clean as defined by CDC), an estimated 40 to 60% of these infections are preventable.

A review of the medical literature shows that the following care components reduce the incidence of surgical site infection: appropriate use of prophylactic antibiotics; appropriate hair removal, controlled postoperative serum glucose for cardiac surgery patients, and immediate postoperative normothermia for colorectal surgery patients. These components, if implemented reliably, can drastically reduce the incidence of surgical site infection, resulting in the nearly complete elimination of preventable surgical site infection in many cases.




(2012). "How-to Guide: Prevent Surgical Site Infections." Institute for Healthcare Improvement; Cambridge, MA (Available at

IHI Innovation Series 2012 - Using care bundles to improve health care quality

In 2001, the Institute for Healthcare Improvement (IHI) developed the “bundle” concept in the context of an IHI and Voluntary Hospital Association (VHA) joint initiative—Idealized Design of the Intensive Care Unit (IDICU)—involving 13 hospitals focused on improving critical care. The goal of the initiative was to improve critical care processes to the highest levels of reliability, which would result in vastly improved outcomes. The theory was that enhancing teamwork and communication in multidisciplinary teams would create the necessary conditions for safe and reliable care in the ICU. We focused on areas with potential for great harm and high cost, and where the evidence base was strong.

While there were many changes the teams in the initiative worked toward implementing, care of patients on ventilators and those who had central lines became a strong focus, as it satisfied all of our criteria; the evidence for the clinical changes was robust, and there was little or no controversy concerning their efficacy. Further, teams would need to find new and better ways to work together to produce reliable change and superior patient outcomes. We found that by using a “bundle”—a small set of evidence-based interventions for a defined patient population and care setting—the improvements in patient outcomes exceeded expectations of both teams and faculty.

Thus began an innovative approach to improving care: the use of bundles. This white paper describes the history, theory of change, design concepts, and outcomes associated with the development and use of bundles over the past decade. We reflect on what we have learned and make suggestions for further research and implementation of the bundle approach to improving care.




Resar, R., F. A. Griffin, et al. (2012). "Using Care Bundles to Improve Health Care Quality. IHI Innovation Series white paper." Institute for Healthcare Improvement; Cambridge, MA (Available at

New York hospitals team up to reduce Clostridium difficile infections

There is an urgent need to implement evidence-based strategies that effectively prevent Clostridium difficile (C. difficile) transmission and infection because of the increasing incidence, severity, and costs in the United States. In March 2008, the Greater New York Hospital Association (GNYHA) and United Hospital Fund (UHF) collaborated with New York State Department of Health to begin the Clostridium difficile Collaborative. The collaborative project aimed to reduce hospital-associated C. difficile by implementing an evidence-based “prevention bundle” and standardized daily and terminal environmental cleaning protocols. The prevention bundle included the following:

  • Placing patients on contact precautions at symptom onset
  • Monitoring the availability and use of personal protective equipment
  • Monitoring hand hygiene
  • Dedicating thermometers for C. difficile patients
  • Implementing a patient placement strategy to optimize the use of private rooms or cohort patients when necessary (no sharing of bathrooms)

PHPSFF New York State v2



(2012) Centers for Disease Control and Prevention

Compliance with handwashing in a teaching hospital - Abstract

BACKGROUND: Transmission of microorganisms from the hands of health care workers is the main source of cross-infection in hospitals and can be prevented by handwashing.

OBJECTIVE: To identify predictors of noncompliance with handwashing during routine patient care.

DESIGN: Observational study.

SETTING: Teaching hospital in Geneva, Switzerland.

PARTICIPANTS: Nurses (66%), physicians (10%), nursing assistants (13%), and other health care workers (11%).

MEASUREMENTS: Compliance with handwashing.

RESULTS: In 2834 observed opportunities for handwashing, average compliance was 48%. In multivariate analysis, noncompliance was higher among physicians (odds ratio [OR], 2.8 (95% CI, 1.9 to 4.1)), nursing assistants (OR, 1.3 (CI, 1.0 to 1.6)), and other health care workers (OR, 2.1 (CI, 1.4 to 3.2)) than among nurses and was lowest on weekends (OR, 0.6 (CI, 0.4 to 0.8)). Noncompliance was higher in intensive care than in internal medicine units (OR, 2.0 (CI, 1.3 to 3.1)), during procedures that carry a high risk for contamination (OR, 1.8 (CI, 1.4 to 2.4)), and when intensity of patient care was high (compared with < or = 20 opportunities for handwashing per hour of care, 21 to 40 opportunities: OR, 1.3 (CI, 1.0 to 1.7); 41 to 60 opportunities: OR, 2.1 (CI, 1.5 to 2.9); and > 60 opportunities: OR, 2.1 (CI, 1.3 to 3.5)).

