Reducing Catheter-Associated Urinary Tract Infection Project

Practice Problem: Catheter-associated urinary tract infections (CAUTIs) are prevalent and responsible for an estimated 13,000 deaths annually in the United States. Reported cases of CAUTIs remain disproportionately high at a rehabilitation center located in South Texas. PICOT: This evidence-based project answered the following question: In rehabilitation patients, what is the effect of a nurse-driven protocol (NDP) CAUTI bundle on the number of indwelling urinary catheter-related infections, compared to the current practice, over a 12-week time period? Evidence: Twenty high-quality studies that met the inclusion and exclusion criteria recommended using an NDP CAUTI bundle, education, and champions to round the unit to decrease the number of catheter-associated urinary tract infections. Intervention: The evidence-based intervention utilized the implementation of an NDP CAUTI bundle. The intervention bundle included catheter indication, hand hygiene, an insertion technique, maintenance, ongoing assessment to evaluate catheter need, and documentation. Outcome: The evaluation of the outcome measures demonstrated that the CAUTI rate decreased from six incidences in 2019 to two from January to May 2020. There were zero incidences during the project implementation from June to August 2020, and the number of catheter days decreased from 59% at baseline to 41% post-intervention. Conclusion: The implementation of a nurse-driven protocol CAUTI bundle, education, and champions in the unit were successful interventions that decreased the catheter-associated urinary tract infection rates in the rehabilitation center.


Evidence-Based Framework and Change Theory
A theoretical framework is valuable in an evidence-based project (EBP) because it increases the possibility of implemented interventions being effective, sustainable, and accessible (Dogherty et al., 2016). It is no longer the norm to rely solely on traditional or personal experiences when providing healthcare to patients (Dogherty et al., 2016). Instead, EBP investigated data to facilitate, promote, and guide healthcare providers when making healthcare decisions for patients (Dogherty et al., 2016). A framework and change model guided this EBP project.

Evidence Based Framework
The Plan-Do-Study-Act (PDSA) is a framework that can be used in evidence-based projects to quickly identify and correct weaknesses (Thomas, 2016). The PDSA framework was selected to guide this DNP scholarly project to decrease incidences of CAUTIs in the rehabilitation center. The framework's first phase is the "Plan" step which was used to define the issue, current state, and recommend a change (Sylvia & Terhaar, 2018). In this phase, an interdisciplinary team was formed, roles were identified, timelines were set, and measures were identified to successfully complete the project. In the "Do" step, the intervention was implemented, data was collected, and evaluated to determine the success of the project (Sylvia & Terhaar, 2018). The "Study" step was used to determine if the intervention was successful or if rapid changes needed to be made (Sylvia & Terhaar, 2018). After the intervention was implemented the team worked together to analyze the results and assess if the outcome measures were met. The final step was "Act," in which a determination was made to maintain the NDP CAUTI bundle or to develop a new process (Sylvia & Terhaar, 2018).

Change Theory
Lewin's change theory (1947) concepts guided this project in changing behavior to reduce or eliminate CAUTIs. Change regarding infection prevention is imminent in rapidly growing, highly competitive healthcare organizations. Lewin's change theory could help organizations change their methodologies, processes, and structures to deliver safe, high-quality care (Hussain et al., 2018).
According to Lewin (1947), change happens in three phases: unfreezing, change, and refreezing. An organization creates opportunities during the unfreezing stage to encourage those affected by the change to let go of the traditional, unsuccessful practices (Wojciechowski et al., 2016). During the unfreezing stage, people generally see for themselves the need for change, which provokes them to unfreeze. Healthcare workers, responsible for the change in practices, increase the driving factors to alter and reduce, or eliminate resistance and barriers (Wojciechowski et al., 2016). Transparency in sharing the rates of CAUTIs at the unit level helped employees acknowledge the problem (Wojciechowski et al., 2016).
The next stage of the theory, change, is when movement occurs (Wojciechowski et al., 2016). It focuses on planning and implementing new practices while influencing the thoughts and behaviors about change (Wojciechowski et al., 2016). Involving frontline employees, physicians and other healthcare providers in the planning and implementation process was instrumental in moving the transition forward (Wojciechowski et al., 2016). During this stage, the team had strong support from the administrators to implement the intervention. In this EBP, the staff was educated with mandatory training regarding the importance of decreasing or eliminating inappropriate use of the catheter, along with proper placement and discontinuance.
In Lewin's theory, the final stage, re-freezing, leads to stabilization and assessment (Wojciechowski et al., 2016). Providing information to employees about the implementation of new CAUTI protocols and giving feedback opportunities during the evaluation helped solidify the change. In this EBP, the director and the supervisor rounded the unit and reviewed the electronic medical records to ensure that patients met the criteria required for needing a catheter.
The director and the supervisor assigned a "champion" for each shift so that if the staff had any questions regarding the new process, the champion could guide the employee. The champion was also responsible for reporting all issues regarding IUCs (Hussain et al., 2018).
The project manager, director, and supervisor helped maintain and sustain the intervention by collecting data and evaluating the process. They informed the administration whether the intervention decreased or eliminated CAUTIs and if any re-design work was needed.
They ensured the rehabilitation unit was following the standardized NDP CAUTI bundle.
Lewin's change theory (1947) offered a platform for positive change within the organization. In this case, it was used to decrease CAUTIs, length of stay, and total healthcare costs while also improving patients' quality of care (Hussain et al., 2018).

