BACKGROUND:

Catheter-associated urinary tract infections (CAUTIs) are a leading cause of health care–associated infection. Catheter insertion bundles (IBs) and maintenance bundles (MBs) have been developed to prevent CAUTIs but have not been extensively validated for use in pediatric populations. We report the CAUTI prevention efforts of a large network of children’s hospitals.

METHODS:

Children’s hospitals joined the Children’s Hospitals’ Solutions for Patient Safety engagement network from 2011 to 2017, using an open start time engagement approach, and elected to participate in CAUTI prevention efforts, with 26 submitting data initially and 128 at the end. CAUTI prevention recommendations were first released in May 2012, and IBs and MBs were released in May 2014. Hospitals reported on CAUTIs, patient-days, and urinary catheter-line days and tracked reliability to each bundle. For the network, run charts or control charts were used to plot CAUTI rates, urinary catheter use, and reliability to each bundle component.

RESULTS:

After the introduction of the pediatric CAUTI IBs and MBs, CAUTI rates across the network decreased 61.6%, from 2.55 to 0.98 infections per 1000 catheter-line days. Centerline shifts occurred both before and after the 2015 Centers for Disease Control and Prevention CAUTI definition change. Urinary catheter use rates did not decline during the intervention period. Network reliability to the IBs and MBs increased to 95.4% and 86.9%, respectively.

CONCLUSIONS:

IBs and MBs aimed at preventing CAUTIs were introduced across a large network of children’s hospitals. Across the network, the rate of urinary tract infections among hospitalized children with indwelling urinary catheters decreased 61.6%.

Among children’s hospitals, catheter-associated urinary tract infections (CAUTIs) are among the top 2 or 3 most common causes of health care–associated infection.1  Pediatric patients with CAUTIs spend on average 2.4 more days in the hospital and have $7200 of excess charges.2  CAUTI prevention guidelines have been developed; however, their applicability to pediatric populations are unclear because supporting data and validation studies come primarily from adult populations.37  In general, the prevention of CAUTIs in adult populations focuses on judicious catheter use as well as proper aseptic practices for catheter insertion and maintenance.810  To reduce CAUTIs, adult hospitals have adopted strategies to limit urinary catheter use and to promote early catheter removal and have implemented evidence-based insertion bundles (IBs) and maintenance bundles (MBs).1113 

Children’s Hospitals’ Solutions for Patient Safety (SPS) is a network of >135 children’s hospitals collaborating to reduce health care–associated complications among children.1,14,15  SPS evaluated best practices in CAUTI prevention to develop and implement IBs and MBs for use in children. Our assessment was that bundles developed for use in adults were being introduced by children’s hospitals and were largely applicable for pediatric use. We describe the process by which SPS CAUTI prevention bundles were implemented in children’s hospitals and report the impact on network-wide CAUTI rates.

The quality improvement (QI) initiative included patients admitted to children’s hospitals in North America that were members of SPS. The SPS national network started in 2011 with 33 hospitals; it grew to 78 hospitals by 2013 and currently has >135 hospitals.1,14  Approximately one-third are standalone children’s hospitals, with the remaining being children’s hospitals within larger hospitals or systems. Network hospitals range in size from 42 to 727 beds (median 190). The number of hospitals that contributed data on CAUTI reduction increased from 26 in 2011 to 128 in 2017 (not all hospitals submitted data every month). Because NICUs and observational units are excluded from the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) CAUTI setting definition, they were excluded.16  The reporting period extended from January 1, 2011, to December 31, 2017. Hospitals tracked all patients admitted to an inpatient unit who had an indwelling urinary catheter. The Cincinnati Children’s Institutional Review Board determined this work to be QI activity and exempt human subject research. No protected health information was shared with SPS. Data use was governed by a hospital participant agreement signed by each hospital.

To introduce CAUTI process measures, we used an approach championed by SPS for preventing other health care–associated complications, in which evidence-based bundles are first developed and trialed in a small number of hospitals and then rapidly rolled out across the network, leveraging the lessons learned by the initial hospitals. Hospitals joined SPS and elected to participate in the CAUTI prevention initiative at different times. Because the goal was to rapidly introduce best practices across all children’s hospitals, the study was designed to prioritize hospital engagement over potentially more-rigorous evaluation of the interventions. In this regard, we used an open start time engagement approach, in which subsequent hospitals began data collection and were encouraged to implement process measures concurrently on enrollment.

