National Content Series Facilitator’s Guide

AHRQ Safety Program for Long-Term Care: HAIs/CAUTI

The Culture of Culturing: The Importance of Knowing When to Order Urine Cultures

Facilitator Instructions

This educational module provides staff two ways to practice using SBAR (situation-background-assessment-recommendation) to effectively communicate resident care and when to order urine cultures.

  1. Scripted Role-Play and Guided Discussion

    This activity is a scripted role-play and guided discussion. Facilitators may opt to perform the role-play themselves or recruit staff volunteers to assist them. Begin by setting the scene for staff; read Mrs. Mullin's scenario and introduce who will play Dr. Killbug and Nurse Nohai. Perform the "Ineffective Communication Role-Play" and have staff complete the corresponding discussion questions or guide staff through these questions orally. See the facilitator notes below for talking points. Next perform the "Effective Communication Role-Play." After the role-play, lead a discussion with staff using the discussion questions and/or worksheet provided below.

    Suggested props:

    • C.A.U.T.I. Infographic.
    • NSHN Definitions CAUTI Criteria Pocket Card.
  2. Using Resident Scenarios to Practice SBAR

    This activity provides staff an opportunity to practice constructing their own SBAR communication. Staff can work individually, in partners, or in small groups to work through two fictional resident scenarios. Based on the information provided in the scenarios, staff determine next steps for the residents' care and construct an SBAR to effectively communicate their recommendations to a physician. Move between groups and provide any needed guidance or suggestions; talking points are provided. Ask for volunteers to share their SBAR with the group and lead a discussion in a nonpunitive manner.

Scripted Role-Play and Discussion Guide

Scenario

Mrs. Mullins, a resident of Sunny Terrace Long-Term Care, has just been transferred back from a stay in the hospital. She was admitted 7 days ago for acute abdominal pain, which proved to be appendicitis. She had a successful operation, but developed a Clostridium difficile infection postoperatively. When she initially went into the hospital, she was voiding spontaneously; now she has an indwelling urinary catheter. The urine in the drainage bag and tubing looks cloudy, and some sediment is visible. Dr. Killbug stops by her room and notices the urine. He then approaches Nurse Nohai at the nurses' station.

Ineffective Communication Role-Play Script

Dr. Killbug: Did you see Mrs. Mullins’ urine? That looks pretty bad to me. I wish you had let me know about that urine sooner. Last thing we need is for her to get a urinary tract infection and end up back in the hospital again.
Nurse Nohai: [Defensive] It’s been an extremely busy day. I certainly don’t want her to get a UTI either. But what I was thinking was…
Dr. Killbug: [Cutting off Nurse Nohai] I thought we had increased staffing over this shift? Well look, let’s not lose any more time. I’m going to put her on Bactrim—can you get a urine culture now, before she starts antibiotics?
Nurse Nohai: It says right here on her chart that she’s allergic to Bactrim.
Dr. Killbug: Okay, let’s use Cipro then.
Nurse Nohai: [Sighing] That catheter is really bothering her. Can we take it out?
Dr. Killbug: Bladder pain! We definitely need to get her on some antibiotics.
Nurse Nohai: No, I didn’t mean bladder pain. I think it’s just pulling on her leg.
Dr. Killbug: You think she’s got leg pain? I really wish you would be more clear.
Nurse Nohai: Catheters just aren’t good for our patients. Could we take hers out and give her a voiding trial?
Dr. Killbug: Let’s treat this CAUTI first. We can think about catheter removal next week.
Nurse Nohai: Okay, I’ll go collect that urine culture.

