EBP Question and Literature Search Assignment: Appraising 3 Primary Studies on Nurse-Driven Catheter Removal and CAUTI

EBP question, literature search and appraisal of three primary studies

Develop an EBP question guided by the Question Development Tool (Appendix B; Dearholt & Dang, 2017), then use the question to conduct a literature search. Gather a minimum of 3 primary research study articles (NOT literature reviews, systematic reviews or meta-analyses). A primary research study includes collection of either qualitative or quantitative data. Organize the assignment in 5 parts:

1. Title Page
2. Practice question
3. Develop and implement a search strategy (save and include the search parameters)
4. Appraise 3 articles: (1) level of evidence (I–V) using the Johns Hopkins toolkit; (2) study design (experimental, quasi-experimental, non-experimental) with explanation and type of data (qualitative, quantitative, mixed methods); (3) critique using the ANA Framework for How to Read and Critique a Research Study
5. Reference list in APA format

Appendix B Question Development Tool items: (1) What is the problem? (2) Why is it important? (3) Current practice (4) How was the problem identified? (5) PICO (6) Initial EBP question, background or foreground (7) Search terms, databases, strategies (8) Evidence to gather (9) Revised EBP question (10) Outcome measurement plan.

ANA critique framework: (1) critique title, abstract, introduction, problem, purpose, research questions, theoretical framework, literature review, methods, analysis, results, discussion, limitations, conclusion; (2) determine level and quality of evidence; (3) decide if the study is applicable to your practice.

Original example for study purposes. Unit data are shown as bracketed placeholders; insert your own unit’s numbers.

A. Title Page

Nurse-Driven Urinary Catheter Removal Protocols and Catheter-Associated Urinary Tract Infection: An Evidence-Based Practice Question and Appraisal
[Student Name]
[University, School of Nursing]
[Course Number and Name]
[Instructor]
[Date]

B. Practice Question (Appendix B Question Development Tool)

C. Search Strategy

D. Appraisal of Three Primary Studies

Article 1: Kamel et al. (2025)

Summary. At a 160-bed Veterans Affairs hospital in Colorado, the team implemented the HOUDINI nurse-driven protocol, which lets nurses remove catheters without a physician order when no approved indication exists, on three acute medical-surgical wards, using Lean Six Sigma methods, staff education and a near-real-time catheter dashboard. Over 40 months (9,024 catheter days), CAUTIs fell from 3 in the 12-month pre-period to 1 in the 17-month post-period (0.99 to 0.27 per 1,000 catheter days), and the device utilization ratio fell from 14% to 12%. Nurses used the protocol for 73% of catheter orders. Interrupted time-series changes were not statistically significant (p = .08–.28).

1. Level of evidence: Level II. The researchers introduced an intervention but did not randomize or use a concurrent control group, which meets the Johns Hopkins definition of quasi-experimental research. Quality: B (good): clear methods and NHSN definitions, but a single site and very few events.
2. Design: quasi-experimental (pre/post with interrupted time-series analysis), described by the authors as a pre/postintervention observational quality improvement study. Data are quantitative (infection rates, catheter days, ratios).
3. ANA critique:
   • Title, abstract and introduction: accurate and representative; the purpose (evaluate a nurse-driven protocol and dashboard) is clear.
   • Problem and purpose: CAUTI burden and catheter overuse are well introduced.
   • Research question and framework: aims are stated, but no formal research question or nursing theory; Lean Six Sigma serves as an improvement framework. A theory of behavior change would strengthen it.
   • Literature review: relevant and current, supporting nurse-driven protocols.
   • Methods: design fits a real-world implementation, and NHSN definitions support validity. Excluding ICU and surgical patients limits the sample.
   • Analysis and results: time-series analysis is appropriate; results are clearly presented, but small counts make rates unstable.
   • Discussion, limitations and conclusion: the authors acknowledge single-site design, low power and co-interventions, and they appropriately call the findings preliminary.

Applicability: Highly applicable. The HOUDINI criteria, education approach and dashboard could be adopted on our medical-surgical unit, and nurse uptake (73%) shows feasibility.

Article 2: Liu et al. (2025)

Summary. In the ICU of a large tertiary hospital in Wuhan, China, a nurse-led multidisciplinary team applied a Management by Objectives (MBO) framework to CAUTI prevention, setting patient, nurse and environment goals, with three months of standardized training, spot checks and weekly feedback. Compared with a 2021 historical control group (n = 484), two intervention years (n = 1,122) showed reductions in catheter indwelling rate (78.8% to 70.8%, p < .05), improved bundle compliance (95.0% to 98.1%) and shorter ICU stay. CAUTI incidence fell from 0.41% to 0.19%, but the difference was not statistically significant, with only five CAUTIs in total.