CAUTIs were defined by using the CDC NHSN definition.16  CDC CAUTI definitions were revised in January 2015.17  Concurrently, the SPS CAUTI definition was updated at all hospitals. The major definition changes were as follows: urine cultures with Candida, yeast, or molds and those with colony counts <105 colony-forming units per milliliter were no longer considered during CAUTI surveillance.

After a period in which baseline data were collected from initial hospitals, SPS CAUTI prevention practice recommendations were released in May 2012, referred to as an IB and MB. These were based on literature review and best practices reported by member hospitals. In May 2014, these bundle elements were annotated as “recommended” or “required” on the basis of level of evidence as derived from review of literature (Table 1). In developing these bundles, we surveyed participating hospitals to determine their current prevention methods, receiving responses from 62. Ultimately, the consensus was that the mechanisms of pediatric CAUTIs were sufficiently similar to adult CAUTIs to warrant implementation of bundles similar to those used for adults.1012  Bundle elements were graded by SPS content experts as standard (high supporting evidence) or recommended (moderate supporting evidence).

TABLE 1

Pediatric CAUTI Prevention Bundle Elements and Level of Supporting Evidence

CAUTI Prevention Bundle ElementCare DescriptionLevel of Evidence, CDCa and SPSbRef. No.
Insertion    
 Standard element    
  Use aseptic technique for insertion Perform hand hygiene immediately before and after insertion or any manipulation of the catheter; use sterile gloves, drape, sponges, appropriate antiseptic, or sterile solution for periurethral cleaning and a single packet of lubricant jelly for insertion IBa and scenario 4b 3,1822  
  Avoid unnecessary catherization Consider having written clinical indications IBa and scenario 4b 3,1822  
Maintenance    
 Standard elements    
  Maintain a closed system If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment IBa and scenario 2b 3,1822  
  Maintain hygiene Perform perineal hygiene at minimum daily IBa and scenario 2b 3,1822  
  Keep bag below level of bladder Do not rest bag on floor IBa and scenario 4b 3,1822  
  Maintain unobstructed flow of urine Keep the catheter and collecting tube free from kinking IBa and scenario 4b 3,1822  
  Remove catheter when no longer needed Review necessity daily, document indication daily IBa and scenario 4b 3,1822  
 Recommended element    
  Secure catheter Secure catheter IBa and none 18,20,21  
CAUTI Prevention Bundle ElementCare DescriptionLevel of Evidence, CDCa and SPSbRef. No.
Insertion    
 Standard element    
  Use aseptic technique for insertion Perform hand hygiene immediately before and after insertion or any manipulation of the catheter; use sterile gloves, drape, sponges, appropriate antiseptic, or sterile solution for periurethral cleaning and a single packet of lubricant jelly for insertion IBa and scenario 4b 3,1822  
  Avoid unnecessary catherization Consider having written clinical indications IBa and scenario 4b 3,1822  
Maintenance    
 Standard elements    
  Maintain a closed system If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment IBa and scenario 2b 3,1822  
  Maintain hygiene Perform perineal hygiene at minimum daily IBa and scenario 2b 3,1822  
  Keep bag below level of bladder Do not rest bag on floor IBa and scenario 4b 3,1822  
  Maintain unobstructed flow of urine Keep the catheter and collecting tube free from kinking IBa and scenario 4b 3,1822  
  Remove catheter when no longer needed Review necessity daily, document indication daily IBa and scenario 4b 3,1822  
 Recommended element    
  Secure catheter Secure catheter IBa and none 18,20,21  
a

CDC modified recommendation categories are as follows. IA: a strong recommendation supported by high- to moderate-quality evidence suggesting net clinical benefits or harms; IB: a strong recommendation supported by low-quality evidence suggesting net clinical benefits or harms or an accepted practice (eg, aseptic technique) supported by low- to very low–quality evidence; IC: a strong recommendation required by state or federal regulation; II: a weak recommendation supported by any quality evidence suggesting a trade-off between clinical benefits and harms.

b

SPS evidence categories are as follows. Scenario 1: reliably implementing element is associated with statistically significant improvement; scenario 2: failing to implement element is associated with statistically significant failure to improve along with the system; scenario 3: in cases in which all hospitals implement, implementing an element without measuring reliability of the element is associated with statistically significant failure to improve along with the system; scenario 4: reliably implementing element is not associated with statistically significant improvement; however, literature supports adoption of element as an SPS standard.

