research question

Evidenced based practice

(One)

In this writing, locate an article pertaining to the topic below. Choose your article wisely, because you will be incorporating the article into all three of your writing assignments this session. In this writing, please discuss how this (one) article will be beneficial to your assigned topic. (The article should be a research conducted in United states.) Also state what you will be focusing on.

Topic: Preventing Healthcare Associated Infections.

This should be a page. Do not use direct quotes, but paraphrase. Also, cite the article you chose in

APA 6th edition format.

(Two)

Unit 3: Research Problems and Designs

Would your problem identified in the Unit 2 discussion question lend itself to a qualitative or quantitative design? What level of evidence (research design) would best address the problem? Explain your answer.

Also, include your Picot statement.

APA 6th edition format.

Feature

©2020 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ccn202043

8

Background Catheter-associated urinary tract infections are common health care–associated infections
and have been associated with increased mortality, morbidity, length of stay, and cost. Prevention strate-
gies are grouped into bundles focused on reducing unnecessary catheter use and promptly removing uri-
nary catheters. Before intervention in the study institution, no urinary catheters were unnecessarily used
and compliance with the catheter-associated urinary tract infection bundle was 84%.
Objective To increase bundle compliance by using targeted rounds specifically focused on eliminating
dependent loops in drainage tubing and ensuring appropriate catheter use to reduce the incidence of
catheter-associated urinary tract infections.
Methods A multidisciplinary team was formed to identify misperceptions, highlight best practices, and
eliminate barriers to success over 1 year in a single pediatric intensive care unit. The team completed a
quality improvement project of daily targeted rounding for patients with an indwelling urinary catheter.
The goals were to assess appropriateness of catheterization, increase bundle compliance, and decrease
catheter-associated urinary tract infection risk. Targeted rounds were conducted in addition to the medi-
cal team rounds.
Results Bundle compliance supported by targeted rounding increased from 84% to 93% and helped reduce
the overall catheter-associated urinary tract infection rate from 2.7 infections per 1000 catheter-days at
baseline to 0. This change was sustained for 1 year.
Conclusion Targeted rounding for pediatric patients with an indwelling urinary catheter is an effective
and sustainable strategy to reduce catheter-associated urinary tract infections. The ease of implementa-
tion for this intervention lends itself to generalizability to other patient populations. (Critical Care Nurse.
2020;40[1]:e12-e17)

Megan D. Snyder, MSN, RN, ACCNS-P, CCRN
Margaret A. Priestley, MD
Michelle Weiss, BSN, RN
Cindy L. Hoegg, BSN, RN, CIC
Natalie Plachter, MSN, RN, CPNP
Sarah Ardire, BSN, RN, CCRN
Allison Thompson, MSN, RN, RD, CRNP

Preventing Catheter-
Associated Urinary Tract
Infections in the Pediatric
Intensive Care Unit

Health care–associated infections (HAIs) are common complications for hospitalized patients in the United States.1 Indwelling devices, such as urinary catheters, increase the risk of infec-tion in critically ill patients. Catheter-associated urinary tract infection (CAUTI) is one of the
most common device-related HAIs, accounting for more than 30% of all acute care hospital infections.1

e12 CriticalCareNurse Vol 40, No. 1, FEBRUARY 2020 www.ccnonline.org

www.ccnonline.org CriticalCareNurse Vol 40, No. 1, FEBRUARY 2020 e13

Engaging multidisciplinary team
members and leaders from all levels
is vital to the sustained success of
CAUTI prevention.