Evidence Search Strategy
A thorough literature review was conducted to identify the evidence that supported the problem question. This review led to the scholarly question, in rehabilitation patients, how effective is a nurse-driven intervention bundle on minimizing indwelling urinary catheter-related infections over 12 weeks compared to the current practice?
A comprehensive electronic search was conducted using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Pro-Quest and PubMed. Keywords were combined using Boolean Operators to form relevant statements. The search terms were as follows:

catheter-associated urinary tract infection (CAUTI) OR urinary tract infection (UTI) OR infection prevention OR indwelling catheters AND CAUTI bundle OR checklist OR protocols OR hospitals AND prevention of CAUTIs OR patients 18-years and older.
A total number of 12,787 articles were found. The CINAHL search resulted in 1,183 articles; PubMed produced 5,675 articles; and ProQuest produced 5,959 articles. After limiting the search to only include publications from 2015 to 2020 to integrate the most current best practices, 3,772 articles remained. Inclusion and exclusion criteria were applied to narrow down the search. These were the inclusion criteria: English language, peer-reviewed, and scholarly articles that contained an abstract. Furthermore, the exclusion criteria eliminated studies that focused on pediatrics and non-human test-subjects, thus reducing the number of articles to 542.
An inspection of the titles and abstracts helped to eliminate 254 articles that did not relate to the PICOT question. This reduced the number of articles to 288. The articles were manually sorted, and their full texts were reviewed. Additionally, eight duplicate articles were removed, along with editorials, periodicals, and commentaries. This left 20 articles, which were thereby included in this project.

Evidence Search Results and Evaluation
The 20 articles included in the EBP project identified the importance of implementing a NDP using a prevention bundle to decrease CAUTIs. Methods included limiting the use of IUCs, catheter indication, hand hygiene, insertion technique, catheter maintenance, and promptly removing unnecessary IUCs. The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) appraisal tool was used to critically appraise the quality and strength of the 20 articles retrieved from the literature review (Schaffer et al., 2013). All 20 articles retrieved from the literature were rated as "A" or "B," which was considered high quality with enough evidence to support the intervention to decrease CAUTIs. Lastly, web sites from the American Nurses Association (ANA), Agency for Healthcare Research and Quality (AHRQ, 2015b), and the Center for Disease Control (CDC) were also referenced and included in the paper. A summary of the primary articles reviewed can be found in Appendix A, and a systematic review can be found in Appendix B.

Themes from the Evidence
Synthesis of the literature reviewed findings identified strategies that were credible and consistent with EBP to decrease CAUTIs. Themes included CAUTI bundle, NDP, staff education, and integration of technology. Furthermore, the American Nurses Association (ANA) CAUTI Prevention Tool was identified as a guide for the NDP (ANA, 2017). The use of CDC and AHRQ guidelines for CAUTI prevention was a secondary theme.

Catheter-Associated Urinary Tract Infection Bundle
One of the most effective interventions found in multiple high-quality level studies was the CAUTI bundle (Andrioli et al., 2016;Taha et al., 2017;Zurmehyly, 2017). The CAUTI bundle has been implemented in multiple acute care hospitals, long-term care facilities and rehabilitation centers. It has been proven to decrease CAUTIs in all kinds of medical facilities and services (Hur et al., 2019;Parker et al., 2017;Zurmehyly, 2017). The CAUTI bundle includes checklists, diagrams, and reminders with acceptable clinical indications to insert an IUC (Carr et al., 2016;Taha et al., 2017;Zurmehyly, 2017). It also implements competency checks of catheter insertion, aseptic technique, documentation, maintenance, continuous surveillance for the need of the catheters, and catheter removal (Andrioli et al., 2016;Furtado et al., 2016;Schreiber et al., 2018;Teha et al., 2017;Zurmehyly, 2017). Taha et al. (2017) demonstrated that implementing the CAUTI bundle decreased catheter use and that early removal of the catheter reduced CAUTI rates. Giles et al. (2015) and Meddings et al. (2017) concurred that implementation of the CAUTI bundle increased awareness of patients with IUCs in place, prompting staff to assess whether the IUC was still needed. Hur et al. (2019) stated that the bundle's implementation identified that 30% of the patients with IUCs did not meet the criteria for the IUC. Based on this evidence, significant confirmation shows that an NDP using a CAUTI prevention bundle can decrease HAI in patients.
The AHRQ (2015b) recommended that healthcare providers avoid the use of catheters as much as possible, prompt removal, surveillance, and awareness. These AHRQ (2015b) recommendations, found in many studies, demonstrated a decrease in CAUTI rates (Andrioli et al., 2016;Taha et al., 2017;Zurmehyly, 2017). The NDP CAUTI bundle in this DNP project incorporated five specific actions: nurse-driven protocol, staff education, integration of information technology, American Nurses Association CAUTI Prevention Tool, and guidelines for CAUTI prevention.
(2016), concurred that the implementation of an NDP for early removal of catheters significantly reduced CAUTI rates. The results demonstrated a direct connection between the use of an NDP, catheters, dwell time, and rates of CAUTI (Quinn, 2015). Leticia-Kriegel et al. (2019) agreed that the implementation of an NDP could empower nurses to be active advocates for patients who have an IUC in place, and to remove catheters promptly when patients did not meet criteria.
A group of experts created the ANA CAUTI Prevention Tool, which guides nurses' protocols and supports their effort to reduce CAUTIs (ANA, 2017). The tool kit's goals are to empower the nurses to remove catheters promptly and continuously evaluate patients with IUCs.
The ANA CAUTI Prevention Tool pushed nurses to develop checklists and diagrams with the proper indications to insert a catheter (ANA, 2017).

Staff Education
Studies demonstrated the importance of education in CAUTI prevention. Li et al. (2018) examined a hospital-wide implementation CAUTI prevention bundle. Before project implementation, education was provided for staff, reminder signs were placed in patients' rooms, and checklists were used. On site study representatives provided answers to questions, while monitoring, and evaluating compliance to the intervention. CAUTI rates decreased with the implementation of the bundle. The study findings supported the need for education and monitoring (Li et al., 2018). Furthermore, two studies demonstrated how assigning a champion in each unit when implementing an EBP project could assist in the intervention's sustainability (Li et al., 2018;Underwood, 2015).
Education is an essential element of any process improvement initiative. However, monitoring and feedback are also important (Hernandez et al., 2019). Hernandez et al. (2019) used a daily urinary catheter maintenance checklist to assess if the CAUTI prevention bundle intervention was being effectively implemented. The ability to provide immediate constructive feedback enhanced practice and was an invaluable benefit of implementing the CAUTI prevention bundle. McCoy et al. (2017) determined that education on CAUTI bundle promoted compliance with the newly established protocol, leading to reduced IUC use and CAUTIs to improve patient outcomes.

