Digital Repository Masters Theses Spring 2026 A Quality Improvement Project Reducing Intensive Care Unit Catheter-Associated Urinary Tract Infections Leigha Marigoni Weber State University Follow this and additional works at: https://dc.weber.edu/collection/wsudoctoral Marigoni, L. 2026. A Quality Improvement Project Reducing Intensive Care Unit Catheter-Associated Urinary Tract Infections. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/WSUDoctoral This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. 1 Angela Page, DNP, APRN, PPNP-BC 4/25/26 Anne Kendrick, DNP, RN, CNE 4/25/26 2 A Quality Improvement Project Reducing Intensive Care Unit Catheter-Associated Urinary Tract Infections Leigha Marigoni Annie Taylor Dee School of Nursing Weber State University Dr. Angela Page MSN Project Abstract 3 Purposes/Aims: This quality improvement (QI) project aims to reduce catheter-associated urinary tract infections (CAUTIs) in the intensive care unit (ICU) of an urban Level I trauma hospital. Rationale/Background: CAUTIs are among the most common healthcare-associated infections contributing to increased patient morbidity, prolonged hospital stays, and higher healthcare costs. Literature identifies gaps in nursing knowledge, inconsistent adherence to catheter care protocols, and the lack of standardized maintenance bundles as contributing to elevated CAUTI rates. Research supports nurse-driven protocols, bundled daily care, structured education for both nurses and families, and interdisciplinary team collaboration as effective strategies for prevention. Methods: The project will implement structured nurse education, nurse-driven catheter removal protocols, daily catheter necessity assessments, family education, interdisciplinary collaboration, and continuous monitoring of process and outcome measures. Pre- and post-intervention surveys will assess staff knowledge, confidence, and adherence to the catheter care bundle. Data on catheter use, CAUTI rates, and compliance will be collected via randomized chart audits and the ICU CAUTI monitoring tool. The Iowa Model of Evidence-Based Practice will also guide the project development, implementation, and evaluation. Ethical considerations will include maintaining patient and staff confidentiality and voluntary participation in surveys. Results: The project aims to improve staff knowledge and confidence, increase adherence to catheter care protocols, reduce urinary catheter days, and decrease CAUTI incidence in the ICU. Conclusions: This initiative aims to promote accountability, strengthen evidence-based practice, support professional nursing development, and provide a framework for future hospital-wide CAUTI prevention efforts. 4 Keywords: CAUTI, ICU, nurse-driven protocol, quality improvement, evidence-based practice. A Quality Improvement Project Reducing Intensive Care Unit Catheter-Associated Urinary Tract Infections 5 Catheter-associated urinary tract infections (CAUTIs) are the most common type of healthcare-associated infection (HAI) among hospitalized patients, particularly those in the Intensive Care Unit (ICU) (Gupta et al., 2023). The ICU patient population is at greater risk due to prolonged hospital stays, critical illness, poor prognoses, and multiple invasive interventions (Krauss et al., 2022). Furthermore, patient risk increases significantly when nurses insert or manage indwelling catheters without adequate education, the use of bundled care practices, or regular maintenance discussions (Krauss et al., 2022). Each additional day a urinary catheter remains in place increases the likelihood of developing a CAUTI by approximately 5% (Alqarni, 2021). This quality improvement (QI) project aims to identify evidence-based strategies to enhance nurses' confidence in urinary catheter protocols and to highlight effective methods to reduce CAUTIs in ICU settings. Statement of Problem In an urban hospital ICU in Salt Lake City, Utah, the primary practice gap is inconsistent adherence to evidence-based protocols for catheter use, maintenance, and timely removal within ICU environments. This was highlighted during data meetings with multiple leadership nurses who have been assisting in reducing the rising CAUTI rates in the ICUs. It was observed that when nurses were not fully educated on proper Foley catheter use, and the catheter remained in place for longer than recommended (3 days), the rates increased. (Stacy M. personal communication, October 26, 2025). CAUTIs remain one of the most prevalent healthcareassociated infections (Gupta et al., 2023). These infections frequently result from prolonged or unnecessary urinary catheter use, contributing to complications such as sepsis, extended hospitalizations, and increased healthcare expenditures (Werneburg, 2022). In intensive care settings, critically ill patients often require indwelling urinary catheters to accurately monitor urine output and fluid balance. 6 According to the Centers for Disease Control and Prevention (CDC), CAUTIs account for nearly 75% of healthcare-associated infections (HAI) (CDC, 2022). Approximately 60% of HAIs are associated with urinary catheterization, while the remaining 15% are attributed to other sources (CDC, 2022). The necessity of indwelling catheters in ICU settings increases the risk of infection, with reported CAUTI rates ranging from 1.2 to 4.5 per 1,000 catheter days (Shadle et al., 2023). Beyond the financial implications, CAUTIs lead to patient discomfort, unnecessary antibiotic use, higher mortality rates, and a decrease in the quality of care in an already vulnerable population (Van Decker et al., 2021). Patel et al. (2023) noted that technical measures, such as hand sanitizers, bladder scanners, and social adaptations to organizational culture or clinical practice, could steadily reduce infections from indwelling catheters. Most CAUTIs are preventable through adherence to evidence-based best practices, including timely removal, daily evaluations, and proper catheter hygiene (Gupta et al., 2023). Addressing this persistent practice gap through an evidence-based intervention could increase patient safety and reduce hospital financial strain. Significance of the Project This QI project is crucial for effecting change in ICUs, where patients are particularly vulnerable because they must maintain multiple invasive lines and supportive devices. First, reducing the length of a hospital stay by decreasing the odds of the patient acquiring a CAUTI may lessen the financial burden of hospital-acquired infections (HAIs) (Shadle et al., 2021). Second, continuous education and practice of evidence-based catheter care could successfully implement an improved standard of care within the ICU (Alqarni, M, 2021). Gupta et al. (2023) reported a significant decrease in indwelling catheter infections—from 7.6 per 1,000 days to 0 cases over 2 years—attributed to nurses who were well-trained and educated in catheterization 7 procedures. Finally, successfully implementing CAUTI prevention strategies helps hospitals meet The Joint Commission (TJC) quality and