Multiple national agencies, including The Joint Commis-
sion with its National Patient Safety Goals, have under-
scored the need to reduce CAUTI rates.2 CAUTIs have
been associated with increased mortality, morbidity, bacte-
rial resistance, length of stay, and cost.3 Annually, 13 000
deaths are attributed to urinary tract infections and an
estimated 450 000 CAUTI events occur.4,5 Approximately
$1.7 billion of direct health care costs in the United States
can be attributed to CAUTIs each year.5

Research and quality improvement initiatives reported
in the literature have primarily been aimed at preventing
CAUTIs in adults. Few studies of epidemiology or preven-
tion in the pediatric population have been published.6
Therefore, national guidelines for CAUTI prevention are
based largely on data from studies in adults.7 The
National Healthcare Safety Network demonstrated that
pooled mean CAUTI rates were similar in adults and chil-
dren. The national pooled mean for pediatric intensive care
units (PICUs) was 2.5 infections per 1000 catheter-days.1,8
In a recent study of 2150 CAUTI events in 10 hospitals,
83% of cases were reported in PICUs, as compared with
13% reported in pediatric inpatient units.8

Prevention strategies for CAUTIs and other HAIs have
been grouped into bundles, a concept developed by the
Institute for Healthcare Improvement to describe struc-
tured processes for group interventions.9 Although a

variety of CAUTI bundles exist, many stress 2 key princi-
ples: reducing unnecessary catheter use and ensuring
prompt removal of urinary catheters.7,10 Despite early suc-
cess with CAUTI prevention bundles to reduce urinary
catheterization rates, CAUTI prevention remains chal-
lenging. According to the National Healthcare Safety
Network HAI progress report, overall CAUTI rates did
not change from 2009 to 2014.1,

6

In 2008, the Centers for Medicare & Medicaid Services
instituted a policy of nonpayment for HAIs, including
CAUTIs,11 and in 2012 the agency started the Hospital
Value-Based Purchasing Program to offer financial incen-
tives based on patient care experiences, clinical process
of care, and outcomes.10 Interest in CAUTI prevention
has therefore been renewed, spurring further research
and quality improvement projects.

Patients without a urinary catheter will not develop
a CAUTI. Studies in adults have shown that up to 50%
of patients with an indwelling urinary catheter (IUC)
do not have an appropriate indication for an IUC.10
However, the same result was not found in a pediatric
study in which more than 90% of patients had an appro-
priate indication
for an IUC.7
Appropriate
indications for
IUCs are surgical
procedures, need
for continuous urine monitoring, presence of acute uri-
nary retention or obstruction, healing pressure ulcers in
incontinent patients, need to improve end-of-life com-
fort, presence of an abnormal genitourinary system,
and administration of caustic chemotherapy agents.7

Although educational interventions are an easy first
step in decreasing unnecessary catheter use, more com-
plex strategies are often needed to ensure sustainabil-
ity.10 Engaging the leadership team in harm prevention
is vital to implement and sustain interventions aimed
at decreasing HAIs and is important to ensure the suc-
cess of new patient safety initiatives.12,13 Purvis et al13

found that CAUTI prevention strategies implemented
in isolation and without engagement of the leadership
team did not reduce CAUTI rates. We used our institu-
tion’s quality improvement framework to design an
intervention that engaged the leadership team and a
multidisciplinary team. We implemented targeted
rounds to increase bundle compliance and reduce

Authors

Megan D. Snyder is the Director of Nursing Professional Practice,
Michelle Weiss is a case management specialist, and Natalie Plach-
ter is a primary care nurse practitioner at the Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania.

Margaret A. Priestley is an associate professor of clinical anesthesiol-
ogy and critical care medicine at the Perelman School of Medicine at
the University of Pennsylvania, Philadelphia, Pennsylvania, and the
medical director of the pediatric intensive care unit at the Children’s
Hospital of Philadelphia.

Cindy L. Hoegg is the Senior Infection Preventionist in the Infection
Prevention and Control Department at the Children’s Hospital of
Philadelphia.

Sarah Ardire is a clinical nurse expert in the pediatric intensive care
unit at the Children’s Hospital of Philadelphia.

Allison Thompson is the advanced practice provider manager for the
critical care, sedation/radiology, and surgical subspecialty teams at
the Children’s Hospital of Philadelphia.