Integration of Information Technology
Current technology offers health care practitioners various tools that could be used for the implementation and evaluation of EBP projects. Health information technology (HIT) has played a significant role in enhancing the quality of health care (Liu et al., 2018;McCoy et al., 2017). In New York, White Plains Hospital utilized HIT in its successful CAUTI prevention project to identify patients with IUCs (Quinn, 2015). Staff also used HIT to document the maintenance of IUCs (Quinn, 2015).
Several studies demonstrated that HIT was used successfully to collect and analyze patient demographics as well as to gather data on the incidences of urinary catheters and dwelling time (Carr et al., 2017;Dy et al., 2016;McCoy et al., 2017;Quinn, 2015). Information technology is critical in data collection for EBP projects because it keeps the project manager updated regarding the effectiveness of the implementation. HIT has many applications that can remind frontline staff to reassess patients with an IUC in place and to provide data on catheter utilization (McCoy et al., 2017;Quinn, 2015;Yatim et al., 2016).

American Nurses Association CAUTI Prevention Tool
In partnership with the CDC, the American Nurses Association (ANA) developed an EBP tool for nurses to use when caring for patients with an IUC in place (ANA, 2017). The tool intends to prevent CAUTIs by reducing the use of IUCs, prompting timely removal of catheters, and ensuring continuous evaluation when in use (ANA, 2017). The ANA (2017) CAUTI tool follows the CDC's recommendation (2017) for the insertion of an IUC. Indications include urinary retention, end-of-life care comfort, proper intake and output measurement in critically ill patients, certain surgical procedures, and immobilization in some patients, sacral ulcers, and perineal wounds. The ANA (2017) indicated that patients who meet the criteria for an IUC should be continuously assessed for the appropriate indication of the catheter.

Guidelines for CAUTI Prevention
In 2017, the CDC updated its 2009 guidelines for CAUTI prevention to reflect new scientific findings and offered recommendations for the use, measurement, and monitoring of IUCs (CDC, 2017b). The CDC (2017b) guidelines recommend that IUCs should only be used with certain patients including; patients with obstruction of the bladder outlet; for the intake and output of critically ill patients; designated perioperative patients; patients with open sacral or perineal wounds; patients with long periods of immobilization, such as those with some neurological conditions; and patients with end-of-life comfort needs (CDC, 2017b). The guidelines discourage the use of IUC in patients whose conditions are outside of the indicated categories (CDC, 2017b).
In 2015, the AHRQ published CAUTI prevention guidelines for healthcare providers.
The main recommendations for healthcare providers include catheter avoidance, product selection and care, prompt removal, surveillance, and awareness. The AHRQ guidelines were similar to the ANA and the CDC recommendations, with more suggestions for robust unit-based safety programs (AHRQ, 2015b). The CDC (2017b) recommended that an IUC be inserted by qualified and competent clinicians and use an aseptic technique and sterile equipment for patients identified under the indicated criteria. The catheter should remain sealed, and the patient's urine flow should be unobstructed. Qualified professionals, who should be mindful of avoiding infections, should maintain the catheters. The catheter should be removed as soon as the indication for use is no longer appropriate (CDC, 2017b).

Practice Recommendations
The reviewed articles answered the PICOT question by providing evidence that the implementation of a CAUTI bundle reduced CAUTIs, particularly among elderly and high-risk patients. Results and themes from the evidence can be found in the grading tables (see Appendices A and B). The evidence and themes strongly recommended a NDP using a CAUTI bundle to effectively reduce CAUTIs, hospital days and cost. High quality Level 1 and Level 2 articles had profound similarities, and themes, denoting that the NDP CAUTI bundle approach would reduce CAUTI rates (Fonseca & Veludo, 2016;Galiczewski & Shurpin, 2016;Hernandez et al., 2019;Smith, 2015;Parker et al, 2017).
Another recommendation was staff education. Evidence demonstrated that employee education supported best practice and sustainability. Education awareness programs and regular rounding by the champions, the director, and the supervisor helped reduce incidences of CAUTIs (Galiczewski & Shurpin, 2016;Hernandez et al., 2019;Parker et al, 2017).
Several studies took place in acute care hospitals across the United States using the CDC, the ANA CAUTI prevention toolkit, and AHRQ guidelines. All hospitals reported a significant reduction in CAUTI rates after intervention of the protocol (Hernandez et al., 2019;McCoy et al, 2017;Parker et al, 2017). After a thorough literature review, it was concluded that the evidence supported a comprehensive practice recommendation. Therefore, a nurse-driven protocol CAUTI bundle was recommended for practice. The evidence consisted of Level 1 and grade A articles of high quality, validity, and reliability. The recommendation to implement a NDP CAUTI bundle was presented to the key stakeholders at DHR and to the USAHS EPRC.

Project Setting
The DNP scholarly project setting was the rehabilitation center of a 530-bed acute care hospital in Edinburg, Texas. The hospital provided a full range of medical services, with more than 60 specialties and sub-specialties (DHR, n.d.). The mission of DHR (n.d.) was to enhance the well-being of those they served with a commitment to excellence for each patient, each experience, and each time. The organization's vision was to inspire caregivers to heal through empathy, experience, creativity, integrated treatment, and excellence (DHR, n.d.).
The rehabilitation center treated a variety of acute care needs, including amputations, brain injuries, major multiple traumas, neurological disorders, orthopedics post-operative, spinal cord injuries, and stroke-related disabilities. In the 38-bed rehabilitation center, a team of highly trained physicians, therapists, nurses, and ancillary staff served patients. The rehabilitation's primary goal was to help the patients return to their highest possible level of independence and functioning after a life-altering injury or illness (DHR, n.d.). Specific information about DHR was reviewed below, including the organizational structure, culture, needs, stakeholders, sustainability, interprofessional collaboration, strengths, weaknesses, opportunities, and threats analysis.

