CAUTI Implementation Guide
Engagement of Leadership, Champions, and StaffFocus / Resource / Website
Senior Leadership / Engage the Senior Executive Module - Comprehensive Unit-based Safety Program (CUSP) Toolkit
Curriculum focused on the role and responsibilities of senior executives, from the Agency for Healthcare Research and Quality (AHRQ)
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CUSP Board Checklist Checklist of CUSP and CAUTI reduction activities for senior leadership, from the On the CUSP: Stop CAUTI Implementation Guide /
Unit-Level Leadership / Strategies and Tips for Nurse Engagement
Strategies to engage nurses as champions in CAUTI prevention, from catheterout.org
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Presentation to Nurse Manager & Case Manager (or Unit Champion)
Agenda for presentation to unit champion, from the On the CUSP: Stop CAUTI Implementation Guide /
CAUTI Team/Work Group / Implementation Team Roles and Responsibilities Summary of recommended personnel to engage for CAUTI reduction efforts, from catheterout.org
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Iowa CAUTI Prevention Collaborative Resource Manual, 2011
Chapter 2: Building Your Project (page 14), Chapter 3: Culture (page 32), Chapter 4: Teamwork and Communication (page 37)
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Health Research and Education Trust Eliminating Catheter-Associated Urinary Tract Infections, 2013 /
Staff Person With Dedicated Time / CAUTI Cost Calculator
Tool to engage leadership that estimates facility costs due to CAUTI, from catheterout.org
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CAUTI Nurse Champion / Presentation to Nurse Manager & Case Manager (or Unit Champion)
Agenda for presentation to unit champion, from the On the CUSP: Stop CAUTI Implementation Guide
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Strategies and Tips for Nurse Engagement
Strategies to engage nurses as champions in CAUTI prevention, from catheterout.org /
CAUTI Physician Champion / Strategies and Tips for Physician Engagement
Strategies to engage physicians as champions in CAUTI prevention, from catheterout.org
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AHRQ Resident Physicians as Champions in Preventing Device-Associated Infections - Focus on Reducing Catheter-Associated Urinary Tract Infections /
Staff Training
Focus / Resource / Website
Aseptic Insertion Technique / Overcoming Challenges to CAUTI Prevention
Training for caregivers emphasizing adherence to aseptic insertion, from Safe-Practices.org
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Streamlined Evidence-Based RN Tool
Nurse-driven indwelling urinary catheter tool, including insertion checklist and bladder scan protocol, from the American Nurses Association /
APIC Guide to Preventing Catheter-Associated Urinary Tract Infections, 2014 Section 1: Epidemiology and
Pathogenesis of Catheter-Associated
Urinary Tract Infections (page 7)
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Urinary Catheter Maintenance / CAUTI Prevention Training
Training module for CAUTI prevention, covering CAUTI risks and prevention, from Sharp HealthCare
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Bladder Ultrasound Scanners / Streamlined Evidence-Based RN Tool
Nurse-driven indwelling urinary catheter tool, including insertion checklist and bladder scan protocol, from the American Nurses Association /
Bladder Scan Policy and Checklist
Policy for use of bladder scanners, from the On the CUSP: Stop CAUTI Implementation Guide /
Drainage Bag Handling And Placement / Appropriate Urinary Catheter Use and Management Nursing Education
PowerPoint slide set on appropriate urinary catheter use and management, from catheterout.org /
Indications For Urine Culturing / CMS National Coverage Determination (NCD) for Urine Culture, Bacterial /
Competency Assessment
Focus / Resource / Website
Insertion Upon Hire & Annually / Streamlined Evidence-Based RN Tool
Nurse-driven indwelling urinary catheter tool, including insertion checklist, from the American Nurses Association
Urinary Catheter Insertion Checklist
Checklist of best practices for Foley insertion, reprinted by the Pennsylvania Patient Safety Authority with permission from Doylestown Hospital /
Maintenance Upon Hire & Annually / Strategies to Prevent CAUTI in Acute Care Hospitals: 2014 Update
Practical recommendations for CAUTI prevention for acute care hospitals, from The Society for Healthcare Epidemiology of America (SHEA) /
APIC Guide to Preventing Catheter-Associated Urinary Tract Infections, 2014 /
CAUTI Prevention Training
Training module for CAUTI prevention, covering CAUTI risks and prevention, from Sharp HealthCare /
Bladder Ultrasound Upon Hire & Annually / Streamlined Evidence-Based RN Tool
