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Aim: By December of 2022, Henry Ford Health (HFH) - Detroit inpatients requiring an indwelling urinary catheter will be less likely to develop a Catheter Associated Urinary Tract Infection (CAUTI), by decreasing annual CAUTI occurrence to 3 or less (66% decrease from 2021) utilizing a multifaceted quality improvement approach.

Plan: Urinary Tract Infections (UTIs) are a very common and impact about 150 million people worldwide annually (Werneberg, 2022). Per Lo et al., (2014) and the Centers for Disease Control and Prevention (CDC), up to 75-80% of the complicated UTIs in the United States are due to indwelling urinary catheters. Per the CDC, approximately 15-25% of patients have an indwelling catheter during their hospitalization. CAUTIs continue to be the most identified healthcare associated infection (HAI) and can often lead to other HAI including blood stream infections. Costs related to avoidable CAUTIs are estimated to cost $115 million to $182 billion annually (Werneberg, 2022). Henry Ford Health-Detroit (HFH-Detroit) initiated a CAUTI Prevention Team in 2012. This multidisciplinary team includes physician champions from urology and infection control, infection prevention specialists, and nursing representatives (leaders and bedside staff) from administration, inpatient departments, emergency department, and surgical services. The team was tasked with identifying opportunities and driving bedside practice to decrease catheter utilization and CAUTIs. The CAUTI team recognized the need to further improvements in practice regarding indwelling catheters. Although the number of CAUTIs decreased over time from 89 (2015) to 15 (2020) there was still opportunities to decrease patient harm. Identification of high impact actions that could be sustained was vital to the overall goal of decreasing indwelling catheter usage and CAUTI prevalence. Through 2021 and 2022, three main initiatives were introduced including the Urine Culture Hard Stop (UCHS), the Urinary Catheter Alleviation Navigation Protocol (UCANP), and adding male external catheters to meet the team’s goal of decreasing CAUTI occurrence to 3 or less per year.

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Henry Ford Health


Detroit, MI


Quality Expo, posters, poster competition

Project #73: Implementation of a Multi-Faceted Approach to Reduce Catheter Associated Urinary Tract Infection (CAUTI)



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