Organizational Structure
The DHR Healthcare System was one of the largest physician-owned facilities in the United States (DHR, n.d.). The organization included multiple units, such as outpatient rehabilitation, long-term care, urgent care centers, psychiatric services, women's services, bariatric services, and hospice (DHR, n.d.). Its organizational structure was composed of the chief executive officer (CEO), the chief finance officer (CFO), chief nursing officer (CNO), and its board of directors. The DHR healthcare system's daily operations were managed and controlled by the board of directors.

Organizational Culture
Employees were empowered to provide the highest and safest level of care through compassion, knowledge, innovation, integrated care, and excellence (DHR, n.d.). The organizational culture provided education and training to all staff members to improve their competency with the goals of delivering the best healthcare possible and increasing productivity.
Staff members were diverse and included people from different educational backgrounds. DHR promoted education by offering its employees scholarships and provided staff incentives to motivate and retain experienced employees (DHR, n.d.).

Organizational Need
An organizational needs assessment identified an increase in CAUTIs throughout the organization since 2019, a statistically higher rate than the national average (DHR, n.d.). The fishbone tool was used to identify why there was a lack of interventions to reduce CAUTIs (Institute for Health Improvement (IHI), 2020). The results of the fishbone demonstrated that there was a lack of organizational awareness, and of staff knowledge regarding CAUTI interventions. The needs-assessment tool (IHI, 2020) was essential in developing ongoing EBP change. The tool helped identify gaps in hospital procedures that led to high infection rates. It was found that there was a knowledge deficit among facility staff that needed to be addressed to decrease HAI throughout the organization. The organization administration supported efforts to reduce or eliminate CAUTIs. A gap analysis (IHI, 2020) determined the need to establish a CAUTI bundle protocol to address the issue. The assessment also identified the need to educate staff about the importance of continuously assessing patients with IUCs and promptly removing catheters as indicated.

Organizational Support and Stakeholders
The stakeholders, particularly DHR's leadership, expressed a need to reduce incidences of CAUTIs. The key stakeholders identified for this scholarly project were the director of the rehabilitation center for departmental decisions, the CNO for authority, the nurse manager to supervise staff compliance, front line nurses to carry out the intervention, and the education department to develop trainings. Other stakeholders included physical therapists, doctors, advanced nurse practitioners, and physician assistants.

Sustainability
Sustainability allows for an EBP project to continue delivering improved results to patients, staff, and the organization (Li et al., 2018;Underwood, 2015). One of the most important concerns was to ensure employees' compliance with the NDP CAUTI bundle. This was tracked by assigning a champion on the floor to monitor staff. Another key factor for the sustainability of this project was continuous education on the CAUTI bundle protocol. New hires received orientation and education about the new CAUTI bundle protocol (McCoy et al., 2017).

Interprofessional Collaboration
Interprofessional collaboration was an essential factor in the success of this scholarly project (Reisinger et al., 2017). To effectively implement the CAUTI bundle protocol and have positive results, the interprofessional team had to work together towards the same goal of decreasing CAUTIs. The frontline nurses were responsible for carrying out the intervention. The nurse manager was responsible for monitoring staff compliance. The infection control disease team was responsible for answering questions pertaining to the interventions and determining the possible causes of infection. The doctor, advanced nurse practitioner, and physician assistant were available to address any doubts clinical staff had while discontinuing catheters. The education department was responsible for providing training to staff members.

Strengths, Weaknesses, Opportunities, and Threats Analysis
The strengths, weaknesses, opportunities, and threats (SWOT) analysis is a strategic planning tool used to help individuals or a company recognize their strengths, weaknesses, opportunities, and risks relevant to business or project planning completion (Gürel & Tat, 2017).
See Appendix E for the project's SWOT Analysis. The primary strength of the hospital was leadership members' dedication to decrease CAUTIs. Effective communication among staff, directors, nurse managers, and leaders helped facilitate the project's implementation. All needed resources to implement the project were available. The director of the rehabilitation center and the supervisor promoted the project. Another identified strength was that the organization had a strong education department that provided ongoing trainings to its staff. A recognized weakness was that frontline staff had busy schedules, which made it difficult to continuously assess the proper indication for the IUC. Opportunities identified were that CAUTI bundle protocol would reduce catheter days, hospital days, and the cost of treating patients with CAUTIs. These opportunities can ultimately improve patient outcomes and satisfaction (DHR, n.d.).

Project Overview
It was necessary to have the vision of the project clearly outlined to achieve the desired goal. The mission and objectives successfully guided the implementation of the project. The short and long-term goals were essential since they effectively guided the intervention to improve processes of mitigating infections in the hospital.

The Project Vision and Mission
The project's mission, vision and objectives effectively conveyed the purpose of the project, kept the participants focused on the desired goal, helped the team stay on schedule, and maintained the intervention's sustainability. The mission of the project was to implement the NDP CAUTI bundle. The vision of the EBP process was to reduce or eliminate CAUTIs in the hospital. The mission and vision of the project were congruent to those of the organization because the purpose was to provide the best EBP to improve healthcare for patients. The objective of the project was to decrease the use of IUCs. The project's desired outcome was accomplished through short term and long-term goals. Achievement of the goals motivated staff compliance to carry out the intervention and sustaining the project.

Objectives
Objectives, short-term goals and long-term goals were the driving forces for this project to be successful. Short-term objectives of this project included: a) to implement an EBP NDP CAUTI bundle by June 2020; b) to improve frontline staff knowledge by 65% regarding the ANA CAUTI prevention tool during the first week of project implementation; and c) to decrease catheter days by 0.5% in the first three months of project implementation. The primary long-term objective was to disseminate the project into the community's acute care hospitals within one year of initial implementation. A second long-term goal was to spread beneficial findings of the project within three years through quality services and interactive webinars at a regional level.

