Catheter Acquired Urinary Infection Research Assignment

You will combine Parts 1, 2, and 3 of your Course Project (assigned in Weeks 2, 4, and 8 respectively) into one cohesive and cogent paper.
Note: In addition, include a 1-page summary of your project.
For this final iteration you will need to:
Submit your paper to Grammarly and SafeAssign through the Walden Writing Center. Based on then Grammarly and SafeAssign reports, revise your paper as necessary.
Reminder: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The School of Nursing Sample Paper provided at the Walden Writing Center provides an example of those required elements (available from the Walden University website found in this week's Learning Resources). All papers submitted must use this formatting.
Note: The Course Project will be your Portfolio Assignment for this course
Part 1
Although Foley Catheter acquired Infections are avoidable, sadly enough, it's pre-valence is on the rise. Urinary tract infection attributed to the use of an indwelling urinary catheter is one of the most common infections acquired by patients in health care facilities. While the proportion of bacteriuric subjects who develop symptomatic infection is low, the high frequency of use of indwelling urinary catheters means there is a substantial burden attributable to these infections. Catheter-acquired urinary infection is the source for about 20% of episodes of health-care acquired bacteremia in acute care facilities, and over 50% in long term care facilities. Kathleen (2014).
Summary of Interest
Writer chose to identify a researchable problem in Practices that increase Urinary Tract Infection in patients that have indwelling Foley Catheter, and will focus on the researchable problem, is routine and as needed care with antimicrobial solutions enough to prevent catheter acquired urinary tract infections?
Other Focus points will include the impact of routine irrigation of the Foley on bacteria / Infection rates, the role of Antimicrobials on the care, Safe practices as defined by facility's policy; how often care and how that care is delivered as relates to catheter infections.
Catheter acquired urinary tract infections (CAUTIs) affect every nursing department in a hospital setting and even in outpatient settings and long-term care settings. CAUTIs are of importance to me due to where I work. “Studies have shown that Urinary Tract Infections (UTIs) are the most common hospital acquired infections and that 80 percent of UTIs are a result of indwelling urinary catheters” (Revello & Gallo, 2013, p. 99)
According to an article written by Revello & Gallo in the Journal of Nursing Education and Practice,
“As of 2010, the Center for Medicare and Medicaid (CMS) no longer reimburses hospitals for the additional costs of treating nosocomial infections such as hospital acquire urinary tract infections. In May of 2011, the Joint Commission announced a new national patient safety goal that requires hospitals to implement an evidence-based practice program to prevent catheter associated urinary tract infections (CAUTIs) by January 1, 2013.” (p. 99)
• In an article from The Online Journal of Issues in Nursing it states, “Newer guidelines emphasize prevention of infection by limiting both catheter use and duration of use so as to decrease the number of hospital-acquired, urinary tract infections (UTIs).” (Welden, 2013, p. 50)
CDC came up with a set of regulations in 2009. “The guideline provides key recommendations related to appropriate catheter use, proper techniques for urinary catheter insertion, proper techniques for catheter maintenance, quality improvement programs, administrative infrastructure, and surveillance.” (Knudson, 2014, p. C1)
With guidelines in place to ensure that care is taking to maintain Foley catheters and limit infection rates, nurses need to be better trained on the best EBP taking care of patients with indwelling catheters when the use of device is deemed unavoidable, as to reduce the risks of Infection.