safety goals. Preventing CAUTIs has been a National Patient Safety Goal (NPSG) with TJC since 2017 (Joint Commission, 2020). This project aims to address a critical clinical problem in the ICU of this urban hospital and to promote a culture change that increases safety and accountability among bedside nurses, management, providers, and certified nursing assistants. Implementing evidence-based interventions provides an opportunity to improve patient outcomes, enhance patient safety, and reduce the financial burden on the healthcare system. The following sections outline the proposed methods to address this clinical problem. Review of the Literature This literature review examines current evidence-based practices designed to reduce the prevalence of catheter-associated urinary tract infections in adult intensive care units. The guiding PICOT question used for this review is: For nurses working in the Intensive Care Unit (ICU) (P), does implementing a standardized, evidence-based bundle of care for urinary catheter management (I), compared to routine care (C), increase nursing confidence and compliance with interventions to reduce Catheter-Associated Urinary Tract Infections (CAUTIs) (O) within 3 months (T)? During the literature search, several recurring themes emerged regarding strategies to decrease CAUTIs in ICU settings. Some of the most common themes that emerged consistent throughout the literature were: (a) continuing education, which created the ability for healthcare providers to remain current with evidence based practices for reduced catheter-associated urinary tract infections; (b) the implementation and importance of daily bundled care, which supports attention to both the patient and the catheter to minimize infection risk; and (c) creating a strong collaborative team approach, ensuring that multiple care team members share responsibility for 8 maintaining catheter hygiene and the ability to support one another in infection prevention efforts. Framework The Iowa Model of Evidence-Based Practice provides a comprehensive and systematic approach to translating research evidence into clinical practice. The model consists of five key action steps, (1) the identification of problem/triggers, (2) selection of an evidence-based intervention, (3) piloting the intervention, (4) determining the correctness of adopting the practice beyond the pilot, and (5) promoting change in units other than the unit the QI project was trialed on (Chiwaula & Jere, 2022). These steps efficiently address complex healthcare challenges, such as healthcare-associated infections (Buckwalter et al., 2024). The Iowa Model promotes collaboration among nurses, physicians, infection preventionists, and administrators while grounding continuous change with evidence-based practice (Titler et al., 2022). Moreover, it emphasizes continuous evaluation of education, the dissemination of evidence-based practices, and the promotion of quality improvement through a cycle of feedback and adaptation (Buckwalter et al., 2024). The Iowa Model directly corresponds with the systematic structure of this MSN project, which aims to reduce CAUTIs in the ICU. The trigger in this project is the persistently high CAUTI rates among the critically ill patients, which represents both an overall quality of care and safety concern. Recognizing this as an organizational priority, the following steps involve forming a multidisciplinary team that includes but is not limited to ICU nurses, ICU nursing assistants, infection preventionists, and intensivists. This interdisciplinary team will review existing evidence and other data sources on risk factors and prevention strategies for CAUTIs. 9 During the evidence appraisal phase, the team will evaluate research supporting current evidence-based interventions, including sterile insertion techniques, early catheter removal, continuing staff education, and the overall use of evidence-based practices. Once the most effective practices are identified, a pilot program will be implemented in one ICU unit to test compliance and outcomes. Following the pilot, the evaluation phase will measure CAUTI incidence rates, staff adherence, attitudes to bundle protocols, and the overall patient outcomes. If the pilot demonstrated improvement, the intervention tested would then proceed to the organization-wide implementation phase. This phase includes policy updates, staff training, and ongoing CAUTI audits. The final sustainment phase will focus on continuous monitoring, feedback sessions, and ongoing updates on outcomes to maintain long-term reductions in CAUTIs and reinforce a culture of evidence-based infection prevention across the ICU and the organization. Strengths and Limitations The Iowa Model of Evidence-Based Practice to Promote Quality Care has several strengths and limitations. One major strength of this model is its clear structure and ease of use for nurses and other healthcare providers in conducting research (Titler et al., 2022). Another strength is continuous revision and validation over time, which keeps the model current and applicable across healthcare settings. It was revised and validated in 2015 as a practical tool for the EBP process across diverse settings (Buckwalter et al., 2024). These strengths are particularly relevant to my MSN project, as they strengthen the reasoning for this research method. However, the Iowa model has some limitations. The use is time- and resource-intensive overall due to the numerous multi-step processes, resulting in inconsistent use among nurses and 10 other healthcare providers conducting EBP research (Duff et al., 2020). Additionally, users must assess the literature and understand how it is applied to the model to minimize gaps and ensure high-quality, evidence-based outcomes for the research (Dusin et al., 2023). Search Strategies A comprehensive literature search was conducted to gather the most current evidence of c CAUTIs in adult ICUs. The literature search was performed using Google Scholar, Weber State Stewart Library’s OneSearch and Advanced Search (which spans multiple databases), the National Institutes of Health (NIH), and CINAHL to guide the exploration of this topic. Only articles published between 2020 and 2025 were selected to ensure the use of current evidence. Keywords used in the search included catheter-associated urinary tract infections (CAUTIs), intensive care units (ICUs), decreasing CAUTIs, healthcare-associated infections (HAIs), urinary catheter management, urinary catheter infection prevention, systematic reviews, qualitative, and quantitative studies. Various Boolean combinations were created using the keywords mentioned above to conduct a comprehensive search across the overall topic. Synthesis of the Literature During the literature search, numerous studies were identified regarding indwelling Foley catheters; however, only a select few contained findings directly relevant to this review. After analyzing and summarizing the chosen articles, three themes were identified in the literature: a) the value of continuing