Corresponding author: Megan D. Snyder, MSN, RN, ACCNS-P, CCRN, Children’s Hospital
of Philadelphia, Critical Care Nursing, 3401 Civic Center Blvd, Philadelphia, PA
19104 (email: snyderm1@email.chop.edu).

To purchase electronic or print reprints, contact the American Association of Critical-
Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or
(949) 362-2050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org.

e14 CriticalCareNurse Vol 40, No. 1, FEBRUARY 2020 www.ccnonline.org

Daily targeted rounds and real-time
training helped achieve and sustain a
rate of 0 CAUTIs for more than a year.

unnecessary catheter use, aiming to ultimately reduce
CAUTI incidence.

Methods
This project was conducted in a 55-bed PICU within

a large (520-bed), urban, academic quaternary care hos-
pital in the mid-Atlantic region. Our PICU accepts 3500
admissions per year. The PICU is staffed by 30 faculty
members, 19 fellows, and more than 20 nurse practi-
tioners in pediatric critical care medicine and by rotating
residents and fellows in pediatrics, emergency medicine,
and anesthesiology. Patients are cared for by 275 pediat-
ric critical care nurses. In the 9 months before interven-
tion (July 2014-March 2015), our PICU averaged 195
IUC days per month. All patients in the PICU had
appropriate indications for catheter placement.

The PICU CAUTI working group consisted of an
attending physician, nurse practitioner, unit-based
clinical nurse specialist, unit-based safety quality spe-
cialist, clinical nurse leader, staff nurse, infection con-
trol specialist, executive sponsor, and data analyst. The
team met 1 to 2 times per month for a year to track
progress and make any needed modifications.

Although targeted rounding has not been compre-
hensively reported in published studies, we implemented
targeted rounds for patients with an IUC to support bun-
dle compliance. We used targeted rounds to provide a
systematic approach to rounding only for patients with
an IUC to ensure that their catheter care adhered to the
bundle elements. The bundle, which was implemented
in October 2010, included the following elements: ensur-
ing that the urinary catheter was secure, documenting

urinary cathe-
ter care, ensur-
ing that the
urinary drain-
age bag was

below the level of the bladder, ensuring that the drainage
collection tubing had no dependent loops, and checking
that the patient still met criteria to keep the IUC in place.
Dependent loops occur when the IUC forms a U shape,
impeding the flow of urine from the bladder into the
drainage bag. Compliance with the CAUTI bundle was
calculated as the percentage of patients with an IUC for
whom all 5 of the bundle elements were met during
rounding and chart review. In March 2015, the PICU
CAUTI team leader began conducting targeted rounds

for patients with an IUC. It quickly became apparent
that relying on 1 person was not a practical way to create
change. A multidisciplinary approach was needed, and
engagement of nurses and physicians was vital to success.

In March 2016, the PICU CAUTI working group for-
malized a daily targeted rounding plan for all patients
with an IUC. Each clinical member of the PICU CAUTI
working group was assigned a day to conduct rounds
each week. Rounds occurred at least once per day and
included education (real-time training) for all nurses
caring for a patient with an IUC. The duration of rounds
varied according to the number of patients with an IUC
but averaged less than 5 minutes per patient.

To evaluate the impact of targeted rounding for CAUTI
prevention, our team examined overall CAUTI bundle
compliance as well as each individual bundle component
to identify areas for improvement. We tracked the CAUTI
count (the raw number of infections) and the CAUTI rate
(the number of infections divided by the number of oppor-
tunities) as balancing metrics, expecting that higher bun-
dle compliance would result in fewer CAUTIs and a lower
CAUTI rate.

Intervention
The targeted rounds focused on bundle compliance,

real-time training, and the indications for IUC use. Real-
time training covered any bundle element with an oppor-
tunity for improvement. Topics included risks of CAUTI,
the need for an IUC, catheter securement, and strategies
to eliminate dependent loops in the tubing.