Risks and Unintended Consequences
Strategies to address problems before they occurred can be developed by identifying risks (Advani & Fakih, 2019). One risk was removing catheters prematurely, leading to the need to recatheterize. The re-insertion of a catheter can cause discomfort, trauma, and other potential complications for patients. It was crucial to assess carefully re-catheterizing avoid unnecessary patient harm (Mody et al., 2017). It was also imperative to provide the needed training to improve the competency level of staff to always maintain a patient-safety culture (Mody et al., 2017). Other possible risks included ineffective communication that could occur among the staff due to staffing issues, and resistance to change from frontline staff, impeding positive outcomes.
The interprofessional team helped address resistance to change as early as possible to prevent delays and adverse project outcomes.

Project Plan
The project's plan included the selection of a model that guided the identification of barriers and facilitators. Lewin's change model was selected to guide the project since it relates to changing behavior, such as implementing processes that reduce or eliminate CAUTIs in an organization (Hussain et al., 2018). The PDSA model set a time frame for completing essential deadlines to ensure the project's timeliness (Sylvia & Terhaar, 2018). The project plan also included a financial budget, which consisted of project expenditures and revenues (Sylvia & Terhaar, 2018). The project manager's role required effective communication, transparency, and trust to achieve the project's goals successfully.

Intervention
The PDSA model was selected because it had been effective in implementing a rapid change in a rehabilitation center and demonstrated to be a useful and practical guide for implementing protocols throughout a hospital (Sylvia & Terhaar, (2018). The initial stage, aligned with Lewin's unfreeze stage, began by creating a sense of urgency in reducing CAUTIs in the rehabilitation center (AHRQ, 2015a). The NDP CAUTI bundle was shared to promote interest and enthusiasm to bridge the gap between the existing and desired practice, while at the same time maintaining compliance with the state requirements and the Joint Commission guidelines (AHRQ, 2015a).
An interdisciplinary team was developed to openly discuss issues, concerns, ideas and possible factors for the success or failure of the project (Hussain et al., 2018). A charter plan was developed to establish roles, responsibilities, and an agreement for the project (Kogan et al., 2015). Creating a cohesive interprofessional partnership was a critical component of the project's success. First, a meeting was held with the interdisciplinary team to share the project's vision of reducing CAUTIs across the rehabilitation center. Afterward, a team was formed, roles were assigned, and responsibilities were given. The project had a strong support from leadership to implement the intervention (Hussain et al., 2018).
An in-depth assessment was conducted to assess weaknesses and threats that could interfere with the intervention (Kogan et al., 2015) and allow for a greater understanding of the microsystem (Gürel & Tat, 2017). A fishbone diagram was displayed in the education room to collect feedback from rehabilitation staff (Kogan et al., 2015). This tool helped define staff needs, raised engagement, and increased buy-in. The results of the SWOT analysis and fishbone diagram were shared with and addressed by the team.
At that time, the rehabilitation center did not have a standardized IUC protocol. The intervention was an NDP CAUTI bundle that included: (a) appropriate indication for insertion of the catheter; (b) proper insertion technique; (c) proper catheter maintenance; (d) timely removal of the catheter; (e) effective documentation in the electronic medical record (EMR) and in the CAUTI bundle compliance tool; and (f) identification of a unit champion for every shift to monitor the staff for compliance to the protocol. The tool included all the key components of the CAUTI bundle and a checklist that prompted nurses to effectively document their actions (see Figure 2). It encouraged nurses to remove catheters when no longer needed.
During the Do stage of the PDSA Model, which aligned with Lewin's Change stage, the EBP project began with the education of the clinical staff regarding the NDP CAUTI bundle (Hussain, et al., 2018;Sylvia & Terhaar, 2018). The training, which was conducted by the education department, included a pre-and post-education training competency check. The checks' results, which determined NDP CAUTI bundle's competency, were evaluated and shared with the team. To implement the CAUTI bundle, the supervisor identified the patients in the unit with an IUC and shared the information with the staff during the morning huddle. The supervisor then reinforced the need to assess the patients with IUCs for the appropriateness of the catheter (see Figure 1). The supervisor also encouraged and reiterated the need for documentation on the CAUTI bundle compliance tool. The assigned champion rounded the floor to support the staff regarding the newly implemented protocol.
Once the intervention was implemented, data was collected weekly to track the progression of the project. The data gathered included the total number of new CAUTI events in the rehabilitation center, the number of patients with catheters, and the number of catheter days.
Other significant data collected were the total number of nurses who completed the NDP CAUTI bundle compliance tool, and the number of clinical staff who completed education and training.
The Study stage of the PDSA Model aligned with Lewin's re-freeze stage and guided the data's evaluation (Hussain, et al., 2018;Sylvia & Terhaar, 2018). An Excel spread sheet was used to display the data collected through bar charts and running charts that were shared with the team. The pre-implementation data was compared to the post-implementation data to determine the intervention's effectiveness.
The final step of the PDSA model was the Act stage (Sylvia & Terhaar, 2018).
Summative and formative evaluations were completed by the DNP student to describe the results in more detail, which were then presented to the key stakeholders. The results determined if the objective of reducing CAUTIs in the rehabilitation center was met. The project's results indicated intervention sustainability. The project proved to be effective because the CAUTI incidences remained at zero after completion of the project. This was followed by disseminating the project across DHR's facility, community, regionally and nationally.