education about indwelling catheter management, b) the effectiveness of bundled daily maintenance care, and c) the significance of a collaborative, team-based approach to Foley catheter use. Value of Continuing Education and Attitude about Indwelling Catheter Management 11 The value of continuing education for ICU nurses is paramount, as it equips them with the necessary knowledge and skills to prevent CAUTIs and ensure patient safety. Alex et al. (2022) found that upskilling nurses and fostering patient-centered care practices can significantly improve patient outcomes with long-term indwelling urinary catheters. Similarly, Mong et al. (2022) reported a positive correlation between nurses’ knowledge and commitment to continuing education and their attitudes towards catheter care. Gupta et al. (2023) also observed that behavioral changes and ongoing education for nurses led to a significant and sustained reduction in CAUTI rates. In contrast, Dessie et al. (2024) demonstrated that units with limited education about catheter care, negative attitudes, and poor prevention practices had higher CAUTI rates than units with well-educated, proactive nurses, resulting in lower overall CAUTI rates. On the other hand, a study by El-Rahmanl et al. (2022) focused on implementing educational booklets for nurses that highlighted key points on catheters and catheter care. The study also noted that ongoing on-the-job training, such as annual pass-offs on infection control and overall catheter care, would be beneficial for reducing CAUTI prevalence after the booklet implementation. Similarly, Alsolami and Tayyib (2023) noted that post-education improvements in CAUTI prevention are only practical when nurses’ knowledge is evaluated both before and after education. This approach ensures that educational interventions are applied consistently and that all nursing staff receive the same evidence-based information to continue infection prevention outcomes in the ICU. The Effectiveness of Bundled Daily Maintenance Care Implementing daily bundled maintenance care in the ICU is a robust strategy for managing Foley catheters, promoting cleanliness, reducing infection risks, and improving overall patient outcomes. Bundled interventions incorporating an electronic daily checklist, a nurse- 12 driven protocol, and daily discussion led to a 30% reduction of reported catheter-associated urinary tract infections (Shadle et al., 2021). As part of the bundled maintenance care, Smith (2025) mentioned how the compliance rate of Foley catheter care only stood at 50%; however, introducing an EHR flag as a daily reminder was found to increase compliance with daily catheter hygiene, which in turn may further decrease the odds of CAUTIs in the ICU setting. Patel et al. (2023) supported the findings of Shadle and Smith by emphasizing the importance of all ICUs adopting electronic reminders and institutional policies that require regular assessments, such as daily reviews of the need for continued catheterization. Their research demonstrated that these interventions decreased urinary tract infections from 6.6 to 5.6 per 1,000 catheter days. Similarly, Smith (2025) reported a 30% decrease in CAUTI rates after implementing the electronic flow sheet and daily bundled care practices. Adherence to all care bundle elements for catheter use could significantly decrease CAUTI rates. (Soundaram et al., 2020). In another study, Andreessen (2022) found that using a urinary catheter bundle focused on continuous assessment and prompt removal resulted in a 71% reduction in catheter device days, accompanied by a 56% reduction in CAUTI rates. These studies highlight that daily bundled maintenance care may reduce the incidence of reported CAUTIs in an ICU setting, improve patient outcomes, and lower the risk of healthcare-associated infections among vulnerable populations. The Significance of a Collaborative Team-Based Approach Costa et al. (2020) demonstrate that a collaborative team-based approach in the ICU, involving certified nursing assistants (CNAs), nurses, and physicians, is crucial for ensuring proper Foley catheter management. Effective communication and shared accountability among all team members are also essential in preventing CAUTIs. This team also found that ICU 13 patients cared for by one additional resource caregiver, such as a CNA, had significantly lower odds of in-hospital mortality. Although this study focused primarily on overall care rather than catheter care, it still emphasizes the importance of teamwork in reducing patient harm during hospitalization. Similarly, Li et al. (2025) noted that CAUTI reduction is achieved through a sustained multidisciplinary team approach and participation. These findings align with those of Gupta et al. (2023), who reported that empowering frontline nurses to work collaboratively with a multidisciplinary team significantly decreased CAUTIs, maintaining 280 consecutive calendar days without a reported CAUTI. An additional study suggested that nursing team composition influences the risk of device-associated HAIs, including catheter-associated urinary tract infections. Shah et al. (2021) found that across multiple ICUs, days with inadequate staffing were often followed by an increase in HAI diagnoses. Although this study could not establish a direct correlation between staff ratios and HAI diagnoses due to differences from other hospitals, it highlighted the importance of both. These authors also emphasized the need for better documentation on the level of support required for ICU nurses to maintain effective HAI prevention using CNAs and other multidisciplinary team members. Overall, the literature demonstrated that a team-based approach to Foley catheter management contributes to a measurable reduction in CAUTI rates over time. Summary of Literature Review Findings and Application to the Project The literature synthesized for this review consistently highlights that continuing education for nursing and other multidisciplinary healthcare team members plays a crucial role in decreasing the incidence of catheter-associated urinary tract infections (CAUTIs). Additionally, effective prevention strategies involve implementing a comprehensive care bundle that includes: 14 1. A discussion of catheter care necessity each shift. 2. Consistent catheter hygiene. 