Identification of the Problem
The main problem identified with the safe implementation of Foley Catheter care is the policy in place as negates the CDC guidelines which stipulates that, Catheter irrigation is not recommended unless there is an obstruction with clots or mucous build up, breaking the catheter drainage bag connection closed system can be a potential risk of bacterial entry into the system, CDC also advises not to reuse sterile syringes for flushing, to change Foleys as necessary per patients specific needs, to use the ports for urine collections, or change the catheter and bag for large amounts needed for culture to avoid culturing the system versus samples. Per CDC recommendations, we are not to aspirate inflated balloons when removing a catheter as this potentiates trauma, but allow solution to drain back into tubing by gravity and last but not the least, recommends hand washing above sanitizers. Hand wash after 3-4 times of use of sanitizers! The VA has a standard to irrigate twice daily, we tend to reuse syringes for irrigating to conserve supplies, the norm here is to hasten the process; change bags and collect urine, we aspirate to deflate balloons and lastly have been told against my good judgment that it is okay to just walk around all day using the hand sanitizers unless in dealing with c- dif Patients. Changes to nursing practice frequently occur because of evidence-based practice (EBP) initiatives (Polit & Beck, 2017, p. 4). Delving into this search is an eye opener. Nursing assistants not cleansing the tubing routinely with warm soapy water during ADL care and Incontinent care, relying on nurses to use antimicrobial solutions to prevent contaminations. It is hard to understand that even as Nurses with our high wealth of knowledge and training, we tend to derail from EBP due to policies, MD's orders and above all time and supplies.
Significance of problem to Nursing practice
A major significance of the Evidence Based Research problem to Nursing practice would be a review of existing policy or differently put, implementation of a new protocol. Change is difficult to embrace, especially with the bottle necks to influencing new decisions in a government owed facility. Old Nurses are also so set in their ways that they just tend to continue with their conservative practices.
5 Questions Generated
What are Catheter acquired infections?
How can we reduce them?
Does incessant irrigating of Catheters increase the risk of infections?
How does Catheter Acquired infections affect the health care systems?
Does irrigating Foleys in Long Term Care Facilities introduce bacteria into the body? Infections?
Analysis of Feasibility
There is no identified perfect system in place. Many factors may readily affect feasibility studies, and somite is pertinent to foresee the possible clauses when undertaking on a Research. Policies, Staff ratio, staff education and willingness to participate, Time and money would be factors to bear in mind.
PICOT QUESTION
In patients with urinary catheters is routine and as needed catheter care with antimicrobial solutions alone enough to prevent catheter acquired urinary tract infections within 120 days of hospitalization?
The PICOT variables
P: Patients with Foley catheters.
I: Non-irrigation of catheters unless indicated.
C: incessant daily irrigation of Foley catheter
O: reducing catheter acquired infections
T: over four months

10 keywords for Literature search and Rationale
Prevention of CAUTI, to find out if proper care can reduce infection
Patients with Foley and those without, to know if Foley increases the risk of prevalence of UTI
Indwelling Foleys placed only when Indicated, alternatives/ avoid ability?
Comparison, compare the benefits of using antimicrobials to warm soapy water to cleanse tubing.
The placement of drainage bags above the bladder and back flow, Infection
The problems that can generate as a result of the placement of drainage bags on floor, this will assist in generating information on the issue of UTI
Does incessant irrigating of Catheters increase the risk of infections? To assess Best practices.
How does Catheter Acquired infections affect the health care systems? EBP/Reimbursements
Does irrigating Foleys in Long Term Care Facilities introduce bacteria into the body? Infections?
Nursing Assistants and Licensed staff- Nursing Assistants are usually the ones that provide routine Incontinent care; knowledge/education of care.
An Isolated good practice is inadequate to maintain an indwelling Foley Catheter. Per CDC guidelines, a number a EBP must be put in place for standard care of the Foley. Antimicrobials as an Isolated practice is not adequate to prevent the incidence of UTI in patients. Non-routine irrigations, handwashing, cleansing of the tubing with Incontinent care and ADL are some of the other complimentary steps in caring for patients with Foley catheters.

References
Dumont, C. P., & Wakeman, J. B. (2010). Preventing catheter-associated UTIs: Survey report.
Nursing 2010, 24-30.
Knudson, L. (2014). CAUTI prevention requires improved practices and policies. Association of
Operating Room Nurses, C1, C9-C10.
Revello, K., & Gallo, A.-M. (2013). Implementing an evidence-based practice protocol.
Journal of Nursing Education and Practice, 99-107.
Welden, L. M. (2013). Electronic Health Record: Driving Evidence-Based Catheter- Associated Urinary Tract Infections (CAUTI) Care Practices. The Online Journal of Issues in Nursing, 50-59.