SPS member hospitals were provided a change package containing background information on CAUTIs, contact information for SPS CAUTI leads and subject matter experts, a key driver diagram (Fig 1), operational definitions, bundle elements, data collections requirements, and access to an online CAUTI discussion board. SPS CAUTI leaders and subject matter experts facilitated network-wide learning sessions through virtual meetings (monthly from 2012 to 2013, quarterly in 2014, and annually from 2015 to 2017) and biannual SPS National Learning Sessions. Learning sessions were focused on data collection, education about the bundles, best practices for auditing bundles, and development of key driver diagrams and included the sharing of best practices. SPS CAUTI leads reviewed data at least quarterly and discussed with individual hospitals their run charts and any identified special cause variation. High-performing hospitals shared best practices during learning sessions. Instructional resources are available through SPS describing the bundle elements.23  SPS instructional videos describe the proper steps for compliance with the urinary catheter IBs and MBs.24,25 

FIGURE 1

CAUTI prevention key driver diagram. PDSA, plan-do-study-act.

FIGURE 1

CAUTI prevention key driver diagram. PDSA, plan-do-study-act.

Close modal

SPS hospitals reported the number of CAUTIs, urinary catheter-line days (CLDs), and patient-days each month using an Internet form. For both the IB and the MB, hospitals audited patients and reported the number of patients audited and the number of audited patients in which there was adherence to 100% of the elements within each bundle. Hospital data were included in analyses as long as a numerator and denominator were submitted and the denominator was not 0.

The primary outcome was the network CAUTI rate per 1000 CLDs, calculated as total CAUTIs reported by all hospitals (numerator) divided by the total CLDs reported by all hospitals (denominator) multiplied by 1000. Data were analyzed by using statistical process control methods.26  CAUTI rates were plotted monthly on a u-chart, with an initial centerline established by using data from January to December of 2011.

For each bundle, the primary process measure was total audits in which there was 100% element adherence (numerator) divided by total audits (denominator), as a percentage each month. Process reliability rates were plotted on run charts. SPS recommended that hospitals submit at least 20 audits per month, but the actual number ranged from 1 to 2243. Hospitals that conducted electronic medical record audits tended to audit more patients. Individual hospital audit methods were not validated by SPS. To weight the aggregate monthly reliability calculation by hospital size rather than number of audits performed, hospital process reliability rates were weighted by CLD to determine the aggregate network rate. Network aggregate monthly process reliability rate = .

The number of hospitals submitting data increased as new hospitals joined or existing hospitals initiated CAUTI improvement initiatives, and the reliability to the bundles improved over time. Given the fluidity of participation, for the full set of hospitals, we analyzed the relationship between outcomes rates and bundle reliability using only 1 year of sustainment data. This was done by calculating the correlation coefficient and with funnel plots. For funnel plots, hospitals were placed into 1 of 3 reliability categories for IB and MB separately, and the CAUTI rates were plotted. Hospitals that submitted at least 10 months of outcomes and reliability data in 2017 were included in both analyses. A special cause event is indicated by groups falling outside of control limits. Similar analyses were performed for the original 26 hospitals by using various time periods, including 2014, the year original hospitals began submitting reliability data.

The urinary catheter use rate over time (total number of CLDs divided by the total number of patient-days, recorded as a percentage) was tracked on a run chart.

For the various charts, special cause rules were used to monitor the stability of the system, and the centerline, representing the mean, was shifted if there were at least 8 consecutive points above or below the centerline. When a centerline shifted, the new centerline began on the first point of the 8 that fell above or below the centerline, and the 8 data points were used in the calculation of the new centerline. This shifting rule was applied to the u-chart, the 2 process run charts, and the urinary catheter use run chart. For the u-chart, additional special cause rules were used to identify signals of a change: (1) a point that falls above the upper control limit or a point that falls below the lower control limit, (2) 6 consecutive points increasing or decreasing (a trend), (3) 2 out of 3 consecutive points near a control limit (in the outer one-third of the control limit window), and (4) 15 consecutive points close to the centerline (in the inner one-third of the control limit window). Hospital-level and network-level control charts were reviewed monthly. After visual inspection, special cause events were identified, and centerlines were recomputed manually when needed. No special software was used to identify special cause events.

