Pa Patient Saf Advis 2009 Sep;6(3):98-101. 
Barriers to Urinary Catheter Insertion and Management Practices


Despite evidence that catheter-associated urinary tract infections (CAUTIs) and accompanying adverse outcomes can often be prevented, these infections remain among the most predominant healthcare-acquired infections in the United States. In May 2009, hospital infection preventionists (IPs) across Pennsylvania participated in a detailed survey of implementation of urinary catheter insertion and management practices. The survey was designed to measure the level of adoption of practices and tools useful to overcome obstacles to uniform implementation of CAUTI-prevention practices. The following discussion highlights the survey results, which were also presented during the June 2009 Pennsylvania Patient Safety Authority Webinar “Getting Past the Policy: Overcoming Barriers to CAUTI Prevention Practices” (see "Multimedia" at Patient Safety Topic).

Clinical and Economic Consequences of CAUTIs

Between 12% and 25% of all hospitalized patients are catheterized during their hospital stay, and as many as 80% of all hospital-acquired urinary tract infections can be attributed to indwelling urinary catheters.1 Use of an indwelling urethral catheter is an invasive intervention that carries a significant risk for patient harm leading to prolonged length of stay, secondary bacteremia, sepsis, and increased mortality.1 In a catheter awareness survey, 288 physicians and medical students from 4 university-affiliated U.S. hospitals were asked whether patients under their care had a Foley catheter. The physicians surveyed were unaware of Foley catheterization in 28% of 117 patients, and subsequent patient observations indicated that 31% of catheter use was inappropriate.2 Among the nonreimbursable hospital-acquired conditions selected by the U.S. Centers for Medicare & Medicaid Services, CAUTIs received a high priority due to the high cost and high volume and because prevention is reasonable through application of accepted evidence-based prevention guidelines.3 A systematic review of evidence published between January 2001 and June 2004 found that the average cost of treating a CAUTI is $1,006 in 2002 U.S. dollars.4 A cost study from the University of Michigan Health System found the minimum cost of treating a patient with catheter-related bacteremia is at least $2,836 in 1998 U.S. dollars.5

Authority Survey of CAUTI Prevention Practices

Methods and Limitations

The Authority surveyed IPs from Pennsylvania hospitals about obstacles to implementing CAUTI prevention guidelines. Sixty-five IPs completed the survey. The IPs were surveyed about implementation of 16 practice elements (see Table), which were defined according to guidelines from the Centers for Diseases Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology (APIC), and the Institute for Healthcare Improvement (IHI). Limitations of the survey include that results represent about 26% of reporting hospitals in Pennsylvania at the time of the survey, and the results may not reflect statewide adoption practices.

Table. Pennsylvania Patient Safety Authority Hospital Foley Catheter Practice Survey (N = 65) ​ ​ ​ ​ ​ ​
Survey QuestionFully Implemented throughout the OrganizationFully Implemented In Some Areas of the OrganizationPartially Implemented in Some or All AreasFormally Discussed and Considered but not ImplementedThere Has Been No Activity to Implement this ItemNumber of Respondents
Hospital policy requires that a Foley catheter (FC) securement device be used on all catheterized patients.63.1%10.8%4.6%9.2%12.3%65
A catheter-associated urinary tract infection (CAUTI) prevention program is in place with a designated physician champion.51.6%3.1%17.2%21.9%6.3%64
A written CAUTI prevention plan is in place that is communicated to clinical staff.49.2%9.2%10.8%24.6%6.2%65
The hospital has adopted written FC criteria.49.2%9.2%13.8%18.5%9.2%65
Clinical staff receives at least annual competency on CAUTI prevention strategies.42.2%7.8%20.3%17.2%12.5%64
Silver-coated FCs are used on catheterized patients.39.1%4.7%1.6%21.9%32.8%64
Hospital policy includes standing orders allowing nurses to discontinue/remove FCs that no longer meet criteria.13.8%6.2%3.1%44.6%32.3%65
Chronic FCs are changed on admission.10.9%4.7%3.1%15.6%65.6%64
Hospital policy prohibits FC insertion if criteria are not met.4.7%3.1%7.8%29.7%54.7%64
Routine maintenance activities (catheter securement, collection bag below bladder, emptying protocol) are prompted by automatic alerts or reminders to nursing staff.16.9%6.2%7.7%24.6%44.6%65
An FC insertion checklist is used to verify aseptic techniques and insertion criteria.10.8%3.1%10.8%33.8%41.5%65
FC-insertion criteria are incorporated into the physician's order form.13.8%6.2%9.2%27.7%43.1%65
Catheterized patients receive written education materials on FC and infection prevention.13.8%4.6%15.4%29.2%36.9%65
Physicians are required to document FC necessity on a daily basis.20%6.2%6.2%32.3%35.4%65
The CAUTI prevention program includes periodic physician education on CAUTI prevention strategies, including FC- insertion criteria. 0%6.2%7.7%30.8%35.4%65
A monitoring system is in place for documentation of FC criteria on physician's orders.24.6%7.7%10.8%26.2%30.8%65



