Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: a single institution's success

Clinical article

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To date, there has been a shortage of evidence-based quality improvement initiatives that have shown positive outcomes in the neurosurgical patient population. A single-institution prospective intervention trial with continuous feedback was conducted to investigate the implementation of a urinary tract infection (UTI) prevention bundle to decrease the catheter-associated UTI rate.


All patients admitted to the adult neurological intensive care unit (neuro ICU) during a 30-month period were included. The study consisted of two 1-month preintervention observation periods (approximately 1200 catheter days) followed by a 30-month intervention phase (20,394 catheter days). A comprehensive evidence-based UTI bundle encompassing avoidance of catheter insertion, maintenance of sterility, product standardization, and early catheter removal was enacted.


The urinary catheter utilization rate dropped from 100% to 73.3% during the intervention phase (p < 0.0001) without any increase in the rate of sacral decubitus ulcers or other skin breakdown. The rate of catheter-associated UTI was also significantly reduced from 13.3 to 4.0 infections per 1000 catheter days (p < 0.001). There was a linear relationship between the decreased quarterly catheter utilization rate and the decreased catheter-associated UTI rate (r2 = 0.79, p < 0.0001).


This single-center prospective study demonstrated that a comprehensive UTI prevention bundle along with a continuous quality improvement program can significantly reduce the duration of urinary catheterization and rate of catheter-associated UTI in a neuro ICU.

Article Information

Address correspondence to: J Mocco, M.D., M.S., Department of Neurosurgery, University of Florida, P.O. Box 100265, Gainesville, Florida 32610. email:

Please include this information when citing this paper: published online January 6, 2012; DOI: 10.3171/2011.11.JNS11974.

© AANS, except where prohibited by US copyright law.



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    Flow chart showing the daily process for review of indwelling urinary catheters. Each patient in the neuro ICU was evaluated daily for both the presence of a urinary catheter and necessity of said catheter. First, catheter placement was reviewed by both unit nurses and by Clinical Nurse Leaders on Foley Rounds. Recommendations for removal were based on catheters not meeting 1 of the 5 previously specified indications. Requests for removal were then presented to an attending physician who either provided a clarification of catheter necessity or removed the catheter. If urine management was still necessary, then alternative methods were pursued. I/O Cath = in-and-out catheterization.

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    Graphs showing reductions in urinary catheter utilization and catheter-associated UTI over time (months). Note that in all graphs, the time zero corresponds to October 2008. A: Average number of urinary catheters per day present in the 30-bed neuro ICU per quarter. B: The rate of urinary catheter utilization measured as a percentage of ICU patient beds, both 9 months prior to intervention and 30 months postintervention. C: Decrease in the total number of UTIs during the same period. This decrease correlates strongly with the UTI rate because the number of patients in the neuro ICU remained relatively constant through the study period. Note that the total numbers of UTIs during the preintervention 1-month study periods were normalized to reflect a quarterly amount. D: Catheter-associated UTI (CAUTI) rate tracked through the same time period. Note that the CAUTI rate fell prior to official implementation of the UTI bundle. Lines in panels B and D are the 25th, 50th, and 75th quartiles from the NHSN.

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    Graph showing the frequency of pathogens responsible for UTI during the study period. Note the continual decline of E. coli with the periodic increases of Proteus and Pseudomonas and relative stability of Enterococcus, Candida, and Klebsiella species. “Other” pathogens include Serratia, S. aureus, Morganella, and Stenotrophomonas.



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