The reporting period spanned 7 years and includes data from 128 SPS hospitals that submitted CAUTI outcomes data. There were 2555 CAUTIs and 1 574 216 urinary CLDs. The baseline CAUTI rate was 2.55 infections per 1000 CLDs, which was tracked for the participating 26 original hospitals starting in January 2011 (Fig 2). After the release of initial SPS CAUTI prevention recommendations in May 2012, the centerline shifted downward to 1.93 infections per 1000 CLDs. SPS CAUTI IBs and MBs were released in May 2014. A CDC CAUTI definition change occurred January 1, 2015; soon thereafter, the centerline readjusted to 1.37 infections per 1000 CLDs. An additional centerline shift to 0.98 occurred in January 2016 and has been sustained through 2017, representing a 61.6% decrease. For the most-recent centerline, the mean number of monthly reporting hospitals was 119 (maximum 125). Because the u-chart control limits depend on the value of the centerline and the total number of CLDs each month, the control limits narrowed over time as new hospitals joined and the number of submitting hospitals increased. For the 26 original hospitals, through 2017, there was a 54.9% decrease in CAUTIs, with the centerline declining from 2.55 to 1.15 (Supplemental Fig 5).

FIGURE 2

SPS network aggregate CAUTI rate. The number of CAUTIs per 1000 CLDs is plotted monthly on a u-chart, in which n is the number of hospitals reporting data for that month (every other month is reported for ease of display). Dates for key events include May 2012, release of SPS recommended bundle; May 2014, release of SPS bundle and evidence; and January 2015, CDC NHSN CAUTI definition change. The yellow line denotes the centerline. The blue line with dots denotes CAUTI rate. The red dashed line denotes control limits. Readjustment of the centerline required 8 consecutive points above or below the centerline.

FIGURE 2

SPS network aggregate CAUTI rate. The number of CAUTIs per 1000 CLDs is plotted monthly on a u-chart, in which n is the number of hospitals reporting data for that month (every other month is reported for ease of display). Dates for key events include May 2012, release of SPS recommended bundle; May 2014, release of SPS bundle and evidence; and January 2015, CDC NHSN CAUTI definition change. The yellow line denotes the centerline. The blue line with dots denotes CAUTI rate. The red dashed line denotes control limits. Readjustment of the centerline required 8 consecutive points above or below the centerline.

Close modal

Throughout the study period, urinary catheter use rates fluctuated in a nonsignificant manner (Supplemental Fig 6). For the final recording period, the centerline for urinary catheter use was 5.83%. The data for the original 26 hospitals are similar (Supplemental Fig 7).

Participating hospitals were encouraged to track reliability to the CAUTI IB (Fig 3) and MB (Fig 4). Reliability data are available from January 2014 onward. The initial centerline for the network reliability to the IB was 85.7%, shifted upward twice, and was 95.4% at the end of 2017. The initial centerline for network MB reliability was 74.0%, shifted upward 3 times, and was 86.9% at the end of 2017. Bundle reliability data were not submitted by all hospitals, and the number of hospitals submitting data varied by month and across the study period. For the most-recent centerline, the mean number of hospitals reporting insertion and maintenance data was 46 and 81, respectively. Overall, the correlation observed between hospital CAUTI rates and IB reliability (r = −0.238; P = .129) and MB reliability (r = 0.0055; P = .963) was not statistically significant. For the funnel plots, we observed that for the IB (Supplemental Fig 8), those hospitals with lower reliability (<90%) had unusually high CAUTI rates (above the upper control limit using 3 SDs). For the MB (Supplemental Fig 9), however, the funnel plot revealed that CAUTI rates for the 3 reliability categories were not unusually high or low.

FIGURE 3

SPS weighted network aggregate reliability to CAUTI IB. Reliability refers to the percentage of hospitals that reported audit adherence to 100% of the IB elements. Monthly data are plotted on a run chart, in which n is the number of hospitals reporting data for that month (every other month is reported for ease of display). The yellow line denotes the centerline. The blue line with dots denotes the percentage of hospitals reporting 100% reliability to the IB. Readjustment of the centerline required 8 consecutive points above or below the centerline.