Barriers and Facilitators
There were barriers and facilitators when implementing this EBP project. The identification of some of these barriers before the project began played an essential role in its success. Some barriers included staffing issues (which made it difficult for employees to attend the trainings), clinical staff turnover, and staff non-compliance to the protocol. One way to facilitate some of the barriers was having the project manager perform ongoing assessments to address the barriers as soon as possible. Another way was assigning the champion and supervisor on the unit to ensure staff members were following the protocol. The director and supervisor of the rehabilitation center helped with the staffing issues that were presented. A very important facilitator was having leadership support to sustain the ongoing trainings needed throughout the project.

Project Schedule
Before implementation of the DNP scholarly project, approval from the EPRC from the University of St. Augustine for Health Sciences (USAHS) was obtained. Following the approval of USAHS, the project was submitted to the DHR IRB for consent. After obtaining approval, an interdisciplinary team was developed, education sessions were scheduled, a competency evaluation was completed, the frontline staff was ready, and all the resources needed were in place. This allowed for the implementation of the intervention to commence. The evaluation of the process was ongoing to determine if there was compliance with the intervention. Project implementation occurred over 12 weeks. A detailed project timeline is presented in Appendix C.

Resources and Budget
The interprofessional team's resources supported all areas of the project, training rooms and educational materials, such as handouts, flyers, posters, and signs to promote the NDP CAUTI bundle. The budget included training for twenty rehabilitation nurses at a rate of $33.00 per hour. The training was two hours long, costing approximately $1,320, with additional attendee snacks costing roughly $250. The budget also included educational materials that cost about $450.00. The total cost of the project was approximately $1,720 (see Table 1).

Project Management Role and Leadership Skills
A project manager must possess strong leadership skills to lead the team to success and achieve desired goals (Ramazani & Jergeas, 2015). The role of the project manager in this EBP project was to supervise and make important decisions. The project manager was also responsible for scheduling meetings, assigning tasks, setting deadlines and goals. Other responsibilities for the project manager were negotiating and mitigating the intricate nature of the numerous affected stakeholders (Ramazani & Jergeas, 2015). Additional tasks of the project manager were to lead the team during the EBP project and to set the mission and vision, as well as to motivate and empower the team. The project manager also communicated the goals and progress of the project to everyone involved, with the additional goal of providing mentorship, inspiration, and building trusting relationships (Seidle et al., 2016).

Project Evaluation
The evaluation plan had several purposes, including monitoring the success of the project and identifying problems (Thomas, 2016). Lewin's change model and the PDSA model guided the project evaluation (AHRQ, 2015 a; Hussain, et al., 2018). During the evaluation stage of this scholarly project, the CAUTI bundle compliance tool, the pre-and post-education/training tool, and the EMR facilitated the collection, analysis, and data measurement to evaluate the success of the NDP CAUTI bundle intervention.

Selection of Participants
The participants were patients in the rehabilitation unit with an IUC. Other participants were the clinical staff that assisted in the implementation of the NDP CAUTI bundle. Patients in the rehabilitation center who did not have an IUC and those from other medical units did not participate in the project.

Protection of the Participants' Rights and Privacy
The project involved continuous monitoring for ethical considerations, such as protecting participants' rights and maintaining privacy. The project proposal was submitted for approval to the University's EPRC and the facility's IRB Committee. To optimize compliance, the hospital's Ethics Committee reviewed the project. Previously set practices were enforced by the Health Insurance Portability & Accountability Act regulations (HIPAA, 1996). The department used patients' medical record numbers and room numbers for identification purposes. A hard copy of the information was kept in a locked drawer in a locked office. Digital information was stored in an Excel spread sheet. No one was given access to it without the project manager's permission.

Data Details
The data collected for this EBP project were used to measure the success of the project.

Variables
This project's independent variable was implementing the NDP CAUTI bundle, which positively affected the rehabilitation unit. The compliance clinical of staff with the protocol was a dependent variable, with 76% demonstrated compliance. The CAUTI incidences stayed at zero, which was a positive outcome. The project outcome evaluation results confirmed that the intervention was effective.

Validity, Reliability, and Data Sources
It is essential that reviewers consistently measure data when assigning a value to a variable (Calderon et al., 2015). The project manager, director, supervisor, quality management (QM) registered nurse and infection control nurse were responsible for collecting data daily and applied reliable methods to verify the findings. Databases were managed and protected by the IT department. For example, the database Cerner required staff members to change their password every 90 days to maintain security (DHR, 2019). The project manager, director, supervisor, QM nurse, and the infection control nurse audited charts in the EMR. They oversaw the measuring, collected the data separately, and compared their findings. Any disagreements were discussed and mutually resolved.
Data collection tools and surveys used in this DNP scholarly project were reliable tools commonly used in healthcare to improve practice. The tools and surveys have been utilized in several EBP projects across the healthcare systems, generating consistent and accurate results to improve processes (Galiczewski & Shurpin, 2016;Hernandez et al., 2019;McCoy et al., 2017;Parker et al., 2017). The tools used for this EBP project were available for use as long as there was an acknowledgment of the source (Durant, 2017;Dy et al., 2016;Leticia-Kriegel et al., 2019;Quinn, 2015).

Missing Data
Missing data presents a significant and common challenge to the integrity of a project (Galliano, 2019). According to Galliano (2019), missing data in the project can cause erroneous results. The lack of information reduces statistical significance, can cause bias in the calculation of metrics, and reduces sample robustness. Since this was an EBP project, missing data could have complicated the evaluation of the study. Only the assigned team members collected, stored, and analyzed the data. No missing data were noted throughout the collection, storage, and analysis of the data.

Evaluation Design
The project evaluation design was quantitative. Pre-and post-intervention data were collected and compared to measure the project's success (Watson, 2015). The evaluation design of this EBP project generated substantive results related to the project's outcomes, best practice, and improved performance (Watson, 2015). The data provided the team with an overview of the project's success and what needed to be changed.

Categories of Measures
Measures are a vital component of evaluating and implementing change. IHI (2020) claimed that measures were needed to keep the team informed of the implementation's progress.
Five measures relevant to this EBP project were: outcome measures, process measures, balance measures, finance measures, and sustainability.