3. The use of a flag or mandatory prompt in the patient’s electronic healthcare record (EHR) that must be addressed and documented as complete at the end of each shift. Finally, applying a strong team approach ensures that all care team members are adequately trained, supported, and actively engaged in both catheter care and documentation. The discovery and application of these three evidence-based themes—education, care bundles, and teamwork— can significantly reduce CAUTI prevalence by highlighting the most effective and wellresearched strategies for achieving CAUTI-reduced healthcare. Project Plan and Implementation This project seeks to implement a quality improvement initiative to reduce CAUTIs in an ICU, using evidence identified in the literature review. Nurse-driven interventions focus on improving adherence to best practices for urinary catheter insertion, maintenance, and timely removal. This project emphasizes staff education, standardization of care, and interdisciplinary collaboration to enhance patient safety and reduce CAUTI rates. Prior to implementation, a mandatory ICU all-staff in-service will be conducted to review the project, outcomes, and baseline data on catheter use in the unit and CAUTIs. During the inservice, staff members will complete an anonymous Pre-survey 5-question Likert-scale questionnaire (see Appendix A) to assess their perceptions of the current CAUTI bundle. Afterward, a facilitated discussion will take place to assess staff engagement and identify areas for improvement. This conversation will allow staff to share experiences, ask questions about catheter bundle care, and discuss strategies for initiating and discontinuing catheters during 15 rounds with the multidisciplinary team, using the Nurse-Driven Urinary Catheter Removal Protocol checklist (see Appendix B). Plan and Implementation Process Implementation of the change plan will occur over three months and follow a phased approach outlined in the Iowa Model, including preparation, pilot, implementation, and evaluation phases. Pre-Implementation Phase: During this phase, a multidisciplinary project team will be formed, including ICU nurses, CNAs, leadership, infection prevention specialists, and ICU intensivists. Data collected in the ICU CAUTI Process Monitoring Tool will document the 3 months prior to the start of implementation and will serve as the project's baseline (see Appendix G). Educational sessions will be provided through in-service training led by infectious disease specialists (ID), intensivists, and leadership nurses. These in-services will address CAUTI risk factors, the use of the Nurse-Driven Urinary Catheter Removal Protocol (see Appendix B), and Quick Catheter Facts for families (see Appendix D). Following these in-services, unit-based champions will be recruited to reinforce best practices, provide peer support, assist with data collection on CAUTIs and foley catheters, and help address barriers. Unit champions will receive recognition from the unit for their dedication and support of this project through the hospital’s online recognition portal. They will act as an asset to this project by assisting in gathering pre-implementation data alongside the project leadership team, which includes bedside nurses, infectious disease specialists, and other interdisciplinary team members. They will also be given a responsibility checklist that includes duties such as data collection, assisting with chart audits, reminding nurses to chart catheter care, etc. (see Appendix E) 16 Implementation Phase: This Nurse-Driven Urinary Catheter Removal Protocol, including guidance on catheter responsibility and in conjunction with Preventing CAUTIs: Why it is More Important Than You Think, which serves indications for insertion (see Appendix B and C), will then be piloted in the Trauma ICU. Nurses will complete daily catheter necessity assessments each shift, supported by EHR reminders created by the clinical documentation team prior to implementation. Catheter care will be incorporated into routine patient care, and the bedside nurse will be made responsible for making it a discussed point during interdisciplinary rounds to promote accountability shared among nurses, providers, and nursing assistants. Unit champions selected with reservations by the leadership team and the project leadership team, including bedside nurses, infectious disease, and charge nurses, will provide ongoing feedback through weekly emails and staff meetings. Evaluation and Sustainment Phase: During the three-month CAUTI pilot, process vs outcomes measures (see Appendix F) will be reviewed weekly for the first month, and then monthly thereafter by leadership, unit champions, and the ID team. Anticipated outcomes include reductions in CAUTI rates and urinary catheter use compared to pre-implementation. Process measures will include compliance with daily catheter necessity documentation, completion of catheter care, and staff participation in educational sessions. Findings will be shared with ICU staff by the leadership team through staff meetings and weekly emails to promote transparency and continuous improvement. Based on the pilot results, the intervention may be expanded to additional ICU units after consideration by the project interdisciplinary team and other ICU managers. 17 Interdisciplinary Team Through ongoing collaboration, accountability sharing, and open communication, the interdisciplinary team will work together to support the continual implementation of the CAUTI prevention bundle on the ICU unit to improve patient outcomes. ICU nurses, CNAs, providers, infection prevention specialists, and nursing leadership will coordinate efforts together during daily patient care rounds to assess catheter necessity, reinforce evidence-based practices, and discuss timely catheter removal. In addition, the unit-based champions and nursing leadership will facilitate communication by sharing data through weekly emails. This helps address compliance barriers and provides feedback to support staff. Description and Development of Project Deliverables Throughout this project, deliverables have been consistently revised and well-defined to guide both the process and expected outcomes. In this section, the focus is on describing and developing the specific materials and tools designed to support this project's objectives. These deliverables include assessments, teaching materials, evaluations, and other resources that were deemed fit to ensure consistent implementation, effective knowledge acquisition, and measurable outcomes. Assessing Confidence Levels with CAUTI Prevention Measures An anonymous Likert-scale pre-evaluation tool (Appendix A) was developed to assess baseline knowledge, confidence, and perceptions related to urinary catheter management and CAUTI prevention among nurses before the implementation of the QI intervention. This tool includes five Likert-scale statements that measure the nurses’ self-reported confidence in understanding the nurse-driven catheter removal protocol, assessing daily catheter necessity, and performing catheter care and maintenance. An additional open-ended question, not on a Likert 18 scale, was included to help identify perceived barriers to implementing bundled CAUTI prevention practices. Pre-implementation assessments of staff knowledge and confidence are a critical component of effective quality improvement initiatives. The literature consistently demonstrates that nurses' knowledge, attitudes, and self-efficacy significantly influence adherence to evidencebased catheter care practices (Alsolami & Tayyib, 2024; Mong et al., 2022; Essie et al., 2024). Likert-scale instruments are widely used in healthcare quality improvement to quantify baseline perception and identify gaps that may impede successful implementation (Alex et al., 2022). Including open-ended questions allows for qualitative insight into unit-specific barriers, such as workflow constraints, perceived lack of support, and attitudes, which have been shown to impact the sustainability of CAUTI prevention interventions (Chiwaula & Jere, 2022; Krauss et al., 2022). Nurse-Driven Urinary Catheter Removal Protocol The Daily Catheter Necessity Checklist (Appendix B) was developed to support consistent, nurse-driven evaluation of urinary catheters in adult intensive care units. This checklist prompts bedside nurses to assess the need for a catheter each shift using evidence-based criteria, such as hemodynamic instability requiring strict intake and output monitoring, urologic indications, or end-of-life care. If no approved indication is identified, the nurse is authorized to remove the catheter that day, in accordance with the unit’s nurse-driven removal protocol. The checklist also helps identify team members responsible for maintenance, reinforcing shared accountability among nurses, CNAs, and charge nurses. Daily assessment of catheter necessity is supported to reduce unnecessary catheter days and prevent CAUTIs. Multiple studies have demonstrated that nurse-driven protocols and the 19 standardization of family review tools can significantly reduce catheter use and infection rates in the ICU (Patel et al., 2023; Gupta et al., 2023; Van Decker et al., 2021). Empowering nurses to assess and remove catheters independently aligns well with evidence showing that nursing autonomy with structured workflows improves adherence to best practices and patient safety outcomes (Krauss et al., 2022; Werneburg, 2022). Family Education Material and Teaching Strategies Family education materials (Appendix C) were created to improve the family's knowledge of the ICU patient. Helping them adjust to the different devices that aid their loved one’s recovery, but especially their catheter. These materials include educational handouts and visual resources on appropriate catheter use, questions to ask the bedside nurse when unsure, and our commitment to the patient with a catheter. Using this handout supports teaching strategies that include detailed guided discussions, bedside education, and reinforcement of the rationale for using a catheter. The literature strongly supports nurse-guided education as a critical component of CAUTI prevention initiatives. Systematic reviews and interventional studies consistently demonstrate that structured education improves families' knowledge and understanding, leading to reduced CAUTI rates and improved patient outcomes (Alex et al., 2022; Alsolami & Tayyib, 2024; Mong et al., 2022). Embedding education into routine workflows supports an evidencebased practice environment. It facilitates the successful implementation of quality improvement initiatives, thereby supporting the commitment to patients and families by reducing infection risk. 20 Preventing CAUTIs: Why it is More Important Than You Think. Nursing education modules (Appendix D) were developed as a deliverable to support ICU nurses in preventing catheter-associated urinary tract infections (CAUTIs) by providing helpful guidance on appropriate catheter use. This module addresses when catheter insertion is clinically necessary, including for critically ill patients, for acute urinary retention that does not respond to intermittent straight catheterization, for end-of-life care, and for preparation for surgical procedures, and lastly, for patients with stage 3 or stage 4 pressure injuries that need time to heal. It also helps highlight situations when catheter insertion is not appropriate, such as when it is done for the nurse's convenience or when the patient has to get up multiple times an hour. This helps ensure nurses can apply these principles confidently, no matter where they are in their nursing careers. Evidence supports this targeted nurse education as a key strategy for reducing CAUTI incidences. Demonstrated by research, education that is structured, interactive, and aims to improve nurses’ knowledge, enhance clinical decision-making, and promote adherence to evidence-based protocols ultimately increases patient outcomes (CDC, 2022; Alex et al., 2022; Gupta et al., 2023) By implementing this education into routine ICU practice by the nurses it aids in fostering an evidence based environment, supports future quality improvement initiatives, and reinforces the commitment to patient safety and infection prevention. Quick Catheter Fact for Families Another key deliverable for this quality improvement project is a family handout on urinary catheters, designed to provide ICU families with clear, concise information on catheter use, care, and related topics (Appendix E). The handout explains what a catheter is and encourages families to touch it. This empowers families to ask questions during rounding and to 21 the bedside nurse when they are curious. With continued support from all interdisciplinary teams, this emphasizes the commitment to the patient and states when the team will remove it based on clinical signs throughout the recovery process. The evidence supporting the use of family education materials complements nurse-guided teaching to reduce CAUTI risk in the ICU collaboratively. Studies show that providing families with structured information increases understanding, encourages engagement in patient care, and improves outcomes (Alex et al., 2022; Alsolami & Tayyib, 2024; Mong et al., 2022). This handout helps ensure families of ICU patients are informed, continues to support evidence-based practices, and reinforces the interdisciplinary team’s commitment to patient safety. Unit Champion Daily Checklist Unit Champions for this quality improvement project are members of the interdisciplinary team who assist in documentation, chart audits, communication between unit staff, etc. A handout was created for this group, designed to guide and document the daily responsibilities these champions have in supporting the CAUTI prevention initiative (Appendix F). This handout provides a structured format for champions to document the essential tasks assigned to them. Tasks assigned to them include, but are not limited to: assisting with chart audits, verifying that catheter care has been performed and charted on the shift, monitoring for barriers to consistent catheter care, and updating the CAUTI data sheet. Spaces are included to record the date and the Unit Champion’s name, ensuring accountability and accurate tracking of daily activities. This deliverable will increase nurses' sense of systemic support, reinforce the use of evidence-based catheter protocols, and help identify areas for improvement. Throughout the literature review, multiple authors highlight that the use of structured monitoring and auditing by 22 designated team members enhances compliance throughout, improves patient outcomes, and fosters a culture of accountability in the ICU (Gupta et al., 2023; Shadle et al., 2021; Patel et al., 2023). By the Unit Champions completing this