Effective Communication Role-Play Script

Dr. Killbug: Did you see Mrs. Mullins' urine? That looks pretty bad to me. I wish you had let me know about that urine sooner. Last thing we need is for her to get a urinary tract infection and end up back in the hospital again.
Nurse Nohai: Actually, I was hoping to talk to you. I noticed that when she was transferred back from the hospital. She now has an indwelling urinary catheter in place. While her urine is cloudy, she is still doing well without any symptoms of UTI. She does want the catheter out, as it is tugging on her leg. (SITUATION)
Dr. Killbug: Yeah, but she's probably pretty weak now. Yes, but I'd still like to send a urine culture. Who knows what's in her urine now. I'm going to put her on Bactrim, once you get that culture.
Nurse Nohai: I believe she had an allergic reaction to Bactrim in the past—yep, says here in her chart, “rash.”
Dr. Killbug: Okay, I';ll use Cipro then.
Nurse Nohai: I see, but getting back to the catheter, there is no indication provided for it. She has never needed a catheter previously. We are participating in the LTC-HAIs/CAUTI project, and one of the key steps to preventing CAUTI is to remove urinary catheters unless they are medically indicated. (BACKGROUND)
Dr. Killbug: Yes, that is a good point you are making. But, how do you think she is doing today?
Nurse Nohai: On my assessment, Mrs. Mullins does not meet any of the indications for a catheter, per the documentation from the hospital, nor does she need further testing of her urine; however, she might be a little dehydrated today, which might account for her cloudy urine. (ASSESSMENT)
Dr. Killbug: Great, do you think we should get the catheter out?
Nurse Nohai: Yes, I'd like to remove it and give her a voiding trial. If that's OK with you, I'll take it out and let you know how that goes. And let's hold off on the urine culture and antibiotics. I'll keep a close eye on her this shift. If anything seems out of the ordinary with her recovery, I'll call you. (RECOMMENDATION)
Dr. Killbug: That sounds like a good plan. Where can I get more info about this CAUTI AHRQ project?

Discussion Questions About the Ineffective Role-Play

1. What went wrong during this interaction between Nurse Nohai and Dr. Killbug?

Possible Answers:

  • A mutual lack of respect between Nurse Nohai and Dr. Killbug.
  • Both seemed to be blaming the other for lapses in Mrs. Mullins' care.
  • Did not assess if the catheter was necessary. Remember the C.A.U.T.I. mnemonic; it's important to remove catheters that are not clinically indicated as soon as possible.
  • The interaction led to a urine culture being ordered for Mrs. Mullins even though she did not have the appropriate signs and symptoms of a CAUTI. The cloudy color of her urine could be caused by asymptomatic bacteriuria, changes in her medication, dehydration, etc.

2. What could Dr. Killbug have done differently?

Possible Answers:

  • Not start the conversation in an accusatory manner.
  • Not interrupt Nurse Nohai.
  • Review the National Healthcare Safety Network CAUTI criteria pocket cards.
  • Slow down and listen to the information being provided.
  • Assess Mrs. Mullins' urinary-specific symptoms before ordering a urine culture.

3. What could Nurse Nohai have done differently?

Possible Answers:

  • Not be defensive.
  • Not make excuses.
  • Be clearer with communication.
  • Be more specific about Mrs. Mullins' current state and case history.
  • Not give up if she knows something is wrong with the resident.

Discussion Questions About the Effective Role-Play

1. How was this interaction between Nurse Nohai and Dr. Killbug a more effective conversation?

Possible Answers:

  • Nurse Nohai used SBAR.
  • Dr. Killbug didn't interrupt Nurse Nohai.
  • Both people seemed more respectful of the other.
  • Dr. Killbug was more open-minded and seemed to listen to Nurse Nohai's assessment.
  • Nurse Nohai presented the situation more clearly; she provided clear rational for the recommendation.
  • Nurse Nohai wasn't defensive.

2. Nurse Nohai used SBAR to improve communication with Dr. Killbug. Identify the SBAR elements of Nurse Nohai's communication using the following prompts:

  • Situation – What is going on with the resident?
    Possible Answer: "Mrs. Mullins was transferred back from the hospital. She now has an indwelling urinary catheter in place. While her urine is cloudy, she is still doing well without any symptoms of UTI. She does want the catheter out, as it is tugging on her leg."
  • Background – What is the clinical background or context?
    Possible Answer: "Getting back to the catheter, there is no indication provided for it. She has never needed a catheter previously. We are participating in the LTC-HAIs/CAUTI project, and one of the key steps to preventing CAUTI is to remove urinary catheters unless they are medically indicated."
  • Assessment – What did Nurse Nohai think was the problem?
    Possible Answer: "On my assessment, Mrs. Mullins does not meet any of the indications for a catheter, per the documentation from the hospital, nor does she need further testing of her urine; however, she might be a little dehydrated today, which might account for her cloudy urine."
  • Recommendation – What was Nurse Nohai's recommendation for Mrs. Mullins' care?
    Possible Answer: "I'd like to remove it and give her a voiding trial. If that's OK with you, I'll take it out and let you know how that goes. And let's hold off on the urine culture and antibiotics. I'll keep a close eye on her this shift. If anything seems out of the ordinary with her recovery, I'll call you."

Practicing SBAR Using Case Scenarios

Scenario Instructions: Work individually, with partners, or in small groups to determine the appropriate next steps for Mr. Bell's and Ms. Colbert's cases. Craft SBAR scripts a nurse could use to explain to a physician the next steps for both residents' care.

Scenario 1

Mr. Bell is an 85-year-old resident with dementia who has a chronic indwelling urinary catheter. Mr. Bell does not usually have a problem getting around, but he fell three times in the past week. Today the certified nursing assistant (CNA) notices that his urine bag is cloudy.

Possible Answers/Guidance:

  • SBAR
    Situation: What is currently going on with Mr. Bell?
    Background: What is the clinical background or context?
    Assessment: What do you think the problem is?
    Recommendation: What would you recommend?
  • Inappropriate Recommendations:
    • Ordering a urine culture. Based on the information available it would not be advisable to order a urine culture. Mr. Bell has a chronic indwelling urinary catheter, so we know he will have bacteria in his urine. Ordering a urine culture will not help decipher between a CAUTI and asymptomatic bacteriuria and may lead to unnecessary antibiotic use and mask an underlying condition.
  • Appropriate Recommendations:
    • Change the catheter bag.
    • Conduct a fall evaluation of Mr. Bell.
    • Assess Mr. Bell's condition more closely, paying close attention for CAUTI-specific signs and symptoms (e.g., new onset confusion or new onset functional decline with increased leukocytosis) that may be associated with his difficult mobility.
    • Monitor fluids.
    • Assess medication to see if that could be contributing to cloudy urine.

Scenario 2

Ms. Colbert is a 75-year-old female with neurogenic bladder. She has a chronic indwelling urinary catheter to help manage her condition. She has refused to eat her last two meals. It's Friday at 4 p.m., and the nurse knows the doctor is extremely difficult to reach on the weekend.

Possible Answers/Guidance:

  • SBAR
    Situation: What is currently going on with Ms. Colbert?
    Background: What is the clinical background or context?
    Assessment: What do you think the problem is?
    Recommendation: What would you recommend?
  • Inappropriate Recommendations:
    • Ordering a urine culture. Based on the information available it would not be advisable to order a urine culture. Ms. Colbert has a chronic indwelling urinary catheter, so we know she will have bacteria in her urine. Ordering a urine culture will not help decipher between a CAUTI and asymptomatic bacteriuria and may lead to unnecessary antibiotic use and mask an underlying condition.
  • Appropriate Recommendations:
    • Assess Ms. Colbert's condition more closely, paying close attention for CAUTI-specific signs and symptoms (e.g., new onset confusion or new onset functional decline with increased leukocytosis) that may be associated with her decreased appetite.
    • Monitor her fluids.
    • Assess for incontinence because she may stop eating to avoid having an accident.
    • Request Ms. Colbert's favorite staff assists with her care management over the weekend.
Page last reviewed May 2017
Page originally created March 2017
Internet Citation: National Content Series Facilitator’s Guide. Content last reviewed May 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementaion/education-bundles/urine-culturing/whento-order/role-play.html