Appendix J. Long-Term Care CAUTI Surveillance Worksheet
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
The purpose of the Long-Term Care CAUTI Surveillance Worksheet is to use it to streamline the surveillance process with reviewing a resident's chart for a suspected catheter-associated urinary tract infection (CAUTI). The form combines the resident's health assessment and laboratory findings, and gives direction if the infection episode meets NHSN criteria. The infection preventionist or other designated staff person can review the chart and compare if the documentation meets, or doesn't meet, the National Healthcare Safety Network (NHSN) criteria.
Long-Term Care Catheter-Associated Urinary Tract Infection (CAUTI) Surveillance Worksheet
The Long-Term Care (LTC) Catheter-Associated Urinary Tract Infection (CAUTI) Surveillance Worksheet is a tool that was created to streamline the surveillance process when reviewing a resident's chart for a suspected CAUTI. The infection preventionist can review the chart and determine if the documentation meets or doesn't meet the National Healthcare Safety Network (NHSN) criteria, by checking "yes" or "no". The form combines the resident's health assessment and laboratory findings, and gives direction if the infection episode meets NHSN criteria.
The "Notes" column can be used to help document the chart source. For example, the date and time of a fever can be recorded in this column. Additionally, the urine culture results can also be added.
- Symptomatic CAUTI occurs in a resident while having an indwelling urinary catheter in place or removed within the 2 calendar days prior to the event onset (day of removal=Day 1)
- An indwelling urinary catheter should be in place for a minimum of 2 calendar days (Day 1=day of insertion) in order for the symptomatic UTI to be catheter-associated.
Detailed CAUTI protocol is available on the CDC/NHSN Web site.
LTC CAUTI Surveillance Worksheet
Resident Name: _________________________
Date of Catheter Insertion: ________________
MR #: ____________________
Room/Unit #: ____________________
Reason for Catheter Insertion: ____________________
|1 or more of the following signs and symptoms, and laboratory and diagnostic testing:||YES||NO||Notes|
|Fever (single temperate >100°F or >99°F on repeated occasions, or >2°F over baseline); can be used to meet CAUTI criteria even if the resident has another possible cause for the fever (e.g., pneumonia)||☐||☐|
|Rigors (shaking chills)||☐||☐|
|New onset hypotension with no alternate non-infectious cause||☐||☐|
|New onset confusion/functional decline with no alternate diagnosis
Leukocytosis (>14,000 cells/mm3 or Left Shift with >6% or >1,500 bands/mm3)
|New onset costovertebral angle pain or tenderness||☐||☐|
|New or marked increase in suprapubic tenderness||☐||☐|
|Acute pain, swelling or tenderness of the testes, epididymis, or prostate||☐||☐|
|Purulent discharge (pus) from around the catheter||☐||☐|
|Any of the following:|
|If indwelling urinary catheter (IUC) removed within last 2 calendar days:||YES||NO||Notes|
|Specimen collected from clean catch voided urine and positive culture with no more than 2 species of microorganisms1 —at least one of which is bacteria of ≥105 CFU/ml||☐||☐|
|Specimen collected from in/out straight catheter and positive culture with any microorganisms—at least one of which is bacteria ≥102 CFU/ml||☐||☐|
|If urinary catheter in place:|
|Specimen collected from an IUC2 and positive culture with any microorganism—at least one of which is bacteria of ≥105 CFU/ml||☐||☐|
1Yeast and other microorganisms, which are not bacteria, are not NHSN acceptable UTI pathogens.
2An IUC in place for >14 days should be changed prior to specimen collection, but failure to change it does not exclude a UTI for surveillance purposes.
Page originally created March 2017