Nurse-driven indwelling urinary catheter tool, including insertion checklist and bladder scan protocol, from the American Nurses Association /
Bladder Scan Policy and Checklist
Policy for use of bladder scanners, from the On the CUSP: Stop CAUTI Implementation Guide /
Audits
Focus / Resource / Website
Indwelling Urinary Catheter Appropriateness / CAUTI Process Data Collection Tool
Data collection spreadsheet for indications for urinary catheter use, from the On the CUSP: Stop CAUTI Implementation Guide /
Emergency Department (ED) Intervention Urinary Catheter Data Collection Form
Checklist of appropriate indications for ED patients, from On the CUSP: Stop CAUTI Implementation Guide /
Metrics for ED Catheter Placement and Catheterization Rates
Calculations for inappropriately placed catheter rates in the ED, from the On the CUSP: Stop CAUTI Implementation Guide
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Appropriate Urinary Catheter Placement in the Emergency department, February 2012, AHRQ /
CDC Safe Healthcare Blog – Why So Many Foleys? Discussion of best practices for managing urinary catheters and reducing risk of CAUTI, guest author Wendy Kaler, MPH, CIC, Dignity Health /
Presentation of Data:
Use these presentations to educate nurse managers on CAUTI project goals, timeline and progress.
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Shadowing Another Professional Tool:
This easy-to-use tool provides a framework and guide for observing interactions and processes on the unit. Review this
tool before your shadowing experience to help you recognize
teamwork and communication issues among practice domainsthat are important to patient care. / - 15k - 2015-07-07
Indwelling Urinary Catheter Insertion Documentation / Hospital Infection Control Worksheet
Data collection tool (Section 4.A., pg. 28-30) for assessment of aseptic insertion and appropriate maintenance for surveyors, from the Centers for Medicare & Medicaid Services (CMS) /
Urinary Catheter Insertion Checklist
Checklist of best practices for Foley insertion, reprinted by the Pennsylvania Patient Safety Authority with permission from Doylestown Hospital
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Female Insertion Audit Checklist
Checklist of critical behaviors for use in auditing insertion practices in FEMALE urinary catheterization, reprinted by the Pennsylvania Patient Safety Authority with permission from Doylestown Hospital /
Male Insertion Audit Checklist
Checklist of critical behaviors for use in auditing insertion practices in MALE urinary catheterization, reprinted by the Pennsylvania Patient Safety Authority with permission from Doylestown Hospital
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Hospital Infection Control Worksheet
Data collection tool (Section 4.A., pg. 28-30) for assessment of aseptic insertion and appropriate maintenance for surveyors, from the Centers for Medicare & Medicaid Services (CMS) /
AHRQ Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Appendix B. Urinary Catheterization – Sample Policy /
CatheterMaintenance Procedures (E.G., Aseptic Sampling And Emptying, Keeping System Closed, Maintaining Unobstructed Urine Flow)? / Guide to Preventing CAUTI
Data collection tools for catheter appropriateness and insertion found on pg. 23 (Figure 2.2) and pg. 45 (Table 5.1), from the Association for Professionals in Infection Control and Epidemiology (APIC) / Resources_/EliminationGuideForm/0ff6ae59-0a3a-4640-97b5-eee38b8bed5b/File/CAUTI_06.pdf
Hospital Infection Control Worksheet
Data collection tool (Section 4.A., pg. 28-30) for assessment of aseptic insertion and appropriate maintenance for surveyors, from the Centers for Medicare & Medicaid Services (CMS) /
Streamlined Evidence-Based RN Tool
Nurse-driven indwelling urinary catheter tool, including CDC-recommended maintenance procedures (Box 2), from the American Nurses Association /
Iowa CAUTI Prevention Collaborative Resource Manual, 2011
Chapter 6: Prevention Strategies (page 60) /
CAUTI Prevention Training
Training module for CAUTI prevention covering risks and infection prevention, from Sharp HealthCare /
SHEA/IDSA Practice Recommendation Infection Control & Hospital Epidemiology / Volume 35 / Issue 05 / May 2014, pp 464-479 /
Indwelling Urinary Catheter Removal Documentation / Implementing a Nurse-Driven Protocol
Foley Catheter Practice Survey Tool (Figure 1, p. 18), from MedSurg Nursing
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Additional Resources / Centers for Medicare & Medicaid Services
Hospital Infection Control Worksheet with Module 4: Patient Traces page 28 /
AHRQ Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Appendix P. Interpreting CAUTI Data Trends
