1. Onboarding #2 for All Long-Term Care Staff
Catheter-Associated Urinary Tract Infection (CAUTI) Definitions and Reporting
Onboarding #2 for All Long-Term Care Staff
Welcome to today’s onboarding session titled, “Catheter-Associated Urinary Tract Infection (CAUTI) Definitions and Reporting.” This is the second of four onboarding modules for the Agency for Healthcare Research and Quality’s (or AHRQ’s) Safety Program for Long-term Care: Healthcare-acquired Infections (HAIs)/CAUTI. This brief module is intended for all levels of long-term care staff and will introduce you to your role in identifying CAUTI.

2. Learning Objectives
Upon completion of this session, long-term care staff will be able to:
define an indwelling catheter and catheter-associated urinary tract infection (CAUTI);
list the signs and symptoms for a CAUTI; and
understand the importance of their role in CAUTI identification.
We’ve already come a long way from thinking that urinary tract infections are defined by whether or not the resident is being treated with antibiotics.
After viewing this webinar you will be able to:
define an indwelling catheter and catheter associated urinary tract infection (CAUTI);
list the signs and symptoms for a CAUTI; and
understand the importance of your role in CAUTI identification.

3. Four Questions to Identify a CAUTI then the resident has a CAUTI!
What is a CAUTI?
Four Questions to Identify a CAUTI
Question 1
Question 2
Question 3
Question 4
Does the resident have an indwelling urinary catheter connected to a drainage device?
Does the resident have one or more CAUTI symptoms?
Is there no other explanation for this resident’s symptoms?
Does the resident have a urine culture that fits the criteria?
If you suspect that your resident has a CAUTI, here are four easy questions to ask yourself:
Does the resident have an indwelling urinary catheter connected to a drainage device?
Does the resident have one or more CAUTI symptoms?
Is there no other explanation for this resident’s symptoms?
Does the resident have a urine culture that fits the CAUTI criteria?
[Click]
If you answered “YES” to all of these questions,
then your resident does indeed have a CAUTI.
YES YES YES YES
then the resident has a CAUTI!

4. Question 1: What is an Indwelling Urinary Catheter?
An Indwelling Urinary Catheter IS:
An