HOUDINI Impacts on Utilization and Infection Rates – a Retrospective Quality Improvement Initiative

A Retrospective Quality Improvement Initiative

Jay P. Ballard; Susan Parsons; Jennifer Rodgers; Victoria Mosack; Bobbie Starks


Urol Nurs. 2018;38(4):184-191. 

In This Article

Abstract and Introduction


Objective: Ascertain the impact of the nurse-driven removal checklist upon catheter utilization and catheter-associated urinary tract infection (CAUTI) rates on a medical/surgical unit.

Design: Retrospective Quality Improvement Initiative.

Methods: Data were obtained from a de-identified database limited to patient care days, catheter days, catheter utilization ratios, and number of CAUTIs. Data were compared pre-and post-intervention. Comprehensive training regarding the nurse-driven removal of urinary catheters was completed prior to the change initiative. Comprehensive Unit-Based Safety Program (CUSP) framework was utilized to solicit collaborative process and program improvement across the hospital hierarchy.

Results: There were 3,565 patient care days pre-change and 3,699 patient care days post-change (p¬=0.555; CI=-94.166 to 55.88). The number of catheter days was 679 pre-change and 625 post-change (p=0.567; CI=-23.451 to 38.88). Neither measure resulted in statistically significant differences. In addition, the catheter utilization ratio did not change significantly, from 0.19 to 0.17 (p=0.091; CI= -0.006 to 0.063) (see Figure 2). Finally, no CAUTI was observed during either investigational period.

Conclusions: Utilization of the Nurse-Driven Removal Protocol (NRDP) for removal of unnecessary indwelling urinary catheters demonstrated a non-significant but potentially clinically meaningful reduction in their utilization for the medical/surgical unit under investigation.


Catheter-associated urinary tract infections (CAUTIs) have a myriad of negative health consequences, including increased catheter use and associated infections, in creased costs, length of inpatient hospital stay, and mortality (Centers for Disease Control and Prevention [CDC], 2018). The Centers for Medicare & Medicaid Services (CMS) (2016) considers CAUTIs as "never events," and thus, ties reimbursement for care to the CAUTI rate. While hospital-acquired conditions (HACs), such as CAUTIs, can result in a 1% decrease in reimbursement across the board, treatment for CAUTI is not reimbursed at all (Livorsi & Perenccevich, 2015; Peasah, McKay, Harman, Al-Amin, & Cook, 2013). Despite various interventions and a focus on early removal, use of indwelling urinary catheters (IUCs) can still be higher than desired. Attesting to this fact, the CDC calls for minimization of IUC use, including operative patients, those at in creased risk for CAUTI, and incontinent patients (Gould, 2009).

Hospital leadership, in conjunction with historical data, evince a relatively large number of catheter days across units in comparison with state and national averages. Catheter days are defined as the number of patients with an IUC device; data are collected daily (CDC, 2018). Catheter days are an essential metric in calculating catheter use, which was also noted to be elevated in comparison with the previously cited benchmarks. For example, in 2015, prior to the start of quality improvement initiatives (January to July), catheter utilization rates were derived from historical data, which reflect catheter days to total patient days and approximate efficiency with which catheters are withdrawn, and were approximately 0.19. This is higher than the national average of 0.17 and the statewide average of 0.18. This obviates catheter days and utilization rates linkage. It further implicates catheter use in increased morbidity, mortality, length of stay, and costs at the hospital in question.

Catheter use is a strong driver of these consequences (Gould, Umscheid, Agarwal, Kuntz, & Pegues, 2009; Harris, 2010; Quinn, 2015; Richards et al., 2017; Underwood, 2015). Nurse-driven processes for insertion and removal improve utilization and infection rates (Harris, 2010; Quinn, 2015; Richards et al., 2017; Underwood, 2015). The issue is two-pronged. First, initiating an IUC outside of the parameters defined by the Guideline for the Prevention of Catheter Associated Urinary Tract Infection increases utilization and places clients at risk for infection and accompanying sequelae (Gould et al., 2009). Second, continuing an IUC once these indications have subsided also strongly contributes to all negatively impacted metrics cited thus far. To combat this, use of a HOUDINI-based checklist (see Appendix 1), simply for removal of catheters, has demonstrated a strong decrease in the number of catheter days in primary studies (Adams, Bucoir, Day, & Rimmer, 2012; Mori, 2014; Underwood, 2015). For instance, one study relates the percentage of catheters removed within one week was significantly impacted (p=0.015) as determined by a Fischer's exact test (Prayle, Thompson, Lancaster, Molyneux, & Tsang, 2014). Therefore, a retrospective review of catheter use and related infection rates before and after the nurse-driven catheter removal checklist could guide system-wide patient outcome improvement.