Majid, S. (2010). Adopting evidence –based practice in clinical decision making
Part 2
Literature reviews may be conducted to appraise scholarly articles, researched work, or theory, and other wide range of reasons. A in depth review study can add secondary value to research. Researchers typically conduct research within the context of existing knowledge by undertaking a thorough literature review (Polit & Beck, 2017, p. 85). This writer will attempt to provide a analysis of what existing studies expose about the existing state of data on the said PICOT question. Pin point discrepancies and irregularities in the reviews of up to date work relating to the PICOT inquiry. The primary assumption will offer evidence that either validates practice modification or demands for more study.
Preventing Catheter Associated Urinary Tract Infections
Meddings et al, (2013) stated that urinary tract infections (UTI) has long been considered the most common healthcare – associated infection (HAI), with vast majority of these infections occurring after placement of the convenient, often unnecessary and easily forgotten urinary catheter. “With an estimated one million catheter-associated urinary tract infection (CAUTI) per year, associated with an additional cost of $676 per admission, it is not surprising that CAUTIs were among the first hospital acquired conditions selected for nonpayment by Medicare as of 2008.” (Meddings et al 2013) According to the Center for Disease Control and Preventions (CDC), CAUTI have been further targeted for complete elimination as a never event with the goal to reduce it by 25% and reduce urinary catheter use by 50% by 2014.
In an attempt to reduce CAUTI, some guidelines were put in place namely;
• Insert catheters only for appropriate indications; avoid use for management of incontinence. When patients do require indwelling urinary catheters, constantly evaluate the need for use and identify other methods for managing bladder drainage whenever possible.
• Leave catheters in place only as long as needed and remove ASAP preferably within 24 hours post operatively unless there are appropriate indications for continued use.
• Insertion of catheters by properly trained personnel using aseptic technique and sterile equipment. Studies have shown that aseptic technique reduces the infection rate and prevents cross contamination in patients undergoing catheter insertion.
• Aseptic technique is highly recommended as a standard practice for care.
• Incessant irrigations of indwelling catheters have been shown to introduce bacteria into the systems. Do not routinely irrigate unless indicated
PICO APPLICATION
Why formulate a PICO question when conducting a study research in evidence based practice? It is the first step in evidence-based practice involves converting information needs into well-worded clinical questions that can be answered with research evidence (Polit & Beck, 2017, p. 31). The use of Evidence based practice provide the guidelines for health care practitioners to deliver standardized and improved quality care to their patients.
THE PICOT FORMULAR:
In patients with urinary catheters, are routine and as needed catheter care using antimicrobial solutions alone enough to prevent catheter acquired urinary tract infections within 120 days of hospitalization generated very few articles that specified the role of antimicrobial solutions in catheter management, as a topic was too narrow to meet quality research goals. Research questions have to be manageable, clearly defined and well-structured, and answerable by research evidence and within a reasonable time frame. Based on that, below are some research questions chosen for this paper.
The Pico Formula was then modified to be, what is the incidence rate of CAUTI when indwelling catheter is in place for a longer period of time?
Based on that, below are some research questions chosen for this paper.
1. What is the incidence rate of CAUTI when indwelling catheter is in place for a longer period of time in patients admitted on a medical/surgical floor?
2. How effective is the use of aseptic technique in catheter insertion decrease the rate of CAUTI occurrence in patient on a med/surf unit?
3. What is the relationship between UTI and indwelling catheter?
4. What is the relationship between CAUTI and the length of patients stay on a medical/surgical floor?
5. Will reducing the use of indwelling catheter decrease the risk of CAUTI on patients admitted on a medical/surgical floor?
Using the PICO model and its variables; (patient/population, intervention, comparison, and outcome). The preliminary PICO question chosen is:
P – Population; hospitalized patients on a medical/surgical unit
I – Intervention; using aseptic technique in indwelling catheter insertion
C – Comparison; reducing indwelling catheter days
O – Outcome; reduction in rate of CAUTI in hospitalized patients
Key words
When conducting a literature search for my PICO the 10 possible keywords that can be used include: 1) Catheter associated urinary tract infection, 2) hospital acquired infections, 3) hospitalized adults with indwelling catheter, 4) nosocomial infections, 5) Evidence based practice and catheterization, 6) causes of urinary tract infection, 7) Risk associated with indwelling catheter, 8) What is CAUTI, 9) Nurses and Foley catheters, 10) CMS and nosocomial infections.