CONCLUSIONS: Compliance with handwashing was moderate. Variation across hospital ward and type of health care worker suggests that targeted educational programs may be useful. Even though observational data cannot prove causality, the association between noncompliance and intensity of care suggests that understaffing may decrease quality of patient care.

Written by:
Pittet D, Mourouga P, Perneger TV. Are you the author?
University of Geneva Medical School and University of Geneva Hospitals, Switzerland.

Reference: Ann Intern Med. 1999 Jan 19;130(2):126-30. 


A randomized crossover study of silver-coated urinary catheters in hospitalized patients - Abstract

BACKGROUND: Urinary tract infections (UTIs) account for 30% to 40% of nosocomial infections resulting in morbidity, mortality, and increased length of hospital stay.

OBJECTIVE: To assess the efficacy of a silver-alloy, hydrogel-coated latex urinary catheter for the prevention of nosocomial catheter-associated UTIs.

METHODS: A 12-month randomized crossover trial compared rates of nosocomial catheter-associated UTI in patients with silver-coated and uncoated catheters. A cost analysis was conducted.

RESULTS: There were 343 infections among 27,878 patients (1.23 infections per 100 patients) during 114,368 patient-days (3.00 infections per 1000 patient-days). The relative risk of infection per 1000 patient-days was 0.79 (95% confidence interval, 0.63-0.99; P =.04) for study wards randomized to silver-coated catheters compared with those randomized to uncoated catheters. Infections occurred in 291 of 11,032 catheters used on study units (2.64 infections per 100 catheters). The relative risk of infection per 100 silver-coated catheters used on study wards compared with uncoated catheters was 0.68 (95% confidence interval, 0.54-0.86; P =.001). Fourteen catheter-associated UTIs (4.1%) were complicated by secondary bloodstream infection. One death appeared related to the secondary infection. Estimated hospital cost savings with the use of the silver-coated catheters ranged from $14,456 to $573,293.

CONCLUSIONS: The risk of infection declined by 21% among study wards randomized to silver-coated catheters and by 32% among patients in whom silver-coated catheters were used on the wards. Use of the more expensive silver-coated catheter appeared to offer cost savings by preventing excess hospital costs from nosocomial UTI associated with catheter use.

Written by:
Karchmer TB, Giannetta ET, Muto CA, Strain BA, Farr BM. Are you the author?
PO Box 800473, University of Virginia Health System, Charlottesville, VA 22908, USA.

Reference: Arch Intern Med. 2000 Nov 27;160(21):3294-8.


Adherence to urethral catheters by bacteria causing nosocomial infections - Abstract

Previous clinical studies of catheters with hydrophilic coating have, in some instances, shown a delay in the onset of significant bacteriuria, while others reported no such effect. To attempt to determine reasons for these differences we decided to study bacterial adherence of bacteria obtained from nosocomial urinary tract infections associated with catheters. Almost all strains adhered to the silicone catheter and none of them adhered to the catheter with the hydrophilic surface whether incubated in urine or serum. When incubated in urine, all strains adhered to the red rubber catheters. Adherence was variable to the Teflon and elastomer surfaces.

Written by:
Roberts JA, Kaack MB, Fussell EN. Are you the author?
Department of Urology, Tulane Regional Primate Research Center, Covington, Louisiana.

Reference: Urology. 1993 Apr;41(4):338-42.


Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship - Abstract

BACKGROUND: Organisms resistant to antimicrobials continue to emerge and spread. This study was performed to measure the medical and societal cost attributable to antimicrobial-resistant infection (ARI).

METHODS: A sample of high-risk hospitalized adult patients was selected. Measurements included ARI, total cost, duration of stay, comorbidities, acute pathophysiology, Acute Physiology and Chronic Health Evaluation III score, intensive care unit stay, surgery, health care-acquired infection, and mortality. Hospital services used and outcomes were abstracted from electronic and written medical records. Medical costs were measured from the hospital perspective. A sensitivity analysis including 3 study designs was conducted. Regression was used to adjust for potential confounding in the random sample and in the sample expanded with additional patients with ARI. Propensity scores were used to select matched control subjects for each patient with ARI for a comparison of mean cost for patients with and without ARI.

RESULTS: In a sample of 1391 patients, 188 (13.5%) had ARI. The medical costs attributable to ARI ranged from $18,588 to $29,069 per patient in the sensitivity analysis. Excess duration of hospital stay was 6.4-12.7 days, and attributable mortality was 6.5%. The societal costs were $10.7-$15.0 million. Using the lowest estimates from the sensitivity analysis resulted in a total cost of $13.35 million in 2008 dollars in this patient cohort.

