Skip to main content Accessibility help

Reducing Inappropriate Urinary Catheter Use in the Emergency Department: Comparing Two Collaborative Structures

  • M. Todd Greene (a1) (a2) (a3), Mohamad G. Fakih (a4), Sam R. Watson (a5), David Ratz (a1) (a3) and Sanjay Saint (a1) (a2) (a3)...



Urinary catheters, many of which are placed in the emergency department (ED) setting, are often inappropriate, and they are associated with infectious and noninfectious complications. Although several studies evaluating the effect of interventions have focused on reducing catheter use in the ED setting, the organizational contexts within which these interventions were implemented have not been compared.


A total of 18 hospitals in the Ascension health system (ie, system-based hospitals) and 16 hospitals in the state of Michigan (ie, state-based hospitals led by the Michigan Health and Hospital Association) implemented ED interventions focused on reducing urinary catheter use. Data on urinary catheter placement in the ED, indications for catheter use, and presence of physician order for catheter placement were collected for interventions in both hospital types. Multilevel negative binomial regression was used to compare the system-based versus state-based interventions.


A total of 13,215 patients (889 with catheters) from the system-based intervention were compared to 12,104 patients (718 with catheters) from the state-based intervention. Statistically significant and sustainable reductions in urinary catheter placement (incidence rate ratio, 0.79; P=.02) and improvements in appropriate use of urinary catheters (odds ratio [OR], 1.86; P=.004) in the ED were observed in the system-based intervention, compared to the state-based intervention. Differences by collaborative structure in changes in presence of physician order for urinary catheter placement (OR, 1.14; P=.60) were not observed.


An ED intervention consisting of establishing institutional guidelines for appropriate catheter placement and identifying clinical champions to promote adherence was associated with reducing unnecessary urinary catheter use under a system-based collaborative structure.

Infect Control Hosp Epidemiol 2018;39:77–84


Corresponding author

Address correspondence to M. Todd Greene, PhD, MPH, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Department of Internal Medicine, Michigan Medicine, 2800 Plymouth Rd, NCRC Bldg 16, Room 470C, Ann Arbor, MI 48109 (