daily, there will be no gaps in continued care for the patients in the ICU, and they will continue to support the overall success of the CAUTI reduction project. Evaluation and Measurement Tools Evaluations of the project include both process and outcome measures to assess implementation and clinical effectiveness. Process measures include compliance with daily catheter necessity, documentation, adherence to nurse-driven protocols, completion of catheter care and maintenance tasks, and staff participation in education (Appendix G). Outcome measures include CAUTI rates per 1,000 catheter days, total catheter device days, ICU length of stay related to CAUTIs, and antibiotic use associated with HAIs. Data will be collected through chart audits, infection surveillance reports, and regularly conducted interdisciplinary team reviews. The use of combined process and outcome measures is supported by evidence-based practice frameworks, including the Iowa Model, as a practical approach to evaluating quality improvement initiatives (Buckwalter et al., 2024; Titler et al., 2022). Monitoring both types of measures enables early identification of potential barriers, reinforces best practices among the care team, and supports data-driven decision-making to sustain the project. Previous CAUTI reduction initiatives demonstrate that ongoing measurement and feedback are essential to maintaining improvements and fostering a culture of accountability and continuous quality improvement (Li et al., 2025; Shah et al, 2022). ICU CAUTI Monitoring Processing Tool 23 Finally, the use of the ICU CAUTI Process Monitoring Tool deliverable (Appendix H) supports continual evaluation of data and comprehensive use throughout the project, using measurements of both process and outcome indicators to assess effectiveness. Some process measures captured in this deliverable include compliance with daily catheter necessity, appropriate documentation of approved indications, adherence to nurse-driven removal protocols, and completion of catheter care and maintenance checks. Outcome measures include monitoring processes such as CAUTI rates per 1,000 catheter days, total catheter device days per patient, ICU length of stay for CAUTIs, and antibiotic use for hospital-acquired infections. Data will be collected through structured chart audits done by the leadership team and unit champions, infection prevention reports, and interdisciplinary team reviews to ensure accuracy and transparency. The use of both process and outcome metrics is fully supported through evidence-based practice frameworks, including the Iowa Model, which highlights evaluation and sustainability of quality improvement projects (Buckwalter et al., 2024; Titler et al., 2022). By monitoring these indicators, early identification of gaps in practice and reinforcement of evidence-based catheter management can be achieved, as recommended by national and state-level guidelines (CDC, 2022; Patel et al., 2023). It also promotes data-driven decision-making within units. Prior CAUTI reduction initiatives demonstrated that continuous measurement, feedback, and evaluation of practice have been critical for sustaining long-term improvement and strengthening accountability across an interdisciplinary team in ICU settings (Li et al., 2025; Shah et al., 2022). Timeline The implementation of the quality improvement change will occur over a structured and phased timeline spanning 12 weeks. This timeline was designed to ensure that adequate 24 preparation, stakeholder engagement, education delivery, data collection, and evaluation could be completed. The implementation phase will begin with preparatory activities, including interdisciplinary team meetings, tool finalizations, and baseline measurement with the rest of the team. This will be followed by education, rollout of the intervention bundles, and ongoing monitoring. The timeline contains key milestones such as pre-evaluation of staff knowledge and confidence using the Assessing Confidence Levels with CAUTI prevention Measures Likert scale (Appendix A), Nurse-Driven Urinary Catheter Removal Protocol (Appendix B), Preventing CAUTIs: Why it is More Important Than You Think (Appendix C) Quick Catheter Facts for Families (Appendix D), followed by the Unit Champion Daily checklist (Appendix E), and next, a continuous process and outcome data collection (Appendix F), and lastly, the ICU CAUTI Monitoring Tool (Appendix G). The post-implementation evaluation will occur in weeks 11-12 and mirror the baseline measures to allow for direct comparisons. A detailed visual representation of the timetable will be included in Appendix F to illustrate the phases, milestones, and other key elements for the interdisciplinary team. By using this structured timeline, it supports a phased and sustainable approach to quality improvement, allowing for adjustments to be made based on early feedback and compliance data from nursing, aligning with the evidence-based practice framework that prioritizes planning, evaluation, and dissemination of outcomes (Titler et al., 2022; Buckwalter et al., 2024) Below is a text version of the timeline that is represented visually in Appendix F: 1. Weeks 1-2: Preparation & Baseline Assessment - Interdisciplinary team engagement and project team orientation - Finalize implementation materials and tools. 25 - Conduct baseline Likert pre-evaluation survey assessing confidence levels (Appendix A) 2. Weeks 3-4: Staff Education & Training - Deliver staff education using Nurse-Driven Urinary Catheter Removal Protocol (Appendix B) - Help with adjustment for use of Preventing CAUTIs: Why it is More Important Than You Think (Appendix C) - Give the Quick Catheter Facts for Families handout to help assist with education for families (Appendix D) 3. Weeks 5-8: Rollout of Intervention - Introduce the usage of Nurse-Driven Urinary Catheter Removal Protocol (Appendix B) - Start filling in the ICU CAUTI Process Monitoring Tool to highlight data (Appendix G) - Provide reinforcement and coaching during daily rounds. 