Conducting research studies, requires persistence and good organizational skills about the statistics and sources that are applied to the research theme. It is easy to apply non-creditable sources ranging from medMd to Google search engines for their subject. Often times, Researchers find articles on Google, however, CINAHL or ProQuest are credible sources that allow you to enter multiple keywords and find ample articles. Applying evidence pyramids rank evidence sources according to the strength of the information available, and often times, randomized controlled trial's (RCTs) are near the top of these hierarchies (Polit & Beck, 2017, p. 25). Filtered vs unfiltered information using key search words were utilized in this review. Key search words such as; Foley catheter Infections, Foley and irrigations, Foley care were choice words.
Identified Studies
Five research articles related to the incidence of CAUTI were selected for this review. The first article is by Parry, Grant, & Sestovic, (2013), in this study, the researchers were able to establish a relationship between the reductions in unnecessary urinary catheter use with a subsequent decrease in the rate of CAUTI. This study was conducted in a community teaching hospital with 300 – bed, over a thirty six month period. The researcher found that the implementation of nurse and physician directed urinary catheter removal protocol on CAUTI that reminded these clinicians, remove unnecessary catheter use thus decreased CAUTI rates. . At the end of this study, a 50% hospital-wide reduction in catheter use and a 70% reduction in CAUTIs was noted; indicating that aggressive implementation of nurse/physician directed catheter removal protocol was associated with lower catheter use rate and reduction on CAUTI rate.
Investigators, Niel-Weise & Van den Broek, (2009) reviewed urinary catheter policies for short-term bladder drainage in adults; the objective was to determine the advantages and disadvantages of alternative approaches to short-term bladder catheterization in adults in terms of complications, All randomized and quasi-randomized trials comparing intermittent catheterization for adults and indwelling catheter for up to 14 days. The review found evidence that intermittent catheterization reduced the risk of bacteriuria when compared with indwelling urethral catheterization.
The second study evaluated Another group of investigators, Chen, Y., Chi, M. Chen, y., Chan, Y., Chou, S. Wang, F., (2013) used the reminder approach to determine the relationship between the use of urinary catheters and the incidence of catheter associated urinary tract infections. This study was carried out in a respiratory intensive care unit with a 2990-bed, with a randomized control trial approach. The study comprised of patients with indwelling urinary catheters for over two days from April through November 2008. These subjects were randomly assigned to either the intervention group (use of a criteria-based reminder to remove the catheter) or the control group with no reminder). A total of 278 patients were used in this study. In this research analysis, the agent observed that rate of use of indwelling urinary catheters decreased by 22% in the intervention group when compared to the control group. The investigator also noted that the use of use of a criteria-based reminder to remove indwelling catheters remarkably reduced the median duration of catheterization by seven days compared to eleven days for the control group. The led the investigators to conclude that the use of a criteria-based reminder to remove indwelling urinary catheters can decrease the use of urinary catheterization and lower the prevalence of catheter-associated urinary infections.
The third study evaluated Another relevant study done by (Elpern, E., Killeen, K., Kelchem, A., Wilely, A., Patel, G., & Laleef, O., 2009) discovered that implementing a process to monitor appropriate catheter continuance in a medical intensive care unit can reduce catheter-associated urinary tract infections. In this study, the clinicians designed indications for continuing urinary catheterization with indwelling devices. Over a period of six month, patients in a medical intensive care unit who had indwelling urinary catheters were evaluated daily by using criteria for appropriate catheter continuance. Recommendations were made to discontinue indwelling urinary catheters in patients who did not meet the criteria. Days of use of a urinary catheter and rates of catheter-associated urinary tract infections during the intervention were compared with those of the preceding eleven months. During this period, the unit had a total of 337 patients with a total of 1432 days of urinary catheterization. During that intervention period, it was noted that the duration of use was significantly reduced to a mean of 238.6 d/month from the previous rate of 311.7 d/month. Correspondingly, the number of catheter-associated urinary tract infections per 1000 days of use was a mean of 4.7/month before the intervention and zero during the 6-month intervention period. This led these researchers to conclude that t implementation of an intervention to judge appropriateness of indwelling urinary catheters could result in a significant reduction in duration of catheterization days of patients and the occurrences of catheter-associated urinary tract infections in those patients.