Outcome Measures
Outcome measures affect the healthcare system's clinical and financial well-being (IHI, 2020). The main goal was to decrease the incidences of CAUTIs in the rehabilitation center to zero. In 2019, the total number of CAUTIs was six. In 2020, from January through May, the total number of CAUTIs was two. From the beginning of the EBP project until its completion, June to August 2020, there were zero CAUTIs in the rehabilitation center. Another outcome goal was to decrease the catheter days. From June to August 2020, the catheter days decreased by 18%. This indicated a significant improvement in the quality of care and reduced expenditures for the rehabilitation center and the organization.

Process Measures
Process measures are the specific steps in a project that can determine whether an intervention produces positive results (IHI, 2020). In this project's process measure, the goal was to achieve 65% compliance with the NDP CAUTI bundle by the end of the project. The result was 76% compliance, which was 11% higher than the benchmark. Another goal was to measure the efficacy of education and training. This was achieved by comparing the participants' preand post-education survey results. The t-value of 2.488 at alpha = .05, indicated a statistically significant difference between the participants' results of preand post-training. In summary, these two process measures demonstrated successful outcomes.

Balance Measures
Balance measures required looking at the system from various directions and ensuring the occurring changes did not negatively affect other areas of the system (IHI, 2020). In this EBP project, the patient's satisfaction was measured to ensure that other areas of care were not neglected. This measure was completed using the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS), and the QM nurse collected the data. The data produced from the survey were considered ordinal, since the data values followed a standard order (Li, 2016). Data were collected from June to August, and the overall patient satisfaction results had a weighted mean of 4.88 out of 5, where 5 was the highest score possible. The results meant that the patients were satisfied with the overall care received in the rehabilitation unit.
However, the survey did not specifically ask about the CAUTI bundle intervention. Further investigation in future projects would be required to determine the relationship between patient satisfaction and the NDP CAUTI bundle intervention.

Finance Measures
The finance measures' purposes were to monitor and control the organization's financial results or needs (Dobrzykowski et al., 2016). Financial measures determine the project's expenses and its returns. The finance measures included a weekly review of the financial status of the project to ensure budget compliance. The finance measures that were monitored were educating and training staff in the rehabilitation center, and the amount spent on one incidence of a CAUTI. During the training week, the facility was already conducting competency training; therefore, there was no additional money spent on project-related education. There was no money spent on CAUTIs as none occurred. According to the WHO (2019), the healthcare facility spends $2400 per case due to CAUTIs and their associated complications. These results indicated that the facility saved money on the absence of CAUTI incidences.

Sustainability Measures
One measure to ensure the sustained use of the NDP CAUTI bundle was to incorporate the new protocol into the orientation for new recruits. Another method was giving the nurses a laminated pocket card with the NDP CAUTI bundle components as a reminder to use the tool. A final method was to integrate the NDP CAUTI bundle with the annual competency check-off list.

Project Evaluation Results
The project manager, to determine if the results of the project were significant, evaluated several areas. Descriptive statistics were calculated and analyzed to determine any statistical association between the pre-and post-intervention, new CAUTI incidences, and catheter days.
The statistical analyses included calculations of frequency distribution, standard deviation, and change percentages. Several evaluation methods including formative, summative, and process evaluations were implemented.

Outcome in PICOT Question
The primary outcome measure and goal was to reduce the incidences of CAUTIs during the project period of June to August 2020. This was accomplished by following the NDP CAUTI bundle tool, ensuring nurse compliance in removing IUC as early as possible, and proactively preventing IUCs from being automatically inserted. In total, there were six CAUTIs in the rehabilitation center in 2019. There were only two from January to May 2020 and from June to August 2020, the incidences remained at zero.

Formative Evaluation
The formative evaluation was used weekly to ensure the project was implemented as scheduled. The evaluation determined whether any changes needed to be made to improve the project's success (Scanlon et al., 2017). Several tools were used to evaluate the project's success, such as CAUTI bundle compliance tool, data warehouse, dashboard, EMR, and benchmarks. The  (Scanlon et al., 2017).

Summative Evaluations
Although the information was compiled throughout the project, the summative evaluations were completed at the end of the project. The summative evaluations included analyzing the project's outcomes, findings, impacts of the intervention, and potential future implications (Nelson & Staggers, 2018). The baseline average CAUTI rates were collected from the Hospital Compare website for the prior year of 2019. They were then compared to the results collected from the data warehouse and hospital dashboard (DHR, 2019). The data were presented to the team using graphs depicting a reduction of CAUTIs. The compliance of the staff to the protocol was measured by using the CAUTI bundle compliance tool. Compliance with the CAUTI bundle tool was 76% at the end of the project, which was 11% higher than the benchmark of 65%. Patient and staff satisfaction were measured using HCAHPS and staff surveys. The patient satisfaction results demonstrated an overall weighted mean of 4.88 on a scale of 5, which meant patients were satisfied with care. The staff satisfaction survey results showed an overall weighted mean of 3.87 on a scale of 5, which meant that more than half of the employees were satisfied with using the new intervention.

