ALISO VIEJO, Calif. - Aug. 5, 2025 – An initiative at an Atlanta children’s hospital effectively addressed gaps in traditional strategies to prevent catheter-associated urinary tract infections (CAUTIs) in its pediatric intensive care unit (PICU), leading to a sustained rate of zero CAUTIs for more than a year.
CAUTIs are one of the most common types of healthcare-associated infections for both adult and pediatric patients, contributing to longer hospital stays, increased morbidity and mortality, and higher costs of care. National guidelines for prevention are based largely on data from adult populations, with limited pediatric-specific strategies.
“Entering a No Diaper Zone: Rethinking Prevention of Catheter-Associated Urinary Tract Infection” details how an interprofessional task force integrated targeted interventions with established practices to address persistent CAUTI challenges in the 56-bed PICU at Children’s Healthcare of Atlanta. The study is published in Critical Care Nurse (CCN).
Prior to the initiative, in 2020, the baseline CAUTI rate in the PICU was 3.13 per 1,000 catheter days, with a total of four events and an average of 92 days between events. Within the first post-intervention year, the CAUTI rate decreased by 22% to 2.44 per 1,000 catheter days, with an average of 129 days between events. At the end of the four-year reporting period included in the study, in 2023, the PICU achieved a rate of 0 per 1,000 catheter days, with 527 event-free days that began in July 2022.
Co-author Kathryn Cabral, BSN, RN, CCRN, is a critical care nurse and a clinical patient safety coordinator in the quality department at Children’s Healthcare of Atlanta.
“Our No Diaper Zone intervention tackled an aspect of CAUTI prevention not commonly discussed in existing guidelines,” she said. “With limited direct evidence available, we focused on addressing plausible pathways for urinary catheters to become contaminated with stool or urinary backflow.”
During huddles to review the specifics of individual CAUTI cases, the task force identified a pattern of documented liquid stool occurrences among patients with CAUTI, leading to the hypothesis that catheter contamination from stool was contributing to infection rates. As a result, the members proposed the complete removal of diapers for PICU patients with indwelling urinary catheters, which became known as the No Diaper Zone.
The initial intervention began with ceasing diaper use for patients with indwelling urinary catheters and placing them on highly absorbent pads instead. Nurses monitored for the presence of stool every two hours during vital sign checks and position changes, which enabled prompt recognition and cleaning, and reduced prolonged exposure.
Urine output monitoring was also improved for patients with urinary catheters in place for more than 72 hours, a known CAUTI risk factor. The traditional gravity-dependent urine collection bags were replaced with a more advanced system that uses gentle suction and three one-way valves to maintain continuous urine flow and prevent urinary reflux. The system also has integrated sensors that provide accurate hourly urine output data on an easy-to-read digital display. After a trial period, the new monitoring system from Accuryn was implemented in the PICU, as well as in the cardiac ICU and operating room.
The changes were accompanied by educating clinical staff and parents about CAUTI prevention strategies. Weekly infection prevention rounds at the bedside provided ongoing opportunities for real-time teaching and hands-on demonstration of proper technique. New staff members received information about the No Diaper Zone and CAUTI prevention efforts during orientation. Parent education emphasized a collaborative approach to discontinuing diaper use in the presence of urinary catheters and the importance of reducing contamination risks.
As AACN’s bimonthly clinical practice journal for acute and critical care nurses, CCN is a trusted source of information related to the bedside care of critically and acutely ill patients. Access the article abstract and full-text PDF by visiting the CCN website at http://ccn.aacnjournals.org.
About Critical Care Nurse: Critical Care Nurse (CCN), a bimonthly clinical practice journal published by the American Association of Critical-Care Nurses, provides current, relevant and useful information about the bedside care of critically and acutely ill patients. The award-winning journal also offers columns on traditional and emerging issues across the spectrum of critical care, keeping critical care nurses informed on topics that affect their practice in acute, progressive and critical care settings. CCN enjoys a circulation of about 130,000 and can be accessed at http://ccn.aacnjournals.org.
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