CONCLUSIONS: The attributable medical and societal costs of ARI are considerable. Data from this analysis could form the basis for a more comprehensive evaluation of the cost of resistance and the potential economic benefits of prevention programs.

Written by:
Roberts RR, Hota B, Ahmad I, Scott RD 2nd, Foster SD, Abbasi F, Schabowski S, Kampe LM, Ciavarella GG, Supino M, Naples J, Cordell R, Levy SB, Weinstein RA. Are you the author?
Department of Emergency Medicin, John H Stroger Jr Hospital of Cook County, Chicago, Illinois 60612, USA.

Reference: Clin Infect Dis. 2009 Oct 15;49(8):1175-84.
doi: 10.1086/605630. 


Estimating health care-associated infections and deaths in U.S. hospitals, 2002 - Abstract

OBJECTIVE: The purpose of this study was to provide a national estimate of the number of healthcare-associated infections (HAI) and deaths in United States hospitals.

METHODS: No single source of nationally representative data on HAIs is currently available. The authors used a multi-step approach and three data sources. The main source of data was the National Nosocomial Infections Surveillance (NNIS) system, data from 1990-2002, conducted by the Centers for Disease Control and Prevention. Data from the National Hospital Discharge Survey (for 2002) and the American Hospital Association Survey (for 2000) were used to supplement NNIS data. The percentage of patients with an HAI whose death was determined to be caused or associated with the HAI from NNIS data was used to estimate the number of deaths.

RESULTS: In 2002, the estimated number of HAIs in U.S. hospitals, adjusted to include federal facilities, was approximately 1.7 million: 33,269 HAIs among newborns in high-risk nurseries, 19,059 among newborns in well-baby nurseries, 417,946 among adults and children in ICUs, and 1,266,851 among adults and children outside of ICUs. The estimated deaths associated with HAIs in U.S. hospitals were 98,987: of these, 35,967 were for pneumonia, 30,665 for bloodstream infections, 13,088 for urinary tract infections, 8,205 for surgical site infections, and 11,062 for infections of other sites.

CONCLUSION: HAIs in hospitals are a significant cause of morbidity and mortality in the United States. The method described for estimating the number of HAIs makes the best use of existing data at the national level.

Written by:
Klevens RM, Edwards JR, Richards CL Jr, Horan TC, Gaynes RP, Pollock DA, Cardo DM. Are you the author?
Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd., MS A-24, Atlanta, GA 30333, USA.

Reference: Public Health Rep. 2007 Mar-Apr;122(2):160-6.


Complications of Foley catheters--is infection the greatest risk? - Abstract

PURPOSE: Foley catheters cause a variety of harms, including infection, pain and trauma. Although symptomatic urinary tract infection and asymptomatic bacteriuria are frequently discussed, genitourinary trauma receives comparatively little attention.

MATERIALS AND METHODS: A dedicated Foley catheter nurse prospectively reviewed the medical records of inpatients with a Foley catheter at the Minneapolis Veterans Affairs Medical Center from August 21, 2008 to December 31, 2009. Daily surveillance included Foley catheter related bacteriuria and trauma. Data were analyzed as the number of event days per 100 Foley catheter days.

RESULTS: During 6,513 surveyed Foley catheter days, urinalysis/urine culture was done on 407 (6.3%) days. This testing identified 116 possible urinary tract infection episodes (1.8% of Foley catheter days), of which only 21 (18%) involved clinical manifestations. However, the remaining 95 asymptomatic bacteriuria episodes accounted for 39 (70%) of 56 antimicrobial treated possible urinary tract infection episodes (for proportion of treated episodes with vs without symptomatic urinary tract infection manifestations, p = 0.005). Concurrently 100 instances of catheter associated genitourinary trauma (1.5% of Foley catheter days) were recorded, of which 32 (32%) led to interventions such as prolonged catheterization or cystoscopy. Trauma prompting an intervention accounted for as great a proportion of Foley catheter days (0.5%) as did symptomatic urinary tract infection (0.3%) (p = 0.17).

CONCLUSIONS: In this prospective surveillance project, intervention triggering Foley catheter related genitourinary trauma was as common as symptomatic urinary tract infection. Moreover, despite recent increased attention to the distinction between asymptomatic bacteriuria and symptomatic urinary tract infection in catheterized patients, asymptomatic bacteriuria accounted for significantly more antimicrobial treatment than did symptomatic urinary tract infection. Elimination of unnecessary Foley catheter use could prevent symptomatic urinary tract infection, unnecessary antimicrobial therapy for asymptomatic bacteriuria and Foley catheter related trauma.