The fourth study evaluated; An observational study by Cornia, P. Amoty, J., Fraser, S. CSaint, S. Lipsky, B., (2003) explored the relationship between the use of computer-based order entry and the decreased duration of indwelling catheterization in hospitalized patients. In this research study, the researcher used an automatic reminder protocol to physicians through a computerized medical record system at a Veterans Affairs medical system that reminded physicians of the presence of an indwelling catheter. The researchers noted that with an automatic reminder in place, the mean duration of catheterization was shortened by about one third on the study group, which led them to the conclusion that using an automatic reminder protocol to physicians would reduce the duration of indwelling catheter in patients.
Synthesis of What the Studies Reveal About the State of Knowledge
The above studies have shown there is a correlation between CAUTIs and the number of days of having an indwelling Foley catheter. Evidence has demonstrated that patients with indwelling Foley catheter are more at risk for UTIs, “when there is an increase in the duration of time that the catheter is in place. The estimated risk for infection is at least 5% per day of catheterization. Among all risk factors, increased duration of catheterization is the greatest for development of a urinary tract infection.” (Elpern, 2009)
According to Sharma (2013), once a catheter is placed, the daily incidence of bacteriuria is stated to be between 3-10%. Between 10% and 30% of patients who undergo short-term catheterization (i.e., 2-4 days) develop bacteriuria and 90% to 100% of patients who undergo long-term catheterization develop bacteriuria which is about 80% of nosocomial infection rates.
The above studies also demonstrated that CAUTIs are among complications fundamentally linked to nursing care and can be reduced through a nurse –based intervention to avoid unnecessary Foley catheter placement which limit duration of Foley catheter use.
Inconsistencies with explanations
There are no obvious inconsistencies in the above studies. The general conclusion to prevent CAUTI is to avoid unnecessary Foley catheter use and prompt removal of indwelling Foley catheter as appropriate.
Conclusion
Urinary tract infections (UTI) has long been considered the most common healthcare – associated infection (HAI), with vast majority of these infections occurring after placement of the convenient, often unnecessary and easily forgotten urinary catheter”( Meddings et al, 2013). Given its potential preventability, Meddings et al, (2013) stated that hospital-acquired CAUTI was among the first complications selected for nonpayment by the Centers for Medicare and Medicaid Services.
Studies have shown that the greatest risk factor for CAUTI is prolonged duration of indwelling catheter. Urinary catheters often are placed unnecessarily, remain in use without physician awareness, and are not removed promptly when no longer needed. Meddings et al, (2013) also added that one of the best ways to reduce the risk of CAUTI in patients admitted on a med/surg unit is to reduce the use of indwelling catheters. Meddings et al, (2013) continued by saying that the reduction of use of indwelling catheter can be achieved by timely removal and implementation of protocol to remind clinician of the presence of indwelling urinary catheter, either to remove or indicate purpose for use.
“Evidence-based nursing practice is essential to the delivery of high-quality care that optimizes patient's outcomes. Recent Researches are proof that optimal patient outcomes are guaranteed with the application of evidence based skills in health care” (Beth, et al 2013 p.1). The studies applied in this Research analysis demonstrated reductions in CAUTI rates. It therefore is of utmost importance for Management to offer guidance and tutelage to staff to become conversant with changes in Nursing researches as they occur, not only to advance the course of nursing but also to elevate the overall standard of patient care provided.