The majority of IPs indicated that their hospitals have fully implemented the requirement that a Foley catheter securement device be used on all patients, have a CAUTI prevention program in place with a designated physician champion, have a written plan that is communicated to clinical staff, and have adopted criteria for Foley catheter use. About 40% of the IPs indicated that their hospitals have fully implemented assessment of annual competency for clinical staff on CAUTI prevention practices and use of silver-coated Foley catheters on all catheterized patients. Forty-five percent of the IPs indicated that their hospitals have formally discussed and considered a hospital policy on standing orders allowing nurses to discontinue or remove catheters that no longer meet criteria.

Prevention practices that the majority of IPs indicated their hospitals have not implemented include changing of chronic Foley catheters on admission, a hospital policy to prohibit catheter insertion if criteria are not met, automatic reminders to nursing for routine maintenance activities, and use of a catheter-insertion checklist. IPs from these hospitals also indicated that there was no activity to implement the following practices: incorporate catheter criteria into the physician’s order form, provide written Foley catheter education materials for patients, require physicians to document catheter necessity on a daily basis, and periodically educate physicians about CAUTI prevention strategies.

Responses on implementation of a monitoring system for documentation of Foley criteria on physician orders are spread across the categories of fully implemented, formally discussed but not yet implemented, and no activity to implement this item.

System Failures and Barriers

Many organizations have adopted the practices advocated in evidence-based guidelines but still struggle with implementation and lack methods for efficient and reliable performance of prevention practices. The Authority polled attendees of its June 2009 Webinar about the most significant barriers to implementation of CAUTI prevention practices (see Figure). Poll results indicate that the predominant barriers among the attendees are lack of accountability by members of the healthcare team for appropriate and safe practice and active resistance to prevention strategy implementation from staff and/or physicians. Less common barriers included unclear policies and protocols, difficulty enlisting physician and nursing champions, inadequate education and competency programs, and inadequate process or outcome monitoring/measuring systems.

Figure. Barriers to Prevention Practices (N = 48)

Risk Reduction Strategies

Several evidence-based guidelines summarize the most up-to-date, significant prevention and implementation strategies and provide a road map for development of institutional policy and practices to address CAUTIs. The guidelines include the following:

“Compendium of Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals.” The intent of this 2008 compendium, published by SHEA and the Infectious Disease Society of America, is to assist hospitals to prioritize and implement practical strategies for CAUTI prevention. The compendium summarizes specific expert implementation and monitoring methods and addresses accountability as well as detailed process and outcome measures.6 The compendium is available online at

“Guide to the Elimination of Cather-Associated Urinary Tract Infections (CAUTIs).” This 2008 guide, published by APIC, outlines evidence-based practice guidance to CAUTI prevention in acute and long-term care facilities, including antimicrobial stewardship, surveillance, and data dissemination, as well as how to perform a CAUTI risk assessment.7 The guide is available online at

“Getting Started Kit: Prevent Catheter-Associated Urinary Tract Infections: How-to Guide.” This guide from IHI focuses on four components of patient care recommended for all patients and outlines specific methods to translate research into practice change at the bedside.8 The guide is available online at

“Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008.” CDC revised its 1981 guideline on preventing CAUTIs and released a draft guideline for public comment in June 2009.The guideline emphasizes specific recommendations for all aspects of CAUTI prevention and implementation initiatives, updates surveillance definitions, and lists clear indications for Foley catheter use.9 The draft guideline is available online at

Additional Resources Available through the Authority

The Authority conducted its June 2009 Webinar to help hospital IPs identify practical strategies to overcome barriers, recall methods to enlist the support of physician and nursing champions, and recognize how to encourage and monitor staff compliance with CAUTI prevention practices at the bedside. The Webinar included discussion about results of the hospital survey and successful prevention efforts in Pennsylvania.

