This section lists major changes provided in the Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute-Care Hospitals: 2022 Update,¹ including recommendations that have been added, removed, or altered. Recommendations in this document are categorized as “essential practices” that are foundational to all HAI programs in acute-care hospitals (in 2014, these were termed “basic practices”) or “additional approaches” to be considered for use in locations and/or populations within hospitals during outbreaks in addition to full implementation of essential practices (in 2014 these were termed “special approaches”). See Table 1 for a complete summary of the recommendations contained in this document.

This document was developed following the process outlined in the Handbook for SHEA-Sponsored Guidelines and Expert Guidance Documents.² No guideline or expert guidance document can anticipate all clinical situations, and this document is not meant to be a substitute for individual clinical judgement by qualified professionals. This document focuses on prevention of catheter-associated urinary tract infections (CAUTIs) in acute-care hospitals. The strategies highlighted may or may not be applicable for other healthcare settings, such as ambulatory settings or long-term or postacute-care facilities. Furthermore, there may be differences in healthcare environments within the hospital (eg, acute-care wards vs intensive care units vs perioperative spaces, etc) that may affect the feasibility of specific recommendations, which should be considered by stakeholders implementing these strategies.

This document is based on a synthesis of evidence, theoretical rationale, current practices, practical considerations, writing group consensus, and consideration of potential harm, where applicable. A summary of the recommendations is provided in Table 1.

SHEA recruited 3 subject-matter experts in CAUTI prevention to lead the panel of members representing the Compendium partnering organizations: SHEA, IDSA, APIC, AHA, and The Joint Commission, as well as the Centers for Disease Control and Prevention (CDC).

SHEA utilized a consultant medical librarian who worked with the panel to develop a comprehensive search strategy for PubMed and Embase (January 2012–July 2019; updated to August 2021). Article abstracts were reviewed by panel members in a double-blind fashion using Covidence abstract management software (Covidence, Melbourne, Australia). The articles were subsequently reviewed as full text. The Compendium Lead Authors group voted to update the literature findings, and the librarian reran the search to update it to August 2021. Panel members reviewed the abstracts of these articles via Covidence and incorporated relevant references.

Recommendations resulting from this literature review process were classified based on the quality of evidence and the balance between desirable and potential undesirable effects of various interventions (Table 2). Panel members met via video conference to discuss literature findings, recommendations, quality of evidence for these recommendations, and classification as essential practices, additional approaches, or unresolved issues. Panel members reviewed and approved the document and its recommendations.

The Compendium Expert Panel, made up of members with broad healthcare epidemiology and infection prevention expertise, reviewed the draft manuscript after consensus had been reached by writing panel members.

Following review and approval by the expert panel, the 5 Compendium Partners, stakeholder organizations, and CDC reviewed the document. Prior to dissemination, the guidance document was reviewed and approved by the SHEA Guidelines Committee, the IDSA Standards and Practice Guidelines Committee, AHA, and The Joint Commission, and the Boards of SHEA, IDSA, and APIC. All members complied with SHEA and IDSA policies on conflict-of-interest disclosure.

The clinical diagnosis of CAUTI is often a diagnosis of exclusion,³⁵ making it difficult to have a standardized definition. At present, all of the available definitions have substantial limitations.⁴⁵ We discuss the criteria, advantages, and limitations of different definitions used for CAUTI in Table 4.

The optimal definition for CAUTI used for surveillance and quality improvement is one that only captures true instances of symptomatic infection that would benefit from antimicrobial treatment. The NHSN CAUTI definition has been adopted nationally, but other definitions are also used for clinical care and administrative purposes.⁴⁶ The NHSN CAUTI definition has been updated in 2015 with exclusion of yeast as a pathogen and increase in the urine-culture bacterial threshold to ≥10⁵ colony-forming units per milliliter (CFU/mL) to align with a clinical definition for symptomatic CAUTI.^47,48

Recommendations are categorized either as essential practices that should be adopted by all acute-care hospitals or as additional approaches that can be considered for use in locations and/or populations within hospitals when CAUTIs are not controlled using essential practices. Essential practices include recommendations in which the potential to impact CAUTI risk clearly outweighs the potential for undesirable effects. Additional approaches include recommendations in which the intervention is likely to reduce CAUTI risk but there is concern about the risks for undesirable outcomes, the quality of evidence is low, or evidence supports the impact of the intervention in select settings (eg, during outbreaks) or for select patient populations. Hospitals can prioritize their efforts by initially focusing on implementing essential practices. If CAUTI surveillance or other risk assessments suggest that ongoing opportunities for improvement exist, hospitals should then consider adopting some or all of the additional approaches. These interventions can be implemented in specific locations or patient populations or can be implemented hospital-wide, depending on outcome data, risk assessment, and/or local requirements. Each infection prevention recommendation is evaluated for quality of evidence (Table 2). Recommendations for preventing and monitoring CAUTI^34,35,51,52 are summarized in the following section and Table 1.