Literature Analysis/Research Summary Table


Citation Nature of Study
Design Type
Framework/Theory Setting Key Concepts/Variables Findings Hierarchy of Evidence Level
Parry, M., Grant, B., & Sestovic, M. (2013, December). Successful Reduction in Catheter Associated Urinary Tract Infection: Focus on Nurse - Directed Catheter Removal [American Journal of Infection Control]. Retrieved from http://www(dot)ncbi(dot)nlm(dot)nih(dot)gov/pubmed/23768439

Nature of Study: Quantitative
Design Type:
Prospective interventional
Framework/Theory: community teaching hospital Concepts:
Decrease the rate of CAUTI
Independent Variable:
Application of nurse and physician directed urinary catheter removal protocol
Dependent Variable:
Frequency of CAUTI
Controlled Variable:
Indicates that aggressive implementation of nurse/physician directed catheter removal protocol was associated with lower catheter use rate and reduction on CAUTI rate Level 5
Cohort study
Niel-Weise, B., & Van den Broek, P. (2009, January) Urinary Catheter for Short-term Bladder Drainage in Adult. Cochran collaboration Retrieved from http://www(dot)ncbi(dot)nlm(dot)nih(dot)gov/pubmed/160349242. http://dx(dot)doi(dot)org/101002/14651858 Nature of Study:
quantitative quasi experimental study
Design Type:
Prospective interventional
Framework/Theory: Hospital Concepts:
Reduce CAUTI
Independent Variable: comparing the use of intermittent catheterization to indwelling urinary catheter.
.
Dependent Variable: rate of CAUTI
Controlled Variable:
intermittent catheterization reduced the risk of bacteriuria when compared with indwelling urethral catheterization
Level 1 Systematic Reviews / Meta-Analyses
Citation Study
Design Type
Framework/Theory Setting Key Concepts/Variables Findings Hierarchy of Evidence Level
Chen, Y., Chi, M. Chen, y., Chan, Y., Chou, S. Wang, F., (2013) U Using a Criteria-based Reminder to Reduce Use of Indwelling Urinary Catheters and Decrease Urinary Tract Infections. American Journal of Critical Care. Retrieved from http://www(dot)medscape(dot)com/viewarticle
Nature of Study:
Quantitative Comparison study Correlational
Design Type:
Prospective interventional
Framework/Theory: Hospital Concepts: To determine whether a reminder approach reduces the use of urinary catheters and the incidence of catheter associated urinary tract infections
Independent Variable: using
the reminder
approach
Dependent Variable: Frequency of CAUTI
Controlled Variable: Patients with indwelling catheter Urinary catheter reminder
reduced incidence of CAUTI
Level 1
Systematic Reviews / Meta-Analyses
Elpern, E., Killeen, K., Kelchem, A., Wilely, A., Patel, G., & Laleef, O. (2009, Nov 18). Reducing Use of Indwelling Urinary Catheter and Associated Urinary Tract Infection [Amj Crit Care]. Pubmed, 18(6). Retrieved from http://ajcc(dot)aacnjournals(dot)org/content/18/6/535.long
Nature of Study:
Quantitative Correlational
Design Type:
Prospective interventional
Framework/Theory: A medical intensive care unit Concepts: Decrease the frequency of CAUTI
Independent Variable:
Appropriate versus inappropriate catheterization
Dependent Variable: Frequency of catheter insertion and CAUTI
Controlled Variable:
Implementation of an intervention to judge appropriateness of indwelling urinary catheters may result in significant reductions in duration of catheterization and occurrences of catheter-associated urinary tract infections.
Level 5
Cohort study
Cornia, P. Amoty, J., Fraser, S. CSaint, S. Lipsky, B., (2003) Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients. The American Journal of Medicine. Retrieved from http://www(dot)amjmed(dot)com/article/S0002-9343(02)01568-1/abstract.
