2021 Annual Conference

CNS Improving Outcomes
CNS as Project Manager
Quality Initiatives

 The purpose of this evidence-based practice project was to reduce CAUTI Standardized Infection Ratio (SIR) to meet the CMS value-based purchasing target of 0.75. The PICO question was: In the hospital setting, does the implementation of bedside staff CAUTI champions improve CAUTI SIR compared to no champions?

Although the hospital had implemented multiple evidence-based practices to reduce CAUTI SIRs, the quarterly SIRs for several years were consistently above 0.75. The hospital had not implemented bedside staff CAUTI Champions, a demonstrated evidence-based practice.

This project implemented the evidence-based practice of bedside staff CAUTI Champions, who, through education and support from the infection prevention team, became CAUTI experts. The champions conducted rounds on catheterized patients; provided immediate peer education when needed; validated staff competencies for indwelling urinary catheter insertion and maintenance; reported monthly CAUTI outcomes in huddles and staff meetings; advocated for best practices, and assisted in staff education of the standardized procedure for urinary catheter removal, CAUTI prevention patient education, and identification of alternatives to indwelling urinary catheters.

The CAUTI SIR decreased from 1.3 the quarter immediately before implementation, to 0.41, 0.4, and 0.23 in the three quarters post-implementation.  

Bedside staff CAUTI champions have been instrumental in infusing best practices on individual units through rounding on the maintenance bundle and advocating for best practices such as standardization of urinary catheter securement devices.