1. Level of evidence: Level II. An intervention was implemented without randomization, using a historical comparison group. Quality: B (good): large sample, ethics approval and stated hypothesis, but a single center, historical controls and some internal inconsistencies in reported outcomes.
2. Design: quasi-experimental (pre/post with historical control). Data are quantitative (rates, compliance percentages, length of stay).
3. ANA critique:
   • Title and abstract: accurate; the abstract presents the outcomes somewhat more favorably than the nonsignificant CAUTI result.
   • Problem, purpose and hypothesis: clearly stated.
   • Theoretical framework: MBO is described and guides the intervention.
   • Literature review: summarizes CAUTI and MBO evidence but does not describe a structured search.
   • Methods: good sample size and standardized surveillance data; historical controls introduce time bias, and no validated instruments are reported for compliance measures.
   • Analysis and results: chi-square and t-tests are appropriate; tables are clear, but there are discrepancies between sections (for example, prognosis outcomes).
   • Discussion, limitations and conclusion: authors acknowledge single site, historical controls and few events, and call for multicenter studies.

Applicability: Moderately applicable. The goal-setting, training and feedback structure could support our protocol rollout, but the ICU setting and the Chinese health system limit direct transfer to a U.S. medical-surgical unit.

Article 3: Backman et al. (2022)

Summary. At a large Canadian academic health science centre, researchers evaluated a CAUTI protocol aimed at reducing unnecessary catheter use. Phase 1 audited all catheterized inpatients on four units before and after implementation (n = 99 pre, n = 99 post); CAUTI prevalence fell from 18.2% to 14.1%, not statistically significant (p = .563). Phase 2 used semistructured interviews with 18 staff members, analyzed with a theory-based approach, and identified 13 barriers and 19 enablers to implementation.

1. Level of evidence: Level II. The quantitative component is a one-group pretest-posttest (quasi-experimental) evaluation, and Johns Hopkins rates mixed methods studies by their highest-level quantitative component. Quality: C (low) for effectiveness because of the small sample and nonsignificant results, though the qualitative findings are valuable for implementation planning.
2. Design: quasi-experimental with a qualitative process evaluation. Data are mixed methods: quantitative audit data and qualitative interview data.
3. ANA critique:
   • Title and abstract: clearly identify the design and both phases.
   • Problem and purpose: unnecessary catheter use and CAUTI are well justified.
   • Theoretical framework: a theory-based process evaluation is a strength because it explains why implementation succeeded or struggled.
   • Methods: no control group and descriptive analysis limit causal conclusions; interviews add depth.
   • Results: clearly reported; the lack of significance is acknowledged.
   • Discussion and conclusion: barriers and enablers translate into practical recommendations for nurses and leaders.

Applicability: Useful for planning. The barriers and enablers can guide our education, leadership support and workflow design before launching a nurse-driven protocol.

Synthesis

All three studies are Level II with good-to-low quality. Each shows reductions in catheter use or CAUTI after nurse-led protocols, but none reached statistical significance for CAUTI because infections are rare events in single-site studies. Together with clinical practice guidelines, the evidence is consistent but not conclusive, supporting a pilot of a nurse-driven removal protocol on our unit with careful outcome measurement.

E. References

Backman, C., Wooller, K. R., Hasimja-Saraqini, D., Demery Varin, M., Crick, M., Cho-Young, D., Freeman, L., Delaney, L., & Squires, J. E. (2022). Intervention to reduce unnecessary urinary catheter use in a large academic health science centre: A one-group, pretest, posttest study with a theory-based process evaluation. Nursing Open, 9(2), 1432–1444. https://doi.org/10.1002/nop2.920

Dearholt, S. L., & Dang, D. (2017). Johns Hopkins nursing evidence-based practice: Model and guidelines (3rd ed.). Sigma Theta Tau International.

Kamel, M., Harris, N., Berry, A., Warsavage, T., Bessesen, M. T., & Kon, S. E. (2025). Implementation of a nurse-driven protocol for indwelling urinary catheter removal and novel utilization dashboard: A pre/postintervention observational study. Therapeutic Advances in Infectious Disease, 12. https://doi.org/10.1177/20499361251317900

Liu, K., Xiao, Q., Luo, D., Yang, Y., Peng, W., Zou, D., Jiang, M., & Xiong, J. (2025). Evaluating nursing interventions to prevent catheter-associated urinary tract infection in ICU patients: A quasi-experimental study. BMC Nursing, 24, Article 1460. https://doi.org/10.1186/s12912-025-04093-7