170 - Reducing Catheter-Associated Urinary Tract Infections in a High-Risk Pediatric Medical-Surgical Intensive Care Unit through Interdisciplinary Rounds and Diagnostic Stewardship

Publication Number: 3164.170

Jennifer Blumenthal, Boston Children's Hospital, Weston, MA, United States; Thomas J. Sandora, Boston Children's Hospital, Boston, MA, United States; Alon Geva, Harvard Medical School, Boston, MA, United States; Michelle Connors, Boston Children's Hospital, Boston, MA, United States; Christine Hall, Boston Children's Hospital, Boston, MA, United States; Nira Pollock, Boston Children's Hospital, Boston, MA, United States; Dimple Mirchandani, Boston Children's Hospital, Boston, MA, United States; Alexander J.. McAdam, Boston Children's Hospital, Boston, MA, United States; Mari M. Nakamura, Boston Children's Hospital, Boston, MA, United States; Gregory P. Priebe, Boston Children's Hospital, Boston, MA, United States

Background: Catheter-associated urinary tract infections (CAUTIs) remain a persistent challenge in pediatric critical care, particularly among medically complex patients requiring prolonged catheterization. Our 54-bed pediatric medical-surgical ICU (MSICU) had CAUTI rates above our goal despite weekly safety rounds emphasizing timely catheter removal.

Objective: To reduce CAUTI rates by improving reliability of catheter-necessity review and enhancing diagnostic stewardship for urinary testing through structured, systems-based interventions.

Design/Methods: Using Plan-Do-Study-Act (PDSA) cycles, we strengthened existing safety rounds. We increased rounding frequency from once to twice weekly in November 2024. To ensure standardized communication, accurate reporting, and feedback on performance, we integrated a quality improvement (QI) safety consultant within our existing team of infection prevention nurses and physicians in March 2025. During CAUTI root-cause analyses, we determined that urine cultures were frequently ordered without preceding urinalysis, limiting differentiation of infection and colonization. We therefore developed a urinalysis with reflex to culture orderable with multidisciplinary consensus input on reflex criteria. Implementation included provider education; electronic clinical decision support, offered in a new urinalysis and urine culture order panel, on appropriate use of the reflex orderable versus separately ordered urinalysis and urine culture; case-based training; and iterative feedback during safety rounds. We measured the outcome of CAUTI rate per 1000 catheter days and evaluated frequencies of urinalyses and urine cultures ordered as process measures.

Results: Urine culture orders declined from an average of 38 to an average of 24 post-interventions and use of the new urinalysis with reflex to culture orderable increased from 2 to 36 orders per month over the first 4 months of implementation in the MSICU. Control-chart analysis demonstrated 8 consecutive months without a CAUTI in the MSICU leading to centerline shift in March 2025 in the CAUTI rate from 1.3 to zero.

Conclusion(s): Embedding QI consultants into twice-weekly safety rounds and introducing a reflex urine culture order improved reliability of infection prevention practices and diagnostic stewardship in a high-acuity pediatric ICU, with early indicators of sustained CAUTI reduction.

control chart with urinalysis alone, urine culture alone, and urinalysis with reflex culture orders
Improvements noted in orders of urine cultures alone and utilization of new orderable for urinalysis with reflex to culture

CAUTIs in the MSICU
MSICU_CAUTI_Control_Chart_Oct2025.pdfcontrol chart of CAUTIs in the MSICU with annotations and notable for special cause variation