Successful implementation across a multi-hospital health system

Indwelling urinary catheters (IUCs), although frequently overused according to the Centers for Disease Control and Prevention (CDC), are necessary for acute and chronic medical care. For example, the CDC notes several indications for their use, including urinary retention or obstruction, accurate measurement of urinary output in critically ill patients, perioperative use for select surgical procedures, assistance in healing open sacral or perineal wounds in incontinent patients, prolonged immobilization, or to improve comfort during end-of-life care. The CDC estimates that 12% to 16% of adult inpatients will have an IUC at some time during their hospitalization.

Urinary tract infection (UTI) remains one of the most common hospital-acquired infections, and IUCs increase the risk for catheter-associated UTIs (CAUTIs). The CDC reports that each day an IUC remains in place, a patient’s CAUTI risk can increase between 3% and 7%. CAUTIs, which account for up to 67% of all UTIs in hospitalized patients, according to the CDC, can lead to pyelonephritis, urosepsis, bacterial endocarditis, multi-drug resistance, longer hospital stays, increased healthcare costs, and higher mortality and morbidity.

The Centers for Medicare and Medicaid Services named CAUTI an original never event (preventable medical error with serious consequences) and stopped reimbursing hospitals for their treatment. According to the Agency for Healthcare Research and Quality, each CAUTI costs a hospital $13,793.

Rearigh and colleagues found that inappropriate use of IUCs significantly predicts increased length of stay, prolonged catheter use, and higher CAUTI rates. Convenience remains the most cited reason for IUC use, despite guidelines recommending only appropriate indications and their removal as soon as they’re no longer needed.

The CDC supports alternatives to IUCs in its campaign to reduce CAUTIs. Healthcare organizations have responded by implementing other options, such as external urinary catheters (EUCs), which are held in place with suction applied to the external genitalia or pubic area to collect urine output. Male EUCs have long existed, but similar devices for females appeared only recently.

In the study by Rearigh and colleagues, IUC days decreased as the availability of the female EUC increased. They found that promoting use of female devices not only minimized the risk of infection, but also increased patient and nurse satisfaction by allowing for output monitoring and enhanced patient dignity.

In 2018, Yale New Haven Health (YNHH), a 2,409-bed nonprofit healthcare system with five delivery networks, expanded its CAUTI-prevention bundle (which included standard protocols and practices, such as an aseptic technique for insertions and the avoidance of unnecessary catheterization) to include the use of female EUCs. Three years later, to better understand the benefits, limitations, and areas of focus for future recommendations, YNHH nurses examined their colleagues’ experience with the devices.

Identifying the problem

Beginning in 2014, the CAUTI taskforce at YNHH identified practice changes to the organization’s CAUTI bundle using Plan-Do-Study-Act methodology. The team implemented and distributed the practice changes to nurses, physicians, and CAUTI champions and then disseminated them to frontline staff (bedside nurses, nursing assistants, and other support staff) who had responsibility for implementing changes in daily practice.

In 2018, the hospital system’s CAUTI taskforce, which transitioned to a CAUTI performance improvement team, enhanced the CAUTI prevention bundle with changes driven by CAUTI champions. The health system supported this effort for male patients by making EUCs available, but at the time—in 2018—it did not have comparable EUCs available for female patients.

With the assistance of the value purchasing team, a female EUC, PureWick™, was added to the supply inventory, and YNHH began implementing its use. As part of the initial assessment conducted in 2018, the CAUTI performance improvement team and CAUTI champions analyzed IUC usage patterns and identified notable variances between male and female patients. These findings helped justify the need for a female-specific external catheter and informed the decision to expand the CAUTI prevention bundle accordingly.

Implementing a solution

Implementation of the female EUC included staff education and nurse champion engagement. The CAUTI unit-based champions, which included bedside leaders who served as clinical resources around the clock, had the autonomy to offer just-in-time feedback and encourage nurses and physicians to use the EUC when medically appropriate. As an American Nurses Credentialing Center Magnet®–recognized organization, YNHH promotes quality initiatives and clinical excellence to improve patient outcomes. This organizational climate of structural empowerment provides nurses with autonomy, which encourages informal champions—staff members who may not hold formal leadership roles but who influence peers through initiative, enthusiasm, and advocacy—to proactively lead and disseminate transformational change.

Hospital educators and representatives from the EUC’s manufacturer conducted real-time professional development sessions, product demonstrations, champion classes, and unit rounding events. Nursing staff were the intended audience, but education extended to other members of the healthcare team, including physicians and ancillary staff. CAUTI prevention included education and collaboration with all members of the healthcare team to implement a new standard operating procedure for use of the EUC across the organization, which aligned with bundled care models shown to reduce CAUTI rates in critical care settings.

Unit leadership and CAUTI champions conducted daily rounds on female patients with IUCs to review opportunities for removal and replacement with the EUC. The organization added a flowsheet to the electronic health record (EHR) system to document use of the female EUC. Mandatory fields include a skin assessment, date and time of catheter change, patient tolerance of the external device, and urine output.