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AHRQ Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Appendix O. CAUTI Event Report Template /
Feedback of Data
Focus / Resource / Website
CAUTI Rates and/or SIR
Indwelling Urinary Catheter DUR / Urinary Catheter Initiative Results Letter
Form letter to present unit results of urinary catheter initiatives to senior staff, from the On the CUSP: Stop CAUTI Implementation Guide /
NHSN Catheter-Associated Urinary Tract Infections Rate, SIR, urinary catheter utilization ratio, and DUR /
APIC Guide to Preventing Catheter-Associated Urinary Tract Infections, 2014 Section 3: CAUTI Risk Assessment (page 25) /
APIC Guide to Preventing Catheter-Associated Urinary Tract Infections, 2014 Section 4: Definitions, Surveillance,
and Reporting (page 29) /
Indication / APIC Guide to Preventing Catheter-Associated Urinary Tract Infections, 2014 Foley Catheter Prevalence Sheet (page 39) /
The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method
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Indications For Insertion
Focus / Resource / Website
DoOrdering Providers Use Appropriate Indications? / Streamlined Evidence-Based RN Tool
Nurse-driven indwelling urinary catheter tool, including CDC criteria, insertion algorithm, and bladder scanner protocol, from the American Nurses Association /
CAUTI Process Data Collection Tool
Data collection spreadsheet for indications for urinary catheter use, from the On the CUSP: Stop CAUTI Implementation Guide /
The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method
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Nurses Alternative Strategies For Management Of Urinary Incontinence / Implementing a Nurse-Driven Protocol
Evaluation of nurse-driven catheter removal protocols in the acute care setting, from MedSurg Nursing /
Policy/Procedure for Perineal Care for the Incontinent Patient
Perineal care procedures as alternatives to catheterization for incontinent patients, from the Virginia Department of Health /
The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method
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Catheterization Alternatives Flyer
Flyer presenting best practices and alternatives to indwelling catheters (pg. 4), from the South Carolina Hospital Association
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Strategies to Prevent CAUTI in Acute Care Hospitals: 2014 Update
Practical recommendations for CAUTI prevention for acute care hospitals, including a catheter reminder/removal checklist (pg. 8), from The Society for Healthcare Epidemiology of America (SHEA) /
Catheterization. Indwelling catheters in adults: urethral and suprapubic from National Guideline Clearinghouse
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Bladder Ultrasound Scanners / Bladder Scan Policy and Checklist
Policy for use of bladder scanners, from the On the CUSP: Stop CAUTI Implementation Guide /
Streamlined Evidence-Based RN Tool
Nurse-driven indwelling urinary catheter tool, including CDC criteria, insertion algorithm, and bladder scanner protocol, from the American Nurses Association /
AHRQ Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Appendix C. Sample Bladder Scan Policy /
Educational Materials to The Patient and/or Family / Script for Patient/Family Requests for Non-Medically Indicated Urinary Catheters
Information to educate patients on urinary catheter risks and alternatives, from catheterout.org /
Patient Education Brochure – What to Expect: Urinary Catheter
Patient education brochure focusing on catheter explanation and infection prevention, from the Alabama Department of Public Health /
Patient Education: Quick Facts About CAUTI
Fact sheet about CAUTI for patient education, from the Indiana State Department of Health /
AHRQ Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Appendix E. Poster on Urinary Catheter Risks and Indications /
CDC Frequently Asked Questions about Catheter-associated Urinary Tract Infections
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Emergency Department / Emergency Department (ED) Intervention Urinary Catheter Data Collection Form
Checklist of appropriate indications for ED patients, from the On the CUSP: Stop CAUTI Implementation Guide /
Metrics for ED Catheter Placement and Catheterization Rates
Calculations for inappropriately placed catheter rates in the ED, from the On the CUSP: Stop CAUTI Implementation Guide /
Preventing CAUTI: Emergency Nursing Education
CAUTI prevention training tool for emergency department nurses, from the On the CUSP: Stop CAUTI Implementation Guide /
In partnership with AHRQ, the Emergency Nurses Association developed this course to help emergency nurses analyze the appropriate use of catheters and give them tools to remove obstacles involved in effecting change.