Different performance measures have been used for internal and external reporting of CAUTIs and catheter utilization. Hospitals may use a combination of metrics for public reporting and to assess the impact of quality improvement initiatives. Here, we discuss outcome and process measures for both internal and external reporting.

Preventing CAUTI requires a focus on both technical and socioadaptive (or behavioral) components.¹¹⁶ Although the general concepts of implementation science are found in a companion article of the 2022 Compendium, we detail here some of the CAUTI-specific implementation work—and lessons learned—those hospitals should be aware of since the 2014 update.¹¹⁷ Interventions to assist with program implementation and evaluation that have been reported to be associated with improved outcomes are provided in this section. These interventions are often multifaceted and generally include elements of the “4E’s” model.¹¹⁸ This section is particularly aimed toward physicians, nurses, and infection preventionists that are in leadership positions, to review when designing or revising strategies to optimize implementation of CAUTI prevention strategies.

Over the past several years, regional and national CAUTI prevention initiatives have been implemented in acute-care hospitals. Several of these initiatives have been successful^119–121 but not in all patient care locations or settings.^56,122 In 2013, investigators in Michigan published the results of a comparison study in which they surveyed infection preventionists nationally (with an oversample of Michigan hospitals) and also evaluated SIRs comparing Michigan with non-Michigan hospitals.¹¹⁹ In this study, hospitals that were more likely to participate in collaboratives aimed at reducing HAIs, more likely to use bladder scanners, stop orders, reminders, or nurse-initiated removal of urinary catheters, corresponded to a 25% reduction of CAUTI rates compared with other hospitals.¹¹⁹

In a study of 7 Veterans’ Affairs (VA) hospitals, a multidisciplinary team demonstrated a significant reduction in CAUTI rates on medical-surgical wards (from 2.4 to 0.8 CAUTI per 1,000 catheter days; P = .001) but no significant change in ICU CAUTI rates.¹²⁰ The intervention used a 2-tier system of interventions to determine each hospital’s specific needs relative to their CAUTI rates. Tier 1 describes data-gathering needs and a nursing template in the EMR to prompt staff to consider removing catheters at the earliest possible point. This tier alone can create sufficient visibility within the organization to reduce CAUTI rates to the desired level. Tier 2 is a more intensive tier of steps that hospitals can implement for stubborn rates that will not come down, including root-cause analysis. In a separate study by Saint et al, the team implemented a multifactorial intervention at >900 non-VA hospital units in the United States. This intervention utilized the Comprehensive Unit-Based Safety Program (CUSP). As with the Saint VA hospital study, this intervention led to a reduction in CAUTI rates in non-VA hospital medical-surgical wards (from 2.40 to 2.05 CAUTIs per 1,000 catheter days) but not in ICUs.¹²¹ These 2 CAUTI prevention efforts in VA and non-VA hospitals have thus far failed to significantly reduce rates in ICUs, likely related to several reasons including cultural differences between critical-care units and medical-surgical floors in the United States. Specifically, critical-care units often consider indwelling urethral catheters to be a standard of care for their patients,¹²³ even when suitable alternatives could be used.^65,123 The CUSP model was also used to focus entirely on ICUs with elevated baseline rates of CAUTI; this negative study revealed a need to develop a new model for helping such struggling hospitals. In the nursing home setting, as part of the AHRQ Safety Program for Long-Term Care, use of a combined technical and socioadaptive intervention reduced CAUTI rates by 54% and culture orders by 15%.¹²⁴

The CDC recently funded a large-scale CAUTI intervention in medical-surgical units. This approach used 2 levels (or tiers) of interventions to approach and reduce persistently elevated CAUTI rates (Table 5 and Fig. 2). In short, the tier 1 interventions are applicable to all situations, regardless of CAUTI rates. However, if CAUTI rates remain elevated after implementing all 5 steps of tier 1 interventions, then the next tier is used. The process in tier 2 begins by using the Guide to Patient Safety,¹²⁵ a validated tool developed to help HCP through the process of identifying barriers to reducing CAUTI rates. This tool uses a series of questions designed to help an organization identify areas for improvement coupled with evidence-based annotated responses to simple “yes or no” questions (Table 5 and Fig. 3; https://www.catheterout.org/cauti-gps.html).¹²⁶

Additional technical processes are often needed for successful implementation. However, technical processes alone rarely are enough to effect change. Those processes must also be adapted to specific social aspects of a given organization. This distinction between technical and socioadaptive (or behavioral) strategies is critical to proper integration of new processes.

Through social adaptation of technical strategies, innovation can be diffused in an organization.¹²⁷ Consider technical means to reduce infection (eg, ready availability of hand sanitizers or bladder scanners and automatic urinary catheter stop orders in the hospital’s electronic health record system) as well as social adaptations such as changing organizational culture or norms of clinical practice or engaging clinicians with CAUTI initiatives. During a recent survey, Greene et al¹²⁸ collected data from infection preventionists across the United States. Part of the survey evaluated how feelings of psychological safety interact with patient safety goals. Psychological safety is defined as “the degree to which people view the environment as conducive to interpersonally risky behaviors like speaking up if they witness an error or asking for help if they have concerns about an order.”¹²⁸ As an example of such a connection, they calculated the odds of regularly using technical initiatives for CAUTI reduction (eg, urinary catheter reminders) based on the degree of psychological safety the respondent felt in their organization. These researchers found high psychological safety (38% of respondents) to be associated with higher odds of using the technical initiatives (odds ratio, 2.37; P = .002).

