the presence of an indwelling urinary catheter ( iuc ) is the principal risk factor for catheter - associated urinary tract infection ( cauti ) development . despite the risk of prolonged catheter placement
, few hospitals actively track catheterized patients , and providers are often not aware of the presence of catheters in their patients [ 13 ] .  
nurses are at the frontline of catheter care . as the providers most involved with iucs in hospitalized patients , nurses are responsible for iuc placement , day - to - day catheter management , and the removal of iucs .
responsible for specimen collection , nurses play a vital role in the diagnosis of cautis . among catheterized patients ,
they are often the first to notice a clinical change or technical problem .   despite their central role in iuc care and management , only a handful of published reports
the majority of these publications have followed a quality improvement ( qi ) approach , at times bundled with hospital - wide policy changes [ 47 ] .   in a recent paper by drekonja et al .
however , reeducation of surgical nurses in urinary catheter management has shown to have a modest decrease in catheter days .
gaps in knowledge may potentially impair the effectiveness nurses may play in the prevention of catheter - related complications .   with a goal of increasing awareness about the presence of iucs among medical inpatients , our team developed an educational curriculum .
after eliciting staff engagement by cultivating champions and involving the staff in all stages of the process , we instituted a practical , catheter - care curriculum which introduced qi concepts and incorporated principles of basic microbiology and hand hygiene to mirror established infection - control practices .
the curriculum targeted aspects of catheter care within the scope of practice of nursing providers and was built on published guidelines [ 810 ] .  
the purpose of the qi project was to improve compliance with documentation of indwelling urinary catheter insertion .
as a tangible application of their education , we promoted the use of the catheter labels (  tags  ) and monitored engagement over the course of the educational sessions .
nurses of the medical inpatient units of the washington dc veterans affairs medical center voluntarily participated in the initiative between april 2009 and april 2010 .
nursing providers were defined as registered nurses ( rns ) , licensed practicing nurses ( lpns ) , and clinical nurse assistants ( cnas ) .
clinical nurse leaders were invited to participate as project champions , and the educational sessions were built into existing educational time .
the use of the cumulative unidentified feedback from the nurses and results from anonymous surveys was approved by our institutional review board and the research and development committee .  
the interdisciplinary qi team consisted of clinical nurse leader project champions , qi educator , and physician champions . at the onset of the project , the qi team organized and led several focus - groups with small groups of nursing providers of approximately 1012 participants . the focus group format consisted of open - ended questions to explore the role of nurses in catheter care .
we engaged stakeholders in eliciting ideas for educational sessions and obtained invaluable perspectives that led to the design of a feasible , easily used catheter label .
the iuc label ( figure 1 ) design was adapted from existing intravenous tubing labels , familiar to our nursing staff ( manufactured by united ad label , rr donnelly inc . , st .
the nursing staff was responsible for the tag placement , wrapping each self - adhesive label around the tubing above the catheter drainage bag .
the fluorescent yellow tags were designed to be clearly visible standing at the patient 's bedside .
label placement instructions were posted , and packets of labels were made accessible to nursing staff in medication - treatment rooms and mobile medicine carts .  
five thirty - minute educational sessions were cycled over three daily nursing shifts on our two medical floors , to maximize participation . with the support of nursing leadership
participation in the case discussions , interactive segments , and surveys were voluntary for the staff .  
the curriculum introduced the qi process and reinforced use of iuc labels ( table 1 ) . the educational curriculum consisted of five sessions : an introduction to the project goals and iuc tags ( session i ) , nursing role in cauti prevention ( session ii ) , case studies ( session iii ) , hands - on microbiology ( session iv ) , and an educational review session ( session v ) .
there was a focus on the care of iucs in the context of a nurse scope of practice and the consequences of cautis .
we referenced evidence - based guidelines to develop our didactic presentations ; we used case - based scenarios to facilitate discussion and conducted hands - on culturing of the environment . to elicit
the final session featured an educational board game reviewing strategies to reduce cautis through catheter - care management and hand - hygiene guidelines .  
the surveys elicited feedback and provided real - time insight on the learning objectives and content using a 3-point likert - type scale ( strongly agree , moderately agree , and disagree ) .
