The collection and reporting of data is an effective means of first engaging unit staff and physicians in CAUTI prevention programs, providing feedback to teams on how they are doing and sustaining improvement. The first goal of measurement is to determine the efficacy of each intervention. The later goal of measurement is to watch outcome trends to recognize when thresholds of concern are reached that require intervention. If a unit’s CAUTI rate suddenly spikes, an investigation of causes is required when thresholds have been passed. This investigation will include increased process measurement looking for causes for increased infections, (e.g., audits of appropriateness of catheter use, frequency of documented maintenance care such as perineal care, and observations of insertions to validate aseptic technique is used). When the cause of increased CAUTIs is identified, the team will need to work with frontline staff to identify workable solutions to prevent those causes. By continued assessment of process measures and outcome measures, such as CAUTI rate, the effectiveness of the solutions employed can be assessed.
Measuring Culture
The AHRQ Hospital Survey on Patient Safety Culture (HSOPS) can be used to track changes in patient safety culture over time and evaluate the impact of patient safety interventions. The survey should be administered at intervals of no less than 1 year. The survey is anonymous, with no individual staff identifiers. Using the survey results to identify opportunities for improvement allows a team to make specific action plans to address where staff perceptions indicate patient safety culture is not optimal. Administering the survey at least twice allows teams to measure effectiveness of their interventions to improve dimensions of the unit’s safety culture. CUSP can be used to actively strengthen safety culture in participating units. CUSP materials are available on the AHRQ Web site.
Process Measures
The prolonged use of indwelling urinary catheters is a significant risk factor for CAUTI. Catheters should be placed only when appropriate indications are present, and catheters that are no longer needed should be discontinued immediately. Track appropriateness and prevalence of catheter use.
Catheter appropriateness and prevalence can be tracked through daily rounding. Assess each patient on the unit for the presence of a urinary catheter, and record the indication for each catheter. Collect a daily prevalence rate by dividing the number of catheterized patients on your unit by the total number of patients.
As teams evaluate the causes of CAUTI on their unit, other process measures can be identified and collected to assess improvement in prevention of those causes. Some other process measures that can be collected as necessary include but are not limited to: number of staff who insert catheters whose competency has been validated, audits of aseptic insertion compliance, and maintenance measures followed (e.g., urinary drainage bag positioned below the patient’s bladder and off the floor, drainage bag tubing without kinks and loops, etc.).
Outcome Measures
Identify the number of symptomatic CAUTIs attributable to your unit for each month. By using the National Healthcare Safety Network (NHSN)/CDC’s definition of symptomatic CAUTI to identify and count cases on the unit, the team will be able to use NHSN data for benchmarking purposes.34 Comparing your unit’s CAUTI rate with other units of the same patient type and acuity gives the team “apples to apples” information about how their patient outcomes compare to other units.
CAUTI rate is one way to measure the outcomes of the care of patients’ urinary needs on your unit. This is an important metric used by unit and hospital leaders, the Centers for Medicare & Medicaid Services, The Joint Commission, and other regulators to assess the care your staff provide. Documenting the interventions employed by the unit on a graph of the catheter utilization or the CAUTI rate allows the team to visualize the effects of their interventions.
Another metric that can be measured is days since last CAUTI. This metric is very good for engaging frontline staff in your unit in measuring their perception of project success. Post this metric in the nursing station of your unit or on a hallway bulletin board. As the number of days since last CAUTI increases, staff attention and ownership of that success also increase. Frontline staff will have daily information about how well they are doing to prevent this patient harm. When the number of days suddenly goes down to zero when a new case of CAUTI is identified, the staff are more likely to take note and become interested in knowing what happened, who got the infection, and if there was anything they could have done to prevent it. This is a good time to perform an analysis of the case with those staff members involved directly in this patient’s care in the 2–3 days before the day the patient’s CAUTI symptoms began. Using the knowledge of those who cared for the patient just before their symptoms began improves understanding of any risks that occurred that may have been related to the cause of the infection. Involve those same staff members in brainstorming ways those risks may have been mitigated. Collate the findings of each CAUTI case analysis to determine the most frequent causes of CAUTIs on your unit, and work with the entire unit’s staff to brainstorm solutions to prevent those causes.
Tool
Appendix P. Interpreting CAUTI Data Trends Tool
This tool presents suggested questions and action items in response to different trends in teams’ data submission rates and process and outcome data.