4. Weeks 9-10: Monitoring and Feedback - Ongoing data collection for process measures and outcome measures (Appendix F) - Weekly compliance evaluations and feedback to staff 5. Weeks 11-12: Post Implementation Evaluation - Data analysis and comparison with baseline using process/outcome measures (Appendix F) and comparing data (Appendix G) - Final reporting and recommendations 26 This quality improvement project aims to reduce catheter-associated urinary tract infections in the ICU by implementing evidence-based practice through staff education, standardized assessment tools, robust monitoring, and family education. By following the structured timeline and using the targeted deliverables, the project will promote sustainable practice change and improve patient outcomes. Project Evaluation The overall success of the project will be evaluated using both formative and summative methods, incorporating quantitative and qualitative data to assess implementation, staff engagement, and patient outcomes. Formative evaluation will occur continuously throughout the three-month pilot to support timely modifications to interventions. This will allow the unit to foster change within the ICU that promotes safety and the use of evidence-based practice. On the other hand, quantitative formative measures will include weekly chart audits to assess use and compliance with the CAUTI bundle, the daily need for catheter documentation, and adherence to nurse-driven protocols. Together, all of these will measure compliance through unit-level charting. Qualitative formative data will be collected through brief staff surveys and informal feedback to assess nurse confidence, barriers to implementation, and the user-friendliness of the prevention bundle. Summative evaluation will take place at the end of the pilot period to determine the project's overall effectiveness. Quantitative outcome measures will include comparisons of preand post-implementation CAUTI rates per 1000 catheter days and urinary catheter utilization ratios. Additionally, summary data will include post-implementation bundle compliance rates, pulled directly from chart audits. Growth in knowledge and confidence levels regarding catheter management will be evaluated using pre- and post-education surveys developed by the project's 27 leadership and interdisciplinary team. All findings will be analyzed throughout and shared with ICU leadership and staff to continue supporting and advancing sustainability planning for the potential spread of this CAUTI intervention to additional units. Ethical Considerations Ethical considerations for this quality improvement project focus on protecting staff, upholding patient rights, promoting interhospital responsibility, and ensuring the intervention is implemented in a non-discriminatory and equitable way. The CAUTI prevention strategies will be applied to all ICU patients with urinary catheters, regardless of age, gender, diagnosis, social determinants of health, or insurance. This aligns the project with organizational and professional ethical standards by prioritizing patient safety, infection prevention, and harm reduction while promoting accountability and transparency throughout nursing practice. Staff will be made aware that participation in educational activities, completing pre- and post-surveys, and taking advantage of feedback opportunities is voluntary. Individuals who choose not to participate will not face any negative consequences related to employment status, evaluations, or work assignments. All data gathered from staff surveys and chart audits will be reported without the use of personal identifiers to protect privacy and confidentiality. Likewise, patient information will be kept unidentified and confidential in accordance with HIPAA standards. As the project lead, potential personal bias related to clinical experience and expectations for improved catheter practices will be identified and mitigated through standardized data collection tools, objective outcome measures, and a team-wide collaborative review of findings with the project leadership and infection prevention personnel. Discussion 28 This quality improvement (QI) project will address the ongoing problem of catheterassociated urinary tract infections (CAUTIs) in the ICU by implementing standardized, evidence-based catheter management protocols. Interventions include structured nursing education, a nurse-driven urinary catheter removal protocol, daily catheter necessity assessments, family education, interdisciplinary collaboration, and continuous monitoring of both process and outcome measures. The project will be guided by the Iowa Model of Evidence-Based Practice, emphasizing systematic implementation, evaluation, and unit sustainability. This discussion will examine the significance of using evidence-based strategies, their implications for advancing nursing practice, recommendations for the project's sustainability and dissemination, and broader implications for healthcare systems seeking to reduce preventable patient harm associated with catheters. Findings from the literature will strongly support the use of nurse-driven interventions to reduce CAUTI rates in critical care settings. Education will emerge as the foundational component of successful CAUTI prevention initiatives. Across the literature, studies consistently demonstrate that nurses' knowledge, attitudes, and confidence significantly influence their adherence to catheter maintenance and removal protocols (Alsolami & Tayyib, 2024; Mong et al., 2022; Dessie et al., 2024). By incorporating structured in-service education, competency reinforcement, and pre- and post-assessment of staff confidence, this project will address knowledge gaps while fostering accountability from all on the interdisciplinary team. Education not only improves technical competence but also enhances clinical judgment regarding appropriate catheter use and timely removal, which are central to preventing infections (Alex et al., 2022; Gupta et al., 2023). By strengthening nurses' confidence in decision-making, it directly advances nursing autonomy and reinforces the profession's responsibility in infection prevention. 29 In addition to education, the implementation of a standardized catheter care bundle and interdisciplinary collaboration were central to this initiative. The literature emphasizes that education on catheter device days and CAUTI incidence is associated with lower rates when bundled strategies are consistently applied (Patel et al., 2023; Van Decker et al., 2023; Soundaram et al., 2020). In comparison, various authors note continual reductions in deviceassociated infections, which are most successful when bedside nurses, CNAs, providers, and infection prevention specialists share accountability (Gupta et al., 2023; Li et al., 2025). Both initiatives together will aid the project by fostering cultures that reinforce best practices and support real-time problem-solving. Evidence-Based Solutions for Dissemination The results of this quality improvement project will be disseminated to participants and their families, as well as to all staff members, through multiple structured and professional channels to ensure transparency, shared learning, and the sustainability of this practice change. Dissemination to the ICU staff participants will occur first through unit-based presentations during staff meetings and interdisciplinary rounds. These presentations will include summaries of baseline data, post-implementation results, process compliance rates, and outcome measures, such as CAUTI rates per 1,000 catheter days and catheter utilization ratios. By utilizing multiple dissemination strategies such as unit-level reporting, presentations, and academic sharing, this project supports the translation of knowledge, promotes sustainability, and advances professional nursing practice beyond the initial ICU setting. In the near future, this could be expanded hospital-wide. The initiative could be adopted by the hospital's infection prevention department in collaboration with nursing leadership, with support