留置導尿管相關泌尿道感染佔院內感染40%，造成病人生理不適、住院天數及死亡率增加。單位2012年第一季留置導尿管相關泌尿道感染密度5.32‰，高於TCPI同儕2011年平均3.52‰。專案小組採實際觀察法調查單位留置導尿管相關泌尿道感染高的原因，並依據原因擬定實施改善措施為更換病床尿袋懸掛位置、製作倒尿六步驟宣導海報、舉辦在職教育、培育洗手種子教師並進行洗手稽核、制定留置導尿管組合式照護及稽核留置導尿管組合式照護完整率。專案實施後單位留置導尿管相關泌尿道感染密度降為2.75‰，達專案改善目的的3.00‰。藉由本專案推動組合式照護可降低留置導尿管相關泌尿道感染，提升醫療照護品質。

The Catheter-Associated Urinary Tract Infection (CAUTI) accounted for 40% of all nosocomical infections in our hospital. CAUTI can lead to physical discomfort to the patients, prolonged hospital stay and increased mortality. The rate of CAUTI was 5.32% at our unit in the first quarter of 2012, higher than the average rate of 3.52% of TCPI (To Complete Performance Index) in 2011. An observational study was conducted to investigate the causes of high CAUTI rate. The approaches to reduce CAUTI rate according to the analyzed results consisted of providing a space to hang urine bag beside the bed, preparing a poster to disseminate the six steps of draining urine, holding courses of in-job training, cultivating the seed teachers for hand hygiene, auditing the process of hand hygiene, developing the Bundle care for CAUTI, and inspecting the implementing rate of Bundle care for CATUI. After the implementation of this study, the CAUTI rate was decreased to 2.75%, lower than the targeted 3% for this project. This study provides an experience of implementing Bundle care to successfully reduce the CAUTI rate and improve the quality of care.