When a catheter-associated urinary tract infection (CAUTI) occurs on your unit, teams can use this tool, adapted from a report developed by the North Carolina Quality Center, to identify root causes.
| Patient | Medical Record Number | Admit Date |
|---|---|---|
| Diagnosis | Did the patient have diarrhea while the urinary catheter was present? | Infection Date and Criteria |
|---|---|---|
| Patient’s Location/Room No(s) and Occupancy Dates | Microorganism(s) Cultured Out | Credentials of Person Inserting Urinary Catheter |
|---|---|---|
| RN MD PA/NP APRN NA Other: |
| No. | Question | Response |
|---|---|---|
| 1 | Urinary catheter (UC) insertion (date, type, where inserted). Include all reinsertion information. | |
| 2 | Date UC removed | |
| 3 | Length of time UC was in (days): | |
| 4 | Number of days between UC insertion and first symptoms of a UTI: | |
| 5 | Was there a physician order for the Foley? | Yes: ______ No: ______ If no, please explain: |
| 6 | Were alternatives to UC considered and documented? | Yes: ______ No: ______ If no, please explain why: |
| 7 | If the patient experienced urinary retention, was the bladder scanning protocol followed prior to UC insertion/reinsertion? | Yes: ______ No: ______ If no, please explain why: |
| 8 | Did patient meet insertion criteria? | Yes: ______ No: ______ If no, please explain why UC inserted: |
| 9 | Was catheter secured per hospital policy? | Yes: ______ No: ______ If no, please explain why: |
| 10 | Was patient assessed daily for ongoing need for catheter, and did patient meet criteria to keep it in? | Yes: ______ No: ______ If no, please explain why: |
| 11 | Was the UC drainage system opened at any point during duration of catheterization? | Yes: ______ No: ______ If no, please explain: |
| 12 | Did the person who inserted the UC have documented competency to insert a UC? | Yes: ______ No: ______ If no, please explain why: |
| 13 | Was the UC drainage bag kept below bladder level at all times? | Yes: ______ No: ______ If no, please explain why: |
| 14 | Were there any problems with the UC equipment or supplies? | Yes: ______ No: ______ If no, please explain: |
| 15 | Was the patient transported between units/Radiology/OR/ED, etc.? | Yes: ______ No: ______ If no, please explain Foley drainage bag was transported: |
| 16 | Can each staff member involved in this patient’s care verbalize correct strategies to prevent CAUTI? | Yes: ______ No: ______ If no, please explain: |
| 17 | Was the patient and/or family engaged in preventing CAUTI? (Did they receive education on the Foley and things they could do to prevent infection?) | Yes: ______ No: ______ If no, please explain: |
| 18 | Are there any significant patient factors that may have contributed to this infection? | Yes: ______ No: ______ If no, please explain: |
| 19 | Did workload impact the provision of care? | Yes: ______ No: ______ If no, please explain: |
| 20 | Is the presence of a urinary catheter and date of insertion included on all transfer/shift report checklists/protocols? | Yes: ______ No: ______ If no, please explain: |
| 21 | Is there a standard sterile insertion tray available for use that contains a closed drainage system? | Yes: ______ No: ______ If no, please explain why: |
| 22 | What is hand hygiene compliance like for the units in which the patient stayed? | |
| 23 | Does each patient have an individual, clean container in which to empty the UC collection bag? | Yes: ______ No: ______ If no, please explain why: |
| 24 | Is there a nurse-driven protocol to promote catheter removal? | Yes: ______ No: ______ If no, please explain why: |
| 25 | If there is not a nurse-driven protocol to promote catheter removal, is there a standard daily reminder to the physician that the catheter is still in? | Yes: ______ No: ______ If no, please explain: |
| 26 | From the information collected, do you think this CAUTI was potentially avoidable? | Yes: ______ No: ______ Please explain response: |