from a designated system-wide nurse overseeing implementation, who could be involved 30 in the project's start-up. A phased rollout will be used, introducing the intervention unit by unit, assisting units with high-risk patients, and incorporating regular staff education to support nurses during the restandardization of protocols. Just as in the ICU, other floors will have unit champions, hand-selected by the project committee, and recommendations from the floor that will support frontline engagement and assist with accountability and resource allocation. Significance to the Advancement of Nursing Practice Catheter-associated urinary tract infections (CAUTIs) remain a preventable patient safety concern in ICUs. This contributes to increased morbidity, extended hospital stays, and higher healthcare costs (Alqarni, 2021; Werneburg, 2022). This project addresses these challenges by implementing evidence-based interventions, including standardized catheter care protocols, staff education, and process monitoring, which have been repeatedly shown to improve nursing knowledge and clinical outcomes (Alex et al., 2022; Abd El-Rahman et al., 2022). By enhancing nurses' competence in CAUTI prevention, this project supports continual professional development, strengthens adherence to best practices, and reinforces the critical role of nursing in infection control (Alsolami & Tayyib, 2024; Soundram et al., 2020). Furthermore, this demonstrates the translation of research into practice, promoting a culture of whole-team accountability and continuous quality improvement that can be sustained beyond ICU settings (Buckwalter et al., 2024; Patel et al., 2023). In the end, this project advances nursing practice by combining evidence-based strategies with structured implementation to reduce CAUTI incidence, improve patient outcomes, and inform the sustainability of nursing interventions. Implications One potential strength includes improved patient safety through reduced CAUTI incidence. Another one is enhanced nursing knowledge and competency, lastly followed by 31 sustainability for quality improvement (Alex et al., 2022; Van Decker et al., 2021). Utilizing evidence-based bundles, staff education, and standardized monitoring, this project fosters satisfaction and promotes continuous accountability and improvement among nursing staff (Andreessen et al., 2022). Some potential limitations include variability in staff engagement, time constraints during high-acuity shifts, and potential resistance to workflow changes (Chiwaula & Jere, 2022; Gupta et al., 2023). To reduce these obstacles, strategies such as ongoing education, real-time feedback through audits, leadership support, and recognition of staff contributions can be implemented. Additionally, the use of electronic documentation tools, such as catheter flow sheets, can aid in tracking and minimizing documentation burdens (Smith, 2025). Addressing these barriers upfront will enhance the likelihood of successful implementation, sustainability, and a positive impact on both patient outcomes and nursing practice. Recommendations To further strengthen the impact of this quality improvement project, several recommendations can be made. First, ongoing staff education and refresher training on catheter care and CAUTI prevention should be implemented to maintain competency and adherence to evidence-based practices (Alex et al., 2022; Abd El-Rahmn et al., 2022). Incorporating periodic audits with real-time feedback can reinforce compliance and identify areas for improvement (Van Decker et al., 2021; Li et al., 2025). Second, expanding the use of standardized care bundles and electronic documentation tools, such as urinary catheter flow sheets, can help reduce practice variability and facilitate data collection for continuous quality improvement (Smith, 2025; Andreessen et al., 2022). Engaging interdisciplinary teams, including infection prevention specialists and unit leadership, can 32 enhance sustainability and foster a culture of accountability (Gupta et al., 2023; Chiwaula & Jere, 2022). Finally, this project will require long-term sustainability through ongoing educational reinforcement, quarterly review of CAUTI data, continued engagement of bedside nurses, unit champions, and leadership, and the integration of catheter necessity communication into daily rounds as a permanent standard of practice. Also, by expanding electronic reminders and embedding catheter documentation prompts within the EHR, we will further reduce the burden of additional tasks on a bedside nurse's already demanding shift. However, gaps remain regarding the long-term outcomes of nurse-led CAUTI prevention interventions, which are remarkably diverse within the ICU population, and in resource-limited settings outside the ICU, such as the medical and surgical floors. Future research should help explore the effectiveness of various educational strategies, bundled interventions, components, and technology-assisted systems, as measured by CAUTI rates and nursing practice outcomes. Addressing these gaps supports sustained improvements in patient safety and further advancement in the use of evidence-based nursing. Conclusions Catheter-associated urinary tract infections (CAUTIs) are a prevalent and preventable complication in intensive care units (ICUs) that contribute to increased patient morbidity, prolonged hospital stays, and higher healthcare costs (Alqarni, 2021; Werneburg, 2022). The literature consistently demonstrates that gaps in nurses’ knowledge, inconsistent adherence to catheter care protocols, and variable compliance with evidence-based bundles are key contributors to CAUTI incidence (Alsolami & Tayyib, 2024; Alex et al., 2022). Studies used in this project highlight that targeted nurse education, standardized catheter care bundles, and 33 structured data monitoring significantly reduce infection rates and improve patient outcomes (Soundaram et al., 2020; Van Decker et al., 2021; Abd El-Rahman et al., 2022). Based on these literature findings, this quality improvement project was designed to implement an intervention in the ICU, including staff education on best practices, daily catheter audits, family education, and adherence to data tracking through standardized flow sheets. Key findings from the project are projected to include compliance with catheter care protocols, a measurable reduction in CAUTI rates, and increased staff confidence and knowledge in infection prevention. These outcomes are important because they directly enhance patient safety, reduce preventable complications, and demonstrate the impact of nursing-led intervention on the quality of care. 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Research and reports in urology, 14, 109–133. https://doi.org/10.2147/RRU.S273663 39 Appendix A 40 Appendix B 41 Appendix C 42 Appendix D 43 Appendix E 44 Appendix F 45 Appendix G 46 Appendix H Note: This figure illustrates a 12-week phased implementation including baseline preparation, staff training, rollout, monitoring, and post-implementation evaluation.