Minnesota Hospital Association


December 03, 2013

Hospital success story: Firstlight Health System

FirstLight Health System sought to implement a nurse-driven protocol to remove catheters when no longer necessary and engage staff to ensure they were removed in a timely manner, in an effort to reduce health care-associated infections.

Interventions applied:

  • Used evidence-based best practices to identify where catheters were appropriate as well as under what circumstances nurses should continue the use of a catheter.
  • Garnered physician support and approval of policy.
  • Changes were made to the electronic medical record to provide a hard stop requiring an approved reason to order a catheter.
  • Built in a daily reminder to nurses asking whether it was necessary to continue catheter.
  • Nurses document if catheter should continue. If patient does not meet criteria, nurse gets order to discontinue.
  • Conduct coordination of care meetings every morning and discuss patients with foley catheters and whether it’s necessary to continue.

Lessons learned:

It is important to balance the capacity of staff to engage in new improvement efforts. The infection prevention team at FirstLight was already well established, allowing this work to be a natural extension of their efforts.


  • FirstLight Health System has had only one CAUTI in each of the last two years.
  • Excellent implementation of best practice process measures:
    • HAI road map = 91.9%
    • CAUTI gap analysis= 93%
    • CLABSI gap analysis = 89%
    • SSI gap analysis = 100%