Ensuring high psychological safety among HCP should also ideally be a foundational aspect of infection prevention practices. Similarly, survey results examining followership characteristics—personal attributes of those who follow a mentor, such as being energized by work, taking initiative, or independent thinking—demonstrated that the quality of follower has a direct influence on the uptake of recommended infection prevention practices.¹²⁹ Frameworks like the Consolidated Framework for Implementation Research (CFIR) provide constructs across 5 domains: inner setting, outer setting, intervention, individuals, and process.¹³⁰ These constructs provide a practical guide for assessing socioadaptive and technical aspects, diffusion of innovation, and program evaluation.

Investigators have also employed formal qualitative approaches to assess CAUTI implementation successes and challenges. For example, Krein et al¹³¹ examined the statewide impact of a “Bladder Bundle” initiative to reduce unnecessary use of urinary catheters. The team gathered qualitative data through semi-structured interviews and site visits, resulting in the identification of key barriers to successful CAUTI reduction: (1) lack of nurse and/or physician engagement in the program; (2) patient and/or family requests for catheters; and (3) emergency department (ED) customs and practices.¹³¹ Although these barriers represent important impediments, the investigators also identified strategies the participating hospitals used to address those barriers: (1) using urinary management (eg, planned toileting) in combination with other patient safety programs like fall prevention; (2) conversations with patients and/or families to clearly explain the risks associated with catheters; and (3) standardizing appropriateness criteria for staff working in the ED (to prevent placement of catheters for inappropriate reasons).¹³¹ In another qualitative study, Harrod et al¹³² examined the perception of risk of HCP and how that related to their use of infection prevention practices such as indwelling urethral catheter. These study findings indicated that patient risk is not the only consideration for these HCP when deciding whether to use a urinary catheter. The study identified several areas for potential improvement: (1) the need for HCP to deal with competing priorities and insufficient time; (2) identifying “gray areas” where the connection cannot be directly made between the use of a urinary catheter and a negative patient outcome; (3) process weakness in either or both existing organization policies and the new initiative being undertaken; and (4) HCP using “workarounds” to undermine the effectiveness of catheter use reduction programs.¹³² Investigators can thus tailor future interventions to address broader issues of risk to patient safety, realizing that objective risk from device use itself is not the only factor HCP consider when deciding to use a urinary catheter.

Implementation models like Capability–Opportunity–Motivation–Behavior (COM-B), Theoretical Domains Framework (TDF), and the Health Belief Model can be employed for better understanding of barriers and facilitators of CAUTI Prevention. Parker et al¹³³ also examined the barriers to and facilitators of a successful CAUTI reduction program by conducting 8 focus groups with a total of 35 individuals. Their team identified several major themes based on the use of their “NO CAUTI” bundle.¹³⁴ They identified 2 facilitators to this process: (1) early and sustained key stakeholder engagement and (2) effective advance planning that allows for adaptation during implementation. They also reported 2 barriers: (1) managing the change itself is a burden and (2) sustaining practice change is difficult and must be properly managed.¹³³ An overview of practical approaches for problem solving regarding potential barriers to implementation is provided in the Supplementary Content, Appendix 4 (online).

Finally, a key aspect of any intervention to reduce CAUTI (or other HAIs) is how sustainable the effects are. At the VA Ann Arbor Healthcare System, for example, a team implemented an intervention to reduce use of unnecessary urinary catheters (and thus reduce UTI incidence) in 2010.¹³⁵ This intervention significantly reduced catheter use on medical-surgical wards by 4.6% (absolute difference).¹³⁵ Fowler et al¹³⁶ followed-up 8 years after this intervention, finding that the catheter prevalence had decreased from 13% to 25% (depending on unit type) to 7% (all units). Logistic regression of the data over the entire period (September 2010 to September 2019) indicated that catheter use decreased following intervention (odds ratio, 0.91; 95% CI, 0.86–0.97; P = .003). Inappropriate uses of catheters remained low during follow-up and did not appear to be affected by the intervention.¹³⁶ Similarly, Reynolds et al¹³⁷ described a multifaceted CAUTI prevention initiative led by physician and nurse champions in ICUs at Duke University Hospital. The investigators observed a sustained reduction in rates of urine-culture utilization, catheter utilization, and CAUTI over 4 years. Ideally, more studies will assess long-term sustainability when implementing CAUTI prevention initiatives.

The 4-E’s model initially developed by Pronovost et al¹¹⁸ to reduce central-line–associated bloodstream infection can also be useful with efforts to reduce CAUTI. Here, using the 4 E’s model, we have outlined the steps that hospitals can use to implement CAUTI reduction programs.