Hide All
1. Gokula, RR, Hickner, JA, Smith, MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control 2004;32:196199.
2. National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables. Centers for Disease Control and Prevention website. Published 2011. Accessed November 15, 2017.
3. Gardam, MA, Amihod, B, Orenstein, P, Consolacion, N, Miller, MA. Overutilization of indwelling urinary catheters and the development of nosocomial urinary tract infections. Clin Perform Qual Health Care 1998;6:99102.
4. Jain, P, Parada, JP, David, A, Smith, LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med 1995;155:14251429.
5. Munasinghe, RL, Yazdani, H, Siddique, M, Hafeez, W. Appropriateness of use of indwelling urinary catheters in patients admitted to the medical service. Infect Control Hosp Epidemiol 2001;22:647649.
6. Schuur, JD, Chambers, JG, Hou, PC. Urinary catheter use and appropriateness in US emergency departments, 1995–2010. Acad Emerg Med 2014;21:292300.
7. Klevens, RM, Edwards, JR, Richards, CL Jr, et al. Estimating health care-associated infections and deaths in US hospitals, 2002. Public Health Rep 2007;122:160166.
8. Foxman, B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. Am J Med 2002;113(Suppl 1A):5S13S.
9. Saint, S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control 2000;28:6875.
10. Saint, S, Lipsky, BA, Baker, PD, McDonald, LL, Ossenkop, K. Urinary catheters: what type do men and their nurses prefer? J Am Geriatr Soc 1999;47:14531457.
11. Saint, S, Lipsky, BA, Goold, SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med 2002;137:125127.
12. Hollingsworth, JM, Rogers, MA, Krein, SL, et al. Determining the noninfectious complications of indwelling urethral catheters: a systematic review and meta-analysis. Ann Intern Med 2013;159:401410.
13. Gould, CV, Umscheid, CA, Agarwal, RK, Kuntz, G, Pegues, DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol 2010;31:319326.
14. Krein, SL, Kowalski, CP, Hofer, TP, Saint, S. Preventing hospital-acquired infections: a national survey of practices reported by US hospitals in 2005 and 2009. J Gen Intern Med 2012;27:773779.
15. Krein, SL, Greene, MT, Apisarnthanarak, A, et al. Infection prevention practices in Japan, Thailand, and the United States: results from national surveys. Clin Infect Dis 2017;64(Suppl 2):S105S111.
16. Fakih, MG, Heavens, M, Grotemeyer, J, Szpunar, SM, Groves, C, Hendrich, A. Avoiding potential harm by improving appropriateness of urinary catheter use in 18 emergency departments. Ann Emerg Med 2014;63:761768.
17. Fakih, MG, Heavens, M, Ratcliffe, CJ, Hendrich, A. First step to reducing infection risk as a system: evaluation of infection prevention processes for 71 hospitals. Am J Infect Control 2013;41:950954.
18. Fakih, MG, Watson, SR, Greene, MT, et al. Reducing inappropriate urinary catheter use: a statewide effort. Arch Intern Med 2012;172:255260.
19. Saint, S, Greene, MT, Kowalski, CP, Watson, SR, Hofer, TP, Krein, SL. Preventing catheter-associated urinary tract infection in the United States: a national comparative study. JAMA Intern Med 2013;173:874879.
20. Fakih, MG, George, C, Edson, BS, Goeschel, CA, Saint, S. Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies. Infect Control Hosp Epidemiol 2013;34:10481054.
21. Saint, S, Greene, MT, Krein, SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med 2016;374:21112119.
22. Pronovost, P, Needham, D, Berenholtz, S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:27252732.
23. Gokula, RM, Smith, MA, Hickner, J. Emergency room staff education and use of a urinary catheter indication sheet improves appropriate use of Foley catheters. AmJ Infect Control 2007;35:589593.
24. Fakih, MG, Pena, ME, Shemes, S, et al. Effect of establishing guidelines on appropriate urinary catheter placement. Acad Emerg Med 2010;17:337340.
25. Patrizzi, K, Fasnacht, A, Manno, M. A collaborative, nurse-driven initiative to reduce hospital-acquired urinary tract infections. J Emerg Nurs 2009;35:536539.
26. Burnett, KP, Erickson, D, Hunt, A, Beaulieu, L, Bobo, P, Shute, P. Strategies to prevent urinary tract infection from urinary catheter insertion in the emergency department. J Emerg Nurs 2010;36:546550.
27. Fakih, MG HM, Grotemeyer, J, Hendrich, A. The power of a system: addressing catheter-associated urinary tract infections (CAUTI) in intensive care units. ID Week 2015; October 7–11, 2015; San Diego, CA.
28. Viswanathan, K, Rosen, T, Mulcare, MR, et al. Emergency department placement and management of indwelling urinary catheters in older adults: knowledge, attitudes, and practice. J Emerg Nurs 2015;41:414422.
29. Damschroder, LJ, Banaszak-Holl, J, Kowalski, CP, Forman, J, Saint, S, Krein, SL. The role of the champion in infection prevention: results from a multisite qualitative study. Qual Saf Health Care 2009;18:434440.
30. Fakih, MG, Gould, CV, Trautner, BW, et al. Beyond infection: device utilization ratio as a performance measure for urinary catheter harm. Infect Control Hosp Epidemiol 2016;37:327333.

Related content

Powered by UNSILO

Reducing Inappropriate Urinary Catheter Use in the Emergency Department: Comparing Two Collaborative Structures

  • M. Todd Greene (a1) (a2) (a3), Mohamad G. Fakih (a4), Sam R. Watson (a5), David Ratz (a1) (a3) and Sanjay Saint (a1) (a2) (a3)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.