FIGURE 3

SPS weighted network aggregate reliability to CAUTI IB. Reliability refers to the percentage of hospitals that reported audit adherence to 100% of the IB elements. Monthly data are plotted on a run chart, in which n is the number of hospitals reporting data for that month (every other month is reported for ease of display). The yellow line denotes the centerline. The blue line with dots denotes the percentage of hospitals reporting 100% reliability to the IB. Readjustment of the centerline required 8 consecutive points above or below the centerline.

Close modal
FIGURE 4

SPS weighted network aggregate reliability to CAUTI MB. Reliability refers to the percentage of hospitals that reported audit adherence to 100% of the MB elements. Monthly data are plotted on a run chart, in which n is the number of hospitals reporting data for that month (every other month is reported for ease of display). The yellow line denotes the centerline. The blue line with dots denotes the percentage of hospitals reporting 100% reliability to the MB. Readjustment of the centerline required 8 consecutive points above or below the centerline.

FIGURE 4

SPS weighted network aggregate reliability to CAUTI MB. Reliability refers to the percentage of hospitals that reported audit adherence to 100% of the MB elements. Monthly data are plotted on a run chart, in which n is the number of hospitals reporting data for that month (every other month is reported for ease of display). The yellow line denotes the centerline. The blue line with dots denotes the percentage of hospitals reporting 100% reliability to the MB. Readjustment of the centerline required 8 consecutive points above or below the centerline.

Close modal

IB (Supplemental Fig 10) and MB (Supplemental Fig 11) reliability charts for the original 26 hospitals are provided. Overall, no correlation was observed between CAUTI rates and IB reliability (r = 0.196; P = .587) or MB reliability (r = 0.177; P = .455) or for either funnel plot for 2014 to 2017. For 2014, the first year most hospitals submitted reliability data, the IB funnel plot (Supplemental Fig 12) revealed that those hospitals with higher reliability data had lower CAUTI rates (below the lower control limit using 2 SDs). For the MB (Supplemental Fig 13), however, the funnel plot revealed that CAUTI rates for the reliability categories were not unusually high or low.

In this study, we describe QI efforts implemented by the SPS network of 135 children’s hospitals to reduce CAUTIs.1,14  Although CAUTI IBs and MBs have been used in adult populations and researchers of small studies from individual children’s hospitals support use in children, large pediatric validation studies have not previously been performed.36,1113,2729  After release of SPS CAUTI prevention recommendations and bundles, CAUTI rates across the network decreased 61.6%, from 2.55 to 0.98 infections per 1000 CLDs.

Implementation of this massively multicenter initiative posed several challenges and necessitated some study design compromises. With a primary goal of rapidly reducing harm from CAUTIs across all children’s hospital, we took a pragmatic approach with our initiative that favored hospital engagement and participation over a more-rigorous evaluation of intervention methods. Hospitals joined the network at different times and were encouraged to simultaneously begin implementing bundles and submitting process measure data. Entry fluidity made correlating bundle adherence with CAUTI rates challenging, a problem we attempted to compensate for by examining final-year sustainment data for the full cohort and, separately, data from the original 26 hospitals. Researchers of future QI studies using an open start time engagement model should anticipate this problem and might consider alternative designs, such as separating hospitals into cohorts with simultaneous entry times.

Bundle adherence increased from 85.7% to 95.4% for the IB and from 74.0% to 86.9% for the MB. Although reliability reporting increased over time, incomplete reporting and the open start time engagement approach limited our ability to correlate hospital bundle adherence to CAUTI rates. Many hospitals submitted line days without corresponding process measure data, yet centers that did not monitor implementation achieved similar outcomes as centers who exceeded the proposed high-reliability implementation threshold. Additionally, the number of audits performed by hospitals varied, with a few centers submitting electronic medical record audits at 100-fold the suggested rate. Our methods did not allow SPS to evaluate the reliability and fidelity of the various auditing approaches adopted by participating hospitals.

Because we were unable to differentiate between CAUTIs attributable to insertion versus maintenance care with our data, the relative importance of the 2 bundles to overall CAUTI reduction is unclear. For the time period incorporating the most-recent centerline shift, however, funnel plots revealed that hospitals with <90% reliability to the IB had unusually high CAUTI rates. Similarly, for the original 26 hospitals during the first year after bundle implementation, funnel plots revealed that hospitals with ≥90% IB reliability had lower CAUTI rates.