Statistical Analysis
The project included a collaborative effort with a statistician who assisted in analyzing and interpreting the data. The Statistical Package for Social Sciences (SPSS) software program, version 23, was used to analyze and compare the pre-and post-intervention data. The SPSS program was used to verify accuracy using a standard p value ≤ .05 to determine statistical significance of the newly implemented protocol effects. During the project, the primary data collected consisted of pre-and post-catheter days, a new number of CAUTIs, and recatheterizations. The primary data also contained the number of staff who effectively documented using the CAUTI bundle compliance tool. Secondary data included patient satisfaction and staff satisfaction ratings.
There were six incidences of CAUTIs in the rehabilitation center in 2019 and two from January to May 2020. Zero incidences of CAUTIs occurred during the project implementation from June to August 2020. These results were clinically significant in decreased length of stay and decreased healthcare expenditures (see Figure 1).
In the re-catheterization measure frequency and percentage, distribution was used to demonstrate significance in this outcome. In June, there were 5 (38%) re-catheterized participants, 2 (15%) in July, and 6 (47%) in August. In July, the re-catheterizations decreased by 23% among patients with an IUC. In August, the re-catheterizations increased by 32% and did not improve in the last month during the DNP scholarly project implementation (see Figure   2). This area needs further investigation in future projects because re-catheterizations increase the risk for infections in patients with an IUC. It also merits further investigation because it increases pain and suffering in patients.
In the catheter days outcome measure, the frequency and percentage distribution were used to learn if the outcome measure was clinically and statistically significant. From March to May 2020, there were 396 (59%) catheter days. From June to August 2020, there were 275 (41%) catheter days during the implementation period, which meant catheter days decreased by 18%. The results suggested that the intervention significantly decreased the catheter days (see Figure 3). When catheter days were reduced, the risk of patients developing an infection and staying in the rehabilitation longer than needed, decreased.
A paired t-test was used to compare pre-and post-staff education/training results. As seen in Table 2, there was a statistically significant difference between pre-(M = 37.87, SD = 6.29) and post (M = 41.63, SD = 5.76) results t-value of 2.488 at alpha = .05. As seen in Table 3, 38 total admissions and 29 CAUTI bundle tools were completed. Therefore, the compliance was 76%. The results of the descriptive statistics provided evidence of the nurses being compliant with the protocol.
In the staff satisfaction outcome measure, the staff survey had ten questions that had to be answered with "Strongly Agree," "Agree," "Neither," "Disagree," or "Strongly Disagree." The results demonstrated that an overall weighted mean was 3.87 on a scale of 5, which meant that more than half of the staff supported the NDP CAUTI bundle.

Implications
In this DNP scholarly project, implementing the NDP CAUTI bundle was clinically significant because it decreased CAUTI incidences and reduced catheter days in the rehabilitation center. The primary outcome was that CAUTIs decreased. Another relevant outcome measure was an 18% reduction of catheter days during the project implementation.
These results reflected a substantial positive change, which occurred because unit nurses followed protocol and timely removed IUCs.
Before implementation of the project, the rehabilitation center did not have a standardized protocol to address patients who had an IUC in place. The NDP gave the nurses the autonomy to remove catheters in a timely manner, which decreased catheter days and ultimately reduced CAUTIs. Results supporting the effectiveness of the CAUTI bundle were consistent with the literature, which indicated that when catheters were removed early, the risk of CAUTIs decreased (Durant, 2017;Dy et al., 2016;Leticia-Kriegel et al., 2019;Quinn, 2015). This project provided safer and improved care in the rehabilitation center.
One limitation of this project was its small sample size. Since COVID-19 caused the census to decrease in the rehabilitation unit, there were only 38 participants in this project.
However, the project results demonstrated decreased CAUTIs and catheter days despite the small sample size, indicating the primary outcome measures' achievement. Another limitation related to COVID-19 was some of the nurses and CNAs were rotated to other departments, leaving the rehabilitation center short-staffed. This made it more difficult for the remaining staff to complete the CAUTI bundle tool.
Recommendations for the next steps involve integrating the practice change into new employee orientation and annual competency/training programs. It would also be beneficial to conduct the project in other departments and assess the outcomes. Implications of the process measures include suggestions to monitor staffing in the rehabilitation center closely. Maintaining adequate personnel would help nurses follow the NDP CAUTI bundle and help CNAs provide effective peri care.
There should be an ongoing evaluation of the protocol to maintain sustainability. Leaders of the rehabilitation center must review EMR to ensure the nurses are documenting the assessment on the patients that have an IUC in place to ensure appropriateness of the catheter.
Frequently rounding the rehabilitation center would improve productivity and accountability for the prevention of CAUTIs.

Plans for Dissemination
Before disseminating the project results, analysis, and evaluation of the project's strengths and limitations, and potential for change, were required. The project was reviewed by the preceptor, rehabilitation director and supervisor, course professor, and university peers. Once feedback was collected, the project results were shared with the rehabilitation department staff during their monthly meeting and change of shift huddles. The results were presented verbally.
In addition, flyers were made and given to the staff, and visual charts that depicted the department's previous and current status on CAUTIs.
The results of the project will be presented to the leaders of DHR during a quality improvement meeting. These leaders will include the chief medical officer, the CNO, and the directors of every department. The presentation will consist of verbal and visual descriptions of the project results. As approved by leadership, the results will be shared through a morning meeting, an email, an inter-facility newsletter, and during an infection control conference. The closing statement will discuss the availability of training material and additional resources to sustain the practice change.
The external dissemination to support the EBP intervention will include plans to share data with local hospitals, outpatient facilities, long-term care facilities, and nursing school programs through the local healthcare newsletter. The presentation will include project protocol, educational material, timelines, budget, and outcomes. Widespread dissemination will include sharing the results with the University of St. Augustine for Health Sciences. At the national level, project results will be presented at the American Nurses Association Conference. The author will seek publication of this project in the American Journal of Infection Control and the Journal of Urology. Lastly, this doctoral project will be submitted in full text for dissemination through SOAR, an electronic publication database supported by the USAHS.

Conclusion
The primary goal of the EBP project was to implement an intervention to reduce CAUTIs in DHR's rehabilitation center. CAUTIs are the leading cause of hospital-acquired infections.
The literature reviewed identified that HAI is a preventable issue. It was found that the implementation of an NDP CAUTI bundle decreased CAUTIs. The project began with an organizational needs assessment conducted using the SWOT analysis tool. The organizational issue was identified as increased CAUTIs throughout the facility. Lewin's change theory and the PDSA model guided the change process for this EBP project. Consistent educational training and audits promoted the success and sustainability of the project. The expected outcome was to decrease the rate of CAUTIs to improve patient outcomes.