Surveying nurses

In October 2020, the CAUTI performance improvement team created an online survey to gain insight into nurses’ experience with the female EUC. Using the Donabedian Framework, the survey focused on three components: structure, process, and outcomes. The framework considers what an organization needs to provide healthcare (structure), the actions involved in giving and receiving healthcare (process), and the results of providing care (outcomes). The implementation of a nurse-led initiative to provide a female EUC illustrated how the organization translated evidence-based practice into action to achieve meaningful improvements in care. (See The survey.)

A rigorous peer review conducted by clinical experts at YNHH established the face validity (effectiveness) of the online survey. Next, a group of content experts—wound care nurses, clinical outcomes leaders, and nurse educators—validated the survey questions for clinical accuracy and relevance. Once validated, the survey was distributed to 1,776 YNHH nurses on adult medical–surgical units identified as high-volume users of the female EUC.

Reviewing the results

The survey yielded a 30% response rate (536 responses) with nearly 50% reporting no more than 5 years of experience and 20% reporting 6 to 10 years of experience. More than half of the survey respondents worked in medicine services, including general medicine floors, medical intensive care, and medical step-down units. We performed a Test of Two Proportions, at 95% confidence interval, to determine whether a statistically significant difference existed between staff who answered, “strongly agree / agree” and those who answered, “strongly disagree / disagree” to survey questions. The results showed a statistically significant difference on 95% of the questions (19/20), with strong support for using the female EUC.

Most of the surveyed nurses reported receiving comprehensive instructions on how to use and obtain the female EUC. About 47% indicated that they had used the device for patients who required precise measurement of urinary output. Among those who had used the device, nearly three-quarters said it provided more accurate urinary measurements compared to measurements taken from patients without a collection device. In addition, 57% of all respondents reported that the device helps prevent skin irritation and breakdown.

Most of the surveyed nurses reported feeling comfortable with the documentation process associated with the female EUC, including the updates made to the EHR to support its use. Many also expressed confidence in using the EUC as an alternative to an IUC when clinically appropriate. Respondents generally disagreed with the notion that the device causes skin breakdown, noting that they routinely assess patients’ skin for any signs of compromise before applying the device and then every 4 to 6 hours thereafter. Reported challenges included the device’s incompatibility with certain barrier creams and the potential for reduced patient mobility during use.

Since this nurse-led intervention started in October 2019 (Q1 FY2020), YNHH has experienced a statistically significant drop in the CAUTI rate per 1,000 device days. We saw a 38% reduction from the FY2017–FY2019 rate (1.27) to the FY2020–FY2022 rate (0.80). A Chi-squared test of association presented a statistically significant difference between these two time periods (P value=0.01). (See Intervention outcomes: FY2017–FY2022.)

Discussing implications

Bagley and Severud note that CAUTIs remain a significant challenge to manage both medically and financially, but the proper device can help to prevent many of them. The addition of the female EUC to the CAUTI bundle offers a noninvasive alternative for urine management for selected female patients. Early nurse engagement combined with a targeted educational session led to a decreased use of IUCs at YNHH. Bedside nurse leaders’ commitment proved integral to increased EUC use among female patients, early catheter removal, and sustainment of evidence-based initiatives. The successful adoption of the updated bundle effectively eliminated the gender gap in EUC device use at YNHH.

Because YNHH implemented the female EUC in 2018, re-assessment provided valuable insight into nurses’ experiences with the device. Although the project achieved system-wide adoption, the postimplementation survey identified education needs to support ongoing practice, including guidance on proper device placement, troubleshooting suction issues, and strategies for maintaining patient mobility.

To address challenges related to patient mobility (including repositioning and ambulation), educational efforts should emphasize techniques for securing the device in a way that allows movement, as well as protocols for safely disconnecting and reconnecting the device during mobility activities. Overall, nurses found the female EUC easy to use, which contributed to its rapid adoption across the system.

Shifting nursing culture

All nurses have a responsibility to support evidence-based practice and translate and implement research findings into nursing care, practices, and procedures. The success of this nurse-led initiative depended on the collaboration of nursing leadership and staff engagement to achieve cultural change and promote safe patient care. Healthcare organization leaders and individual nurses can take up the challenge to integrate standardized evidence-based practices that support continuous performance improvement, recognizing that efforts to prevent CAUTIs frequently reflect recurring themes in healthcare history and innovation.

The addition of a female EUC aligned with the CDC’s recommendation to limit the use of IUCs. The shift in nursing culture to include these devices led to sustained efforts to decrease CAUTIs among adult inpatients at YNHH.

Justine Moore is the medicine services coordinator at Yale New Haven Health in New Haven, Connecticut. Allison Wall is a clinical outcomes leader at Yale New Haven Hospital. Ruth Merenguelli is a clinical nurse informatics specialist at Yale New Haven Hospital. Cynthia Smith is an infection preventionist at Yale New Haven Hospital. Lauren Thayer is a nurse manager at Bridgeport Hospital in Bridgeport, Connecticut. Jose Rivera-Vinas is a statistician at Yale New Haven Hospital.

American Nurse Journal. 2025; 20(9). Doi: 10.51256/ANJ092513

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Key words: indwelling catheters, female external urinary catheters, catheter-associated urinary tract infection