Patients that develop Catheter-Associated Urinary Tract Infections (CAUTI) have an increased risk of developing sepsis and experiencing pain and discomfort from the infection. In 2017, the thirty-one bed Telemetry unit at a two hundred twenty-two bed community hospital accounted for five of the eight hospital CAUTI for the year which led to a Standardized Infection Rate (SIR) of 5.60 and a Standardized Utilization Rate (SUR) of 1.39.

In response to the high CAUTI SIR and SUR in the Telemetry Unit, the Chief Nursing Executive Officer (CNEO) championed a multifaceted approach to CAUTI reduction. The approach consisted of both a Lean Six Sigma (LSS) project and an, “Every Line Every Day” project. A unit leader collaborated with an Infection Preventionist certified in LSS, to complete the project within twelve weeks. Simultaneously, the "Every Line Every Day" project was launched, which involved assessing each patient's need for a Foley catheter based on hospital policy. The Infection Preventionists began attending the daily bed control meetings to collaborate with nursing leadership on the findings and a unit scorecard was createdweekly. The ongoing focus for CAUTI reduction from the CNEO led to the effort to achieve the improvement.

In 2017 the Telemetry unit had five CAUTI with a SIR of 5.6 and an SUR of 1.39. Projects to reduce the SIR and SUR began in February 2018. The Lean Six Sigma project ended in April and the “Every Line Every Day” project is ongoing. From January to November 2018, the, Telemetry unit had one CAUTI, an eighty percent decrease in CAUTI from 2017, with a SIR of 1.52 and an SUR of 1.05.

The utilization of a multifaceted approach supported by the CNEO to address high CAUTI SIR and SUR achieved a reduction in CAUTI.