Presenters included representatives from hospitals in Pennsylvania that have successfully reduced CAUTI rates through implementation of specific strategies. For example, at Doylestown Hospital, the 2005 intensive care unit (ICU) CAUTI rate averaged 6.6 per 1,000 catheter days. A campaign initiated in 2006 helped reduce the rate to 0 by first quarter 2009. (A 22% decline in catheter utilization from 2006 to 2009 resulted in an accompanying decline in the housewide CAUTI rate from 9.5 in third quarter 2006 to 1.5 in first quarter 2009.) The initiative addressed approved criteria for removal of Foley catheters by a registered nurse without a physician order if criteria for use were not met. Analysis of hospitalwide catheter practices indicated that most ICU Foleys were inserted in the emergency department (ED). A Foley insertion checklist and bundle were initiated in the ED, straight catheters were used for emergency specimens, and Foleys were inserted only in controlled situations with time for proper preparation (i.e., not during a code or a rapid response). The ED coordinator monitors the checklists for orders, criteria, size of the catheters, pericare, and the use of an assistant during insertion. Physicians document the reason for continued Foley use on a Foley utilization chart sticker.

At Paoli Hospital, the IP identified 62 CAUTI cases in 2006, a rate of 5.39 CAUTIs per 1,000 catheter days. Failure modes and effects analysis helped identify opportunities for improvement and standardization, including a nurse-driven catheter-removal protocol, daily assessment of catheter care, and criteria on the nursing flowsheet and daily rounds. A Foley catheter bag label identifying the insertion date, time, location, inserter, and a hand hygiene reminder was developed. Voiding trials and bedside commode use increased, and bladder scanning was initiated. Unit and physician champions were identified, and registered nurses were reeducated about insertion, care, and catheter alternatives. Orders are required for Foley insertion, and daily physician reminders were instituted. Application of these strategies reduced the number of CAUTIs to 33 in 2008, a 47% reduction, or a rate of 3.59 infections per 1,000 catheter days, as well as a consistent decline in unnecessary catheter usage from 11,489 to 9,180 catheter days.

The Authority hosts an online collection of CAUTI resources, including the full Webinar presentations discussing efforts at Pennsylvania hospitals and additional patient safety tools from the Webinar presenters (a detailed nurse-driven Foley catheter-removal protocol; sample physician reminders; insertion, performance, and tracking checklists; and an infection prevention tip sheet). The collection is available online at


  1. Saint S, Chenoweth CE. Biofilms and catheter-associated urinary tract infections. Infect Dis Clin North Am 2003 Jun;17(2):411-32.
  2. Saint S, Wise J, Amory JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med 2000 Oct 15; 109(6):476-80.
  3. U.S. Department of Health and Human Services (HHS). HHS action plan to prevent healthcare-associated infections [online]. [cited 2009 May 8]. Available from Internet:
  4. Stone PW, Braccia D, Larson E. Systematic review of economic analysis of health care-associated infections. Am J Infect Control 2005 Nov;33(9):501-9.
  5. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteruria. Am J Infect Control 2000 Feb;28(1):68-75.
  6. Lo E, Nicolle L, Classen D, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiology 2008 Oct;29 Suppl 1:S41-50.
  7. Association for Professionals in Infection Control and Epidemiology. Guide to the elimination of catheter-associated urinary tract infections (CAUTIs) [online]. 2008 [cited 2009 Jul 17]. Available from Internet:
  8. Institute for Healthcare Improvement. Getting started kit: prevent catheter-associated urinary tract infections: how-to guide [online]. 2009 Feb [cited 2009 Jul 14]. Available from Internet:
  9. Centers for Disease Control and Prevention (CDC). Guideline for prevention of catheter-associated urinary tract infections 2008 [draft online]. [cited 2009 Jul 22]. Available from Internet:

The Pennsylvania Patient Safety Advisory may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration, provided the source is clearly attributed.

Current and previous issues are available online at