Given heightened awareness of the need to prevent CAUTIs and the ground swell of institutional pressure to tackle this problem, the so-called “rising-tide phenomenon,” it is possible that CAUTI prevention practices have diffused into widespread practice, masking the impact of bundle reliability on CAUTI rates.30  It is further possible that hospitals concurrently implemented other initiatives to reduce CAUTIs. For example, among adult hospitals, culture stewardship efforts have been associated with a decrease in the rate of CAUTIs.31 

SPS hospitals concurrently participated in other SPS-sponsored efforts to reduce health care–associated harm.1,14,15  Nonetheless, we cannot exclude the possibility that implementation of this QI initiative had unintended consequences, such as discouraging diagnostic cultures or increasing use of empirical antibiotics. Although this was perhaps defensible in 2011 when this QI initiative was designed, our project did not formally monitor balancing measures. Researchers of future QI studies of this scale should consider the possibility that implementation of change has unintended results in different parts of the system.32 

It is possible, as seen by the fact that urinary catheter use rates did not decline, that there is room for improvement in pediatric CAUTI prevention through efforts to avoid unnecessary catheterization and promote catheter removal. Among adult hospitals, nurse-driven catheter removal programs have engendered some enthusiasm.13  Whether similar programs would reduce catheter use in pediatric patients has not received much attention. An alternative possibility is that catheter use is already optimized, perhaps because of a low tolerance for convenience catheterization in pediatric patients. Indeed, the device use rate across SPS children’s hospitals was 0.06, compared with adult hospital rates of 0.30 and 0.15 in critical care and the noncritical care units, respectively.33 

An important unanticipated event was a CDC CAUTI definition change that occurred during the intervention period, the intent of which was to improve the sensitivity and specificity of the CAUTI definition to make it more suitable for tracking the success of QI initiatives.17  The timing of the change posed a challenge for our initiative and serves as a cautionary reminder of the unintended policy consequences that may result from modifying widely used definitions. To accommodate the definition change, SPS communicated the new definition to local hospital CAUTI leads, updated electronic data reporting fields, and delayed data entry, ensuring that all hospitals adopted the new definition simultaneously. Because the new and old CAUTI definitions may differ in their sensitivity and specificity, the outcome of CAUTI prevention efforts may also differ according to which definition is applied.34  Our data collection methods did not allow us to recalculate baseline CAUTI rates using the new definition. Despite this, we observed declines in CAUTI rates during the periods before and after a centerline shift associated with the definition change, supporting the argument that bundle implementation contributed to a decline in CAUTIs.

Across a network of 128 participating children’s hospitals, we implemented CAUTI IBs and MBs similar to those used in adult populations. After the introduction of the SPS CAUTI prevention bundles, the CAUTI rate across the network decreased 61.6%, from 2.55 to 0.98 infections per 1000 CLDs.

We thank Melanie Miner from SPS for fulfilling some of the data requests and the caregivers from SPS network hospitals who shared best practices, implemented CAUTI bundles, submitted data, and spearheaded local QI efforts.

Dr Foster contributed to the study design, participated in the catheter-associated urinary tract infection (CAUTI) engagement efforts and interpretation of data, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Ackerman and Ms Wenthe contributed to the study design, participated in the CAUTI engagement efforts and interpretation of data, helped draft the initial manuscript, and reviewed and revised the manuscript; Drs Hupertz and Sanders contributed to the study design, participated in the CAUTI engagement efforts, and reviewed and revised the manuscript; Ms Mustin and Ms Sisson helped design the study, coordinated CAUTI engagement efforts, maintained the database, performed statistical analyses, and contributed to and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Supported by contract HHSM-500-2016-00073C, entitled “Partnership for Patients Hospital Improvement Innovation Network,” sponsored by the Centers for Medicare and Medicaid Services, Department of Health and Human Services.

     
  • CAUTI

    catheter-associated urinary tract infection

  •  
  • CDC

    Centers for Disease Control and Prevention

  •  
  • CLD

    catheter-line day

  •  
  • IB

    insertion bundle

  •  
  • MB

    maintenance bundle

  •  
  • NHSN

    National Healthcare Safety Network

  •  
  • QI

    quality improvement

  •  
  • SPS

    Children’s Hospitals’ Solutions for Patient Safety

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data