Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide

Appendix O. CAUTI Event Report Template

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:
Page last reviewed October 2015
Page originally created October 2015
Internet Citation: Appendix O. CAUTI Event Report Template. Content last reviewed October 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-o.html