Using statistical process control charts to measure changes from a nurse-driven protocol to remove urinary catheters.

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Implementing a nurse-driven protocol (NDP) to remove indwelling urinary catheters is a strategy to reduce catheter-associated urinary tract infections (CAUTI). The purpose of this project was to implement a comprehensive NDP to reduce indwelling urinary catheter utilization and CAUTI rates at a large academic health system.


Statistical process control charts, a quality improvement method, was used to identify special cause variation. A formal protocol was developed to provide guidance for nurses to remove indwelling urinary catheters when no longer indicated. Changes were also made within the electronic health record.


Signals of improvement were not noted on the Statistical process control charts for urinary catheter utilization or CAUTI rates. The frequency with which the NDP was documented (process measure) was assessed, showing it is used approximately 600 times each month. Of those catheters removed by the NDP, an average of 6% were reinserted within 48 hours (balancing measure).


Our findings differed from other literature as we did not see a reduction in urinary catheter utilization after implementing a NDP. However, our project adds to the literature as we also evaluated process and balancing measures.


A NDP for urinary catheter removal provides nurses with the autonomy to remove catheters when no longer indicated; however, other interventions should be added to a comprehensive CAUTI-prevention program.





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Reynolds, Staci S, Halie Lozano, Monique Fleurant and Kalpana Bhandari (2022). Using statistical process control charts to measure changes from a nurse-driven protocol to remove urinary catheters. American journal of infection control, 50(12). pp. 1355–1359. 10.1016/j.ajic.2022.03.005 Retrieved from

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Staci Reynolds

Clinical Professor in the School of Nursing

Dr. Staci Reynolds joined Duke in January 2016.  At DUSON, Dr. Reynolds teaches in the ABSN Program (neuroscience nursing) and DNP program (healthcare quality improvement methods). Previously, she clinically served as a Clinical Nurse Specialist (CNS) at DUH within the neuroscience inpatient units and Infection Prevention and Hospital Epidemiology department. In January 2023, Dr. Reynolds was appointed the Editor-in-Chief of the Journal of Nursing Care Quality.  Before coming to DUSON, she was a neurocritical care nurse and a neuroscience CNS at Indiana University Health Methodist Hospital.

Dr. Reynolds received a baccalaureate degree in nursing science from Indiana University (IU) in Indianapolis, Indiana.  She earned a Master’s degree as a Clinical Nurse Specialist at IU in 2011, and completed her PhD at IU in May 2016.  Dr. Reynolds’ dissertation focused on implementation of clinical practice guidelines, and her current research interests includes evidence-based practice implementation and quality improvement.

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