Implementing a urinary tract infection (UTI) quality improvement program resulted in a decrease in UTI diagnoses in orthopedic patients, according to a study published in BMJ Open Quality.

Amit Thakker, from the Division of General Surgery at the University Health Network in Toronto, and colleagues, monitored patients who underwent total hip and knee joint replacements and hip fracture repairs for the incidence of UTI and the use of catheters. The data collected as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) revealed a UTI rate of 2.1% among 666 patients who were treated between January and June 2016, and indwelling urinary catheters were used in 55.2% of the patients. The team planned to compare the baseline data with the data collected after implementation of change ideas, which was from July 2016 to March 2017.

The baseline data on the use of indwelling urinary catheters and NSQIP UTI rate were presented to the senior leadership group and orthopedic surgeons. A working group was formed to communicate the inappropriate use of indwelling urinary catheters. Guidelines relating to elimination of the unnecessary use of indwelling urinary catheters and removal strategies were provided via education to all nursing staff. Interventions included primarily education and a culture change of the nursing staff.

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The quality improvement initiative was implemented using the ‘4 E’s approach’: engage, educate, execute and evaluate. After the change was implemented, the average rate of UTI decreased from 2.1% between January and June 2016 to 1.1% between July 2016 and March 2017. Furthermore, the average rate of indwelling urinary catheter use decreased from 55.2% to 19.8% after implementation of the changes.

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“We demonstrated reduction of postsurgical UTI from 2.1% to 1.1%, which is likely associated with the significant reduction of indwelling urinary catheter use,” the researchers concluded.” A systematic approach engaging all front-line staff helped to facilitate the implementation of this quality improvement initiative. Having a culture change on the inpatient unit was unexpected, yet favorable; the staff nurses acknowledged the impact of indwelling urinary catheter insertion and its risk for UTI and recognized the value for change.”


Thakker A, Briggs N, Maeda A, Byrne J, Davey JR, Jackson TD. Reducing the rate of post-surgical urinary tract infections in orthopedic patients. BMJ Open Qual. 2018;7(2): e000177. Published online 2018 Apr 27. doi:  10.1136/bmjoq-2017-000177