The Next Step in Eliminating CAUTI:The Leading Cause of Avoidable Patient Harm

The Next Step in Eliminating CAUTI:
The Leading Cause of Avoidable Patient Harm

About 30 million Foley catheters are inserted each year, leading to nearly 1 million catheter-associated urinary tract infections (CAUTIs). These infections are the most commonly reported hospital-acquired condition (HAC). Shockingly, studies regularly find that as many as 50% of patients’ indwelling catheters are unnecessary and should not have been ordered, and even properly ordered catheters result in many infections that are avoidable if guidelines are strictly followed.

Rates for every kind of hospital acquired infection (HAI) were reduced between 2009 and 2014—except CAUTI. Despite all efforts, CAUTI has been resistant to improvement.

A major US health system employed the Amplifire training tool to acquire data on what its nurses knew and didn’t know about managing urinary catheters, and to find and fix any misinformation. Could the nurses identify when catheterization is indicated? Did they know how catheterization tubing and equipment should be handled? Were they confident in their knowledge? Was their confidence justified?

Knowledge and Confidence About CAUTI:
Before and After Amplifire


  • 25,826 instances of CHM found and fixed
  • 23,752 instances of uncertainty found and fixed
  • The variation of CAUTI knowledge was high, with some nurses extremely misinformed and others showing confident mastery of the topic.
  • Nurses who were most misinformed spent almost half an hour in the module, while nurses who were most knowledgeable about CAUTI spent only 11 minutes.
  • By the end of the course, 100% of the nurses who completed were confident and correct on all the information.

Confidently Held Misinformation and Implications

Amplifire discovered a significant amount of confidently held misinformation (CHM) around urinary catheters when it came to equipment maintenance, catheterization and incontinence and antimicrobial stewardship.

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