the queries asked nurses to rate the projects workplace importance , its impact on improving patient care , and opportunities for collaboration between disciplines .
individually unidentifiable responses gauged interest in the qi process , tested provider knowledge , and assessed the performance iuc identification over time . at the end of each block of educational sessions , nurses were asked to self - report their tagging behavior .
the proportion of nurses reporting tagging after the introduction of the iuc tags was compared to the last block of educational sessions utilizing two - tailed chi - square test and accepting a p value of < 0.05 ( spss v11 , chicago , il ) .  
the qi team reinforced tagging between educational sessions with routine rounds of the medical floors .
make your work count ,   tag a tube  and  let 's work together to reduce cautis .
 recognition of individual catheter - tagging efforts was published in monthly nursing newsletters , and results of the initiative were widely promoted at hospital - wide quality and educational fairs .
nursing providers completed 152 surveys ; 76.3% were from rns including lpns and 31.6% from cnas . at baseline ,
a minority of participants reported prior experience in qi : only 36.2% ( 42/116 ) of rns ( including rns and lpns ) and 30.5% ( 11/36 ) of cnas .   at the end of each block of educational sessions , survey responses were collated . among those who responded , 98.4% ( 121/123 )
felt increased qi awareness over the course of the educational sessions . in addition , 98.6% ( 142/144 ) felt the project facilitated teamwork , and 99.3% ( 151/152 ) believed that the project was important to their work .
the nurses self - reported catheter - tagging increase after the introduction of the iuc tags in session i ( figure 2 ) . in the post - introduction period
, we found that there was a significant increase in proportion of nurses reporting use of iuc tags ( from 46.2% at the end of session ii to 84.6% at the end of session v , p = 0.001 ) . in the dissemination of a new program , the innovators and early 
adopters  have been implicated in the widespread adaptation of an initiative . from the onset , we targeted nurse providers in the development and implementation of the iuc label consisting of the date of catheter placement .
our carefully designed educational curriculum focused on practical , primarily nurse - controlled risk - reduction interventions .
we introduced several novel strategies including practical case - based discussions and fun interactive hands - on culturing of hospital surfaces , including the catheters themselves .
the board - game format was popular with staff and easily promoted at hospital - wide events .
we set out to change behavior through education and renewed cauti awareness in the hospital setting . in the process , we collected informal assessments of staff perceptions and self - reported behaviors .
we found that the early engagement of nurses and our primary stakeholders , combined with a targeted educational interdisciplinary initiative led to increased awareness of the presence of iucs , including the concepts of qi .
the processes employed in this small scale project can be applied to broader , hospital - wide initiatives and to large - scale initiatives for healthcare interventions . as first line providers with responsibility for the placement and daily maintenance of iucs ,
 catheter - associated urinary tract infections ( cautis ) are preventable complications of hospitalization . 
 an interdisciplinary team developed a curriculum to increase awareness of the presence of indwelling urinary catheters ( iucs ) in hospitalized patients , addressed practical , primarily nurse - controlled inpatient risk - reduction interventions , and promoted the use of the iuc labels (  tags  ) . 
 five thirty - minute educational sessions were cycled over three daily nursing shifts on two inpatient medical floors over a 1-year period ; participants were surveyed ( n = 152 ) to elicit feedback and provide real - time insight on the learning objectives . 
 nurse self - reported iuc tagging was early and sustained ; after the iuc tag was introduced , there was a significant increase in tagging reported by the end of the block of educational sessions ( from 46.2% to 84.6% , p = 0.001 ) . 
 early engagement combined with a targeted educational initiative led to increased knowledge , changes in behavior , and renewed cauti awareness in hospitalized patients with iucs . 
 the processes employed in this small - scale project can be applied to broader , hospitalwide initiatives and to large - scale initiatives for healthcare interventions . as first - line providers with responsibility for the placement and daily maintenance of iucs , 
 nurses are ideally positioned to implement efforts addressing cautis in the hospital setting . 
1. Introduction
2. Methods
3. Results and Discussion 
4. Conclusions