8/12/13

Assessment Checklist

CAUTI Prevention Policy/Protocol and Practice

Based on the Centers for Disease Control’s 2009 CAUTI Prevention Guidelines at:

http://www.cdc.gov/hicpac/cauti/002_cauti_toc.html

Instructions for use: This checklist has been designed for use in evaluating policies and procedures (P&P) ALONG WITH actual practices related to CAUTI prevention to assist hospitals in determining if their P&Ps contain priority recommendations from the most current CAUTI prevention guidelines along with assessing actual practice. There are well-known, common gaps between P&Ps and actual practice in most facilities so it is essential to examine both before claiming evidence-based strategies are fully employed in your hospital to prevent CAUTI.

This checklist does NOT include all evidence-based interventions but only the ones considered priority (i.e. the most basic, minimum) interventions by the Centers for Disease Control’s Healthcare Infection Control Practices Advisory Committee (HIPAC) that wrote the 2009 guidelines. All priority interventions are designated as Class IB recommendations (please see *Table 1 below). You may wish to add additional interventions to this checklist before you conduct a review; therefore, it is in a Word format to allow revisions.

As you begin this assessment, you may want to consider consultation with others who have knowledge of these guidelines yet may be outside of your organization, who can bring objectivity to your review. Some resources for this may be provided to you through the NoCVA HEN HAI Learning Network in the way of one-to-one exchange with colleague hospitals in the Learning Network who have had good success so far in preventing CAUTI, a representative from the NoCVA HEN HAI Learning Network Expert Panel, and/or group consultation with a group of HAI LN hospitals. If you desire any of these or another method you feel may work, please contact the Project Lead for the Learning Network, Shelby Lassiter, at in North Carolina or Jan Mangun at in Virginia.

To use this form, make a check along the far left column under “P&P ?” when content in your P&P is found to be compliant with this recommendation. Document what part of your P&P makes this compliant with evidence. This assessment should be done first. (This is where outside consultation as described above may be able to help you discern whether or not your P&P is truly compliant in a meaningful way.)

The next column, “Practice ?” may be checked when practice is confirmed to be compliant to policy after at least 5-10 observations on different units throughout your organization. Again, document what makes practice compliant. It is important to observe this in the ED and the OR, also, as they are usually where most indwelling urinary catheters are placed. This will take the majority of time and you may need more than one reviewer. If that is the case, make sure each reviewer is assessing the same thing and understands what and how the assessment for compliance is to be done. Do not rely on staff interviews alone, but on actual observation of practice and review of staff competency records to determine compliance.

P&P
? / How Met? / Practice? / How Met? / Topic / Priority Recommendation / Example of Strategies for Compliance
[Place your practice here]
1. Appropriate Urinary Catheter Use / 1a. Insert catheters for only appropriate indications.** / 1a. 1-Clinical indications for urinary catheters have been developed, trialed, and are in place throughout the organizations, particularly in the ED and OR and are being used accurately. 2-Patients and their families are consulted and educated about need for catheter and risks/benefits.
1b. Leave catheters in only as long as needed. / 1b. 1-There is a reliable process for daily assessment for need and catheters are removed as soon as they no longer meet clinical indications. 2- Patients and families are instructed to ask daily if it can be removed.
1c. Avoid use of urinary catheters in patients and nursing home residents for management of incontinence. / 1c. 1-There is a reliable urinary incontinence management protocol in place and it’s utilized appropriately to avoid catheterization. 2-There are functioning and useful supplies and equipment to provide alternatives to catheterization, e.g. adequate numbers of bedside toilets, functioning line of condom catheters, etc. 3-Urinary catheters are monitored to ensure incontinence is not the reason they were placed or kept in.
1d. For operative patients who have an indication for an indwelling catheter, remove it as soon as possible postoperatively, preferably w/in 24 hours, unless there are appropriate indications for continued use. / 1d. Protocol is in place to remove urinary catheters in post-op patients at the appropriate time and this is adhered to. (This is monitored and when catheter is left in, a review of the decision takes place.)
1e. Use urinary catheters in operative patients only as necessary, rather than routinely. / 1e. All hip and knee surgery patients are assessed individually for need for Foley pre-op vs. routinely inserting a urinary catheter as part of the pre-op prep.
2. Aseptic Insertion of Urinary Catheters / 2a. Ensure that only properly trained persons who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility. / 2a. All healthcare workers whose job descriptions include the function of urinary catheter insertion are given education and observed training at the time of new employee orientation and there are periodic (annual) competencies for urinary catheter insertion to ensure compliance to aseptic technique.
2b. In the acute care hospital setting, insert catheters using aseptic technique and sterile equipment. / 2b. There is a clear, written protocol for urinary catheter insertion using aseptic technique and compliance monitoring is done.
3. Proper Urinary Catheter Maintenance / 3a. After insertion, maintain a closed drainage system / 3a. 1-Foley insertion kit is complete with all needed supplies and closed system and is routinely used in all units when urinary catheter is placed. 2-Policy forbidding closed system to be opened without an MD order and for aseptic technique to be used if ordered (E.g. prohibit drainage bags from being switched to/from a urimeter once Foley is placed, obtaining urine specimens by opening the system vs. aspirating from sampling port, etc.).
3b. Maintain unobstructed urine flow / 3b. 1-Keep drainage bag below level of bladder at all times. 2- All personnel coming into contact with the patient with a Foley are trained to keep tubing unkinked and tubing/bag below level of bladder, including transport personnel, radiology staff, and therapy staff. 3- Patient and family are routinely instructed to do the same.
*Table 1. Modified HICPAC Categorization Scheme* for Recommendations
CategoryIA / A strong recommendation supported by high to moderate quality† evidence suggesting net clinical benefits or harms
CategoryIB / A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (e.g., aseptic technique) supported by low to very low quality evidence
Category IC / A strong recommendation required by state or federal regulation.
Category II / A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation/ unresolved issue / Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
** Table 2. Examples of Appropriate Indications for Indwelling Urethral Catheter Use 1-4
Patient has acute urinary retention or bladder outlet obstruction
Need for accurate measurements of urinary output in critically ill patients
Perioperative use for selected surgical procedures:
•  Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract
•  Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in PACU)
•  Patients anticipated to receive large-volume infusions or diuretics during surgery
•  Need for intraoperative monitoring of urinary output
To assist in healing of open sacral or perineal wounds in incontinent patients
Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures)
To improve comfort for end of life care if needed
B. Examples of Inappropriate Uses of Indwelling Catheters
As a substitute for nursing care of the patient or resident with incontinence
As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void
For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia, etc.)
Note: These indications are based primarily on expert consensus.

Developed by the North Carolina-Virginia Hospital Engagement Network: HAI Learning Network in close collaboration with Brittain Wood, BSN, RN, and Connie Clark, BSN, RN, CIC, Infection Preventionists at Duke Raleigh Hospital, Raleigh, NC