.org/sp- Nature of Study
Observational
Design Type:
Prospective interventional
Framework/Theory: Hospital Concepts:
Eliminating Infection
Independent Variable:
Use of reminder system
Dependent Variable:
Duration of indwelling catheter
Controlled Variable: No reminder system use
The duration of indwelling catheter was decreased
Level 5
Cohort study

References
Beth, M., Makic, F., Martin, S., Burns, S., Philbrick, D., Rauen, C., (2013 p. 1-17). Putting Evidence into Nursing Practice: Four Traditional Practices Not Supported by the Evidence. CriticalCareNurse Vol. 33(2). Retrieved from http://www(dot)aacn(dot)org/wd/Cetests/media/C1322.pdf
Chen, Y., Chi, M. Chen, y., Chan, Y., Chou, S. Wang, F., (2013) U Using a Criteria-based Reminder to Reduce Use of Indwelling
Urinary Catheters and Decrease Urinary Tract Infections. American Journal of Critical Care. Retrieved from http://www(dot)medscape(dot)com/viewarticle.
Cornia, P. Amoty, J., Fraser, S. CSaint, S. Lipsky, B., (2003) Computer-based order entry decreases duration of indwelling urinary
catheterization in hospitalized patients. The American Journal of Medicine. Retrieved from http://www(dot)amjmed(dot)com/article/S0002-9343 (02)01568-1/abstract.
Elpern, E., Killeen, K., Kelchem, A., Wilely, A., Patel, G., & Laleef, O. (2009, Nov 18). Reducing Use of Indwelling Urinary Catheter and Associated Urinary Tract Infection [Amj Crit Care]. Pubmed, 18(6). Retrieved from http://ajcc(dot)aacnjournals(dot)org/content/18/6/535.long
Gould, C, (2009) C Catheter-associated Urinary Tract Infection (CAUTI) Toolkit. Retrieved from. CDC.
http://www(dot)cdc(dot)gov/HAI/pdfs/toolkits/CAUTItoolkit
Killeen, E., Kelchem, A., Wilely, A., Patel, G., & Laleef, O. (2009, Nov 18). Reducing Use of Indwelling Urinary Catheter and
Associated Urinary Tract Infection [Amj Crit Care]. PubMed, 18(6). Retrieved from http://ajcc(dot)aacnjournals(dot)org/content/18/6/535.long
Matthew, D. (2013). Urethral Catheter: Removal. The Joanna Briggs Institute, 3. Retrieved from http://ovidsp(dot)tx(dot)ovid(dot)com(dot)ezp(dot)waldenulibrary(dot)org/sp-3.12.0b/ovidweb.cgi
Meddings, J., Krein, S., Fakih, M., Olmsted, R., & Saint, S. (2013). Reducing Unnecessary Urinary Catheter Use and Other Strategies to Prevent Catheter Associated Urinary Tract Infection. PubMed. Retrieved from http://www(dot)ncbi(dot)nlm(dot)nih(dot)gov/books/NBK133354/#ch9.r23
Niel-Weise, B., & Van den Broek, P. (2009, January). Urinary Catheter for Short-term Bladder Drainage in Adult. Cochran collaboration Retrieved from http://www(dot)ncbi(dot)nlm(dot)nih(dot)gov/pubmed/160349242.
Parry, M., Grant, B., & Sestovic, M. (2013, December). Successful Reduction in Catheter Associated Urinary Tract Infection: Focus on Nurse - Directed Catheter Removal [American Journal of Infection Control]. Retrieved from http://www(dot)ncbi(dot)nlm(dot)nih(dot)gov/pubmed/23768439
Polit, D.F., & Beck, C.T. (2012). Nursing Research: Generating and Assessing Evidence for Nursing Practice (Laureate Education Inc., custom ed.) Philadelphia, PA: Lippincott Williams & Wilkins.
Robinson, S., Allen, L., Barners, M., (2007). “Development of an Evidence-based Protocol for Reduction of indwelling Urinary Catheter Usage” MedSurg Nursing 16(3): 157 -161. Retrieved from http://www(dot)ncbi(dot)nlm(dot)nih(dot)gov/pubmed/17849921
Sharma, L. (2013, January, 8). Catheter -Related Urinary Tract Infection. Urinary Catheter Use in hospitalized patients [Systematic Review and Meta-Analysis]. National Institute for Health Research, Retrieved from http://www(dot)medscape(dot)com/viewarticle
University of the West of England, (2007) Research Observation. Retrieved from http://ro(dot)uwe(dot)ac(dot)uk/RenderPages/RenderLearningObject.aspx?