Written by:
Leuck AM, Wright D, Ellingson L, Kraemer L, Kuskowski MA, Johnson JR. Are you the author?
VA Medical Center, University of Minnesota, Minneapolis, Minnesota, USA.

Reference: J Urol. 2012 May;187(5):1662-6. doi: 10.1016/j.juro.2011.12.113.


Are physicians aware of which of their patients have indwelling urinary catheters? - Abstract

PURPOSE: Although infections associated with indwelling urinary catheters are common, costly, and morbid, the use of these catheters is unnecessary in more than one-third of patients. We sought to assess whether attending physicians, medical residents, and medical students are aware if their hospitalized patients have an indwelling urinary catheter, and whether physician awareness is associated with appropriate use of these catheters.

METHODS: The physicians and medical students responsible for patients admitted to the medical services at four university-affiliated hospitals were given a list of the patients on their service. For each patient, the provider was asked: "As of yesterday afternoon, did this patient have an indwelling urethral catheter?" Respondents' answers were compared with the results of examining the patient.

RESULTS: Among 288 physicians and students on 56 medical teams, 256 (89%) completed the survey. Of 469 patients, 117 (25%) had an indwelling catheter. There were a total of 319 provider-patient observations among these 117 patients. Overall, providers were unaware of catheterization for 88 (28%) of the 319 provider-patient observations. Unawareness rates by level of training were 21% for students, 22% for interns, 27% for residents, and 38% for attending physicians (P = 0.06). Catheter use was inappropriate in 36 (31%) of the 117 patients with a catheter. Providers were unaware of catheter use for 44 (41%) of the 108 provider-patient observations of patients who were inappropriately catheterized. Catheterization was more likely to be appropriate if respondents were aware of the catheter (odds ratio = 3.7; 95% confidence interval, 2.1 to 6.7, P <0.001).

CONCLUSIONS: Physicians are commonly unaware that their patients have an indwelling urinary catheter. Inappropriate catheters are more often "forgotten" than appropriate ones. System-wide interventions aimed at discontinuing unnecessary catheterization seem warranted.

Written by:
Saint S, Wiese J, Amory JK, Bernstein ML, Patel UD, Zemencuk JK, Bernstein SJ, Lipsky BA, Hofer TP. Are you the author?
Department of Internal Medicine (SS, MLB, UDP, SJB, TPH), University of Michigan Medical School,;, Ann Arbor, Michigan, USA.

Reference: Am J Med. 2000 Oct 15;109(6):476-80.


Reducing inappropriate urinary catheter use: a statewide effort - Abstract

BACKGROUND: Indwelling urinary catheters may lead to both infectious and noninfectious complications and are often used in the hospital setting without an appropriate indication. The objective of this study was to evaluate the results of a statewide quality improvement effort to reduce inappropriate urinary catheter use.

METHODS: Retrospective analysis of data collected between 2007 and 2010 as part of a statewide collaborative initiative before, during, and after an educational intervention promoting adherence to appropriate urinary catheter indications. The data were collected from 163 inpatient units in 71 participating Michigan hospitals. The intervention consisted of educating clinicians about the appropriate indications for urinary catheter use and promoting the daily assessment of urinary catheter necessity during daily nursing rounds. The main outcome measures were change in prevalence of urinary catheter use and adherence to appropriate indications. We used flexible generalized estimating equation (GEE) and multilevel methods to estimate rates over time while accounting for the clustering of patients within hospital units.

RESULTS: The urinary catheter use rate decreased from 18.1% (95% CI, 16.8%-19.6%) at baseline to 13.8% (95% CI, 12.9%-14.8%) at end of year 2 (P < .001). The proportion of catheterized patients with appropriate indications increased from 44.3% (95% CI, 40.3%-48.4%) to 57.6% (95% CI, 51.7%-63.4%) by the end of year 2 (P = .005).

CONCLUSIONS: A statewide effort to reduce inappropriate urinary catheter use was associated with a significant reduction in catheter use and improved compliance with appropriate use. The effect of the intervention was sustained for at least 2 years.

Written by:
Fakih MG, Watson SR, Greene MT, Kennedy EH, Olmsted RN, Krein SL, Saint S. Are you the author?
University of Michigan Patient Safety Enhancement Program, Ann Arbor, MI 48109-0429, USA.

Reference: Arch Intern Med. 2012 Feb 13;172(3):255-60.
doi: 10.1001/archinternmed.2011.627.



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