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Script for Patient/Family Requests for Non-Medically Indicated Urinary Catheters
Information to educate patients on urinary catheter risks and alternatives, from catheterout.org /
Partners for Patients Emergency Department CAUTI Prevention Guidelines ED CAUTI Algorithm 1 and 2 /
Aseptic Insertion
Focus / Resource / Website
Two Staff Indwelling Urinary Catheter Insertions / Urinary Catheter Insertion Checklist
Checklist of best practices for Foley insertion, reprinted by the Pennsylvania Patient Safety Authority with permission from Doylestown Hospital /
Female Insertion Audit Checklist
Checklist of critical behaviors for use in auditing insertion practices in FEMALE urinary catheterization, reprinted by the Pennsylvania Patient Safety Authority with permission from Doylestown Hospital /
Male Insertion Audit Checklist
Checklist of critical behaviors for use in auditing insertion practices in MALE urinary catheterization, reprinted by the Pennsylvania Patient Safety Authority with permission from Doylestown Hospital /
Hospital Infection Control Worksheet
Data collection tool (Section 4.A., pg. 28-30) for assessment of aseptic insertion and appropriate maintenance for surveyors, from the Centers for Medicare & Medicaid Services (CMS) /
Catheter Maintenance
Focus / Resource / Website
Avoid Opening the Closed Drainage System / APIC Guide to Preventing Catheter-Associated Urinary Tract Infections, 2014 Section 6: Prevention (page 53) /
SHEA/IDSA Practice Recommendation Infection Control & Hospital Epidemiology / Volume 35 / Issue 05 / May 2014, pp 464-479 /
Timely Removal
Focus / Resource / Website
Daily Review for Continued Need / Pocket Cards for Providers
Catheter removal reminder tools for use by physicians and nurses, from catheterout.org /
AHRQ Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Appendix F. Urinary Catheter Decision-Making Algorithm /
Alerts or Reminders / Urinary Catheter Paper-based Removal Reminder
Worksheet to verify indication and remind providers to remove unnecessary indwelling urinary catheters, from the Virginia Department of Health /
Electronic Removal Reminder
Removal reminder for an electronic medical record, from catheterout.org /
Nurse Driven Protocols / Nurse-Driven Protocol for Catheter Removal
Protocol for nurses to evaluate and discontinue urinary catheter use, from the On the CUSP: Stop CAUTI Implementation Guide /
Implementing a Nurse-Driven Protocol
Indwelling Urinary catheter removal protocol (Figure 2, p. 19), from MedSurg Nursing /
Preventing CandiduriaAnd Detection Of Asymptomatic Bacteriuria
Focus / Resource / Website
Antimicrobial Stewardship / Antibiotic Stewardship Driver Diagram and Change Package
A framework to reduce inappropriate antibiotic use in hospitals, including ideas for creating guidance on appropriate culturing (pg. 5), from the CDC and IHI /
Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America
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Do ordering providers send urine cultures on asymptomatic patients at your facility/unit? / Urinalysis Reflex Testing
Policy modification to reduce unnecessary urine cultures (pg. 2), from the University of Maryland Medical Center Nursing Newsletter /
Urinary Tract Infection Patient Education Material, University of Pittsburgh Schools of Health Sciences, 2011 /
Urinary Tract Infections Patient Education, UCLA /
FAQs about Catheter-associated Urinary Tract Infection Patient Resource, Center for Disease Control and Prevention /
This material was prepared in part by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-WI-C1-15-117 111915
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