We built a Harm Prevention Data Review dashboard
with the support of a data analyst from the Office of Clin-
ical Quality Improvement and an improvement advisor
from the Office of Safety and Medical Operations. Before
this dashboard was available, we had no systematic way
to easily share data across the institution, making it hard
to spread information readily to the frontline staff every
day. Through this work, our team was able to measure
and track bundle compliance and CAUTI rate and to
access bedside review data. The dashboard collates
data from a variety of sources such as the electronic health
record and secure electronic surveys and displays the data
comprehensively, allowing anyone in the institution to
see a clear snapshot of the harm metrics updated daily.
As a result, we could review compliance and outcome
trends in real time and take a more proactive approach
to CAUTI prevention.

www.ccnonline.org CriticalCareNurse Vol 40, No. 1, FEBRUARY 2020 e15

Measures and Analysis
We collected data from at least 20 IUCs per month

to track bundle compliance and CAUTI rate. To ensure
accurate sampling of our patient population, the team
entered data from 1 critically ill patient, 3 moderate-
acuity patients, and 1 low-acuity patient per week.

We analyzed our hospital process metrics by using a
data visualization tool that captured bundle compliance
measures obtained from secure electronic surveys to iden-
tify bundle components that were most often missed in
the audits (a major contributor to noncompliance was
dependent loops in the tubing). We focused daily targeted
rounds and follow-up education practices on these com-
ponents. We also continuously tracked the audit data and
outcomes to determine if our targeted rounding and
real-time training was making a difference. Tracking our
outcomes revealed a significant decrease in CAUTIs over
time. The PICU CAUTI working group tracked the data
and discussed them at each meeting. In accordance with
institutional standards, this project was considered qual-
ity improvement and did not necessitate institutional
review board oversight.

Results
Between July 2014 and June 2017, bundle compliance

in the PICU increased (77% in fiscal year 2015, 84% in
fiscal year 2016, and 93% in fiscal year 2017). We tracked
overall CAUTI bundle compliance according to individ-
ual bundle components to identify areas of improvement
(see Table). Compliance for avoiding dependent loops in
the drainage collection tubing (ie, no urine stasis in the

tubing) reached 96% in fiscal year 2017, an improvement
over the 88% compliance in fiscal year 2016. This partic-
ular bundle element drove our overall bundle compliance,
which was 93% for fiscal year 2017 (see Table). Addition-
ally, in the 27 months after implementing the interven-
tion (April 2015 through June 2017), our PICU averaged
208 IUC days per month.

Before implementing daily targeted rounds, our unit’s
overall CAUTI rate was 2.7 infections per 1000 catheter-
days. After implementing daily targeted rounds and real-
time training, we sustained a rate of 0 CAUTIs for more
than 1 year (see Figure). The rate of IUC use did not
change over time until June 2017. In June 2017, our IUC
use decreased by approximately 50% and 1 patient devel-
oped a CAUTI, leading to a higher CAUTI rate. Targeted
rounds also provided an opportunity to highlight best
practices and congratulate staff on providing excellent
care when all bundle elements reached full compliance.
For continued success, we disseminated monthly emails
starting in July 2016 to highlight CAUTI bundle compli-
ance and best practices and to provide education on
areas for improvement.

Discussion
Targeted rounding has been very successful, and we

have continued this practice with the goal of sustaining
a low CAUTI rate. The PICU has become a model of best
practices and improving harm prevention throughout
the organization.

Over time, several themes consistent with the results
of previous studies emerged from our targeted rounds.

Table Compliance with catheter-associated urinary tract infection bundle components by fiscal year
FY 2015 FY 2016 FY 2017

Component Counta Percentage Counta Percentage Counta Percentage
Overall CAUTI bundle complianceb 358/467 77 325/386 84 208/223 93
Checking that catheter is secure 462/467 99 385/386 100 220/223 99
Documenting urinary catheter care 420/466 90 374/386 97 219/223 98
Ensuring that drainage bag is below
bladder level

437/437 100 373/373 100 223/223 10

0

Avoiding dependent loops in
drainage tubing

377/438 86 327/373 88 214/223 96

Checking that criteria for catheter
are met

459/467 98 384/386 99 222/223

100

Abbreviations: CAUTI, catheter-associated urinary tract infection; FY, fiscal year.
a Count indicates the number of bundle audits completed.
b Overall CAUTI bundle compliance is not a simple mean of all of the bundle components. Failure to meet more than 1 bundle component in the same patient has a
cumulative effect, reducing the calculated overall CAUTI bundle compliance.

e16 CriticalCareNurse Vol 40, No. 1, FEBRUARY 2020 www.ccnonline.org

As with another study of pediatric patients,7 all of our
patients had a recognized indication for an IUC. Our
results also demonstrated a relationship between infec-
tion rates and bundle compliance; as bundle compliance
increased, CAUTI rates decreased.14,15 After completing
daily targeted rounds for a full year, we identified elimi-
nating dependent loops in the drainage tubing as a con-
sistent area for improvement. This bundle component
was also a factor in a recent study in which 85% of patients
with an IUC had a dependent loop in the drainage tub-
ing.16 According to the results of our quality improvement
project and those of other studies,12,17 engaging multi-
disciplinary team members and leaders from all levels is
vital to the sustained success of CAUTI prevention. We
attribute our success in increasing compliance with the
bundle element of avoiding dependent tubing loops on
real-time training and adding pictures of proper drain-
age gradients to our nursing procedures.

The generalizability of targeted rounding as an
intervention to reduce CAUTIs may be limited because
this quality improvement project was conducted in
only 1 PICU. However, the ease of implementation for
this intervention lends itself to generalizability within
other populations. Targeted rounding was a feasible
intervention for our team because it was not time inten-
sive, it focused on a small population of patients, and

many team members could share the responsibility of
conducting rounds.

Conclusions
Lowering CAUTI rates requires an interdisciplinary

approach to implement a care bundle aimed at reducing
unnecessary catheter use, maintaining high standards of
urinary catheter care, and ensuring prompt removal of the
IUC when it is no longer needed. In addition to the bundle,
conducting targeted rounds for patients with an IUC is an
effective and sustainable strategy to reduce the most prev-
alent HAI in the United States. Implementing this quality
improvement project, which combines targeted rounds
with attention to care bundle compliance, can help
achieve and sustain a reduction in CAUTI rates. CCN

Financial Disclosures
None reported.

See also
To learn more about catheter-associated urinary tract infections, read
“Zeroing in on Safety: A Pediatric Approach to Preventing Catheter-
Associated Urinary Tract Infections” by Williams in AACN Advanced
Critical Care, October-December 2016;27:372-378. Available at www
.aacnacconline.org.

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Figure Catheter-associated urinary tract infection (CAUTI) rate (left axis) and bundle compliance (right
axis) in the pediatric intensive care unit, calculated monthly from July 2014 through June 2017.

CA
UT

I r
at

e
(p

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1

00
0

ca
th

et
er

-d
ay

s)

Date

Bundle com
pliance, %

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l

2

01

4

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g 2

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4

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4

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4

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4

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01
4

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5

Fe
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01
5
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b 2

01
6

Fe
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01
7

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6
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7

Ma
r 2

01
5
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r 2
01
6
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Ap
r 2

01
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01
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n 2

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l 2
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6
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01
5
Au
g 2
01
6
Oc
t 2
01
5
Oc
t 2
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6
Se
p 2
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5
Se
p 2
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6
No
v 2
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5
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50

40

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rate line cause warning warning special cause target compliance

Unit lead
rounding

Daily rounding
and real-time

education

Monthly education on
bundle compliance

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