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

Purpose:

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.

Definitions:

  • 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.

References:

Adapted from Centers for Disease Control and Prevention (CDC), Urinary Tract Infection (UTI) Event protocol for Long-term Care Facilities (LTCF), January 2016.

Detailed CAUTI protocol is available on the CDC/NHSN Web site.

LTC CAUTI Surveillance Worksheet

Date: __________________________________

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
AND
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  

AND

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  

Signifies CAUTI

 


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 last reviewed March 2017
Page originally created March 2017
Internet Citation: Appendix J. Long-Term Care CAUTI Surveillance Worksheet. Content last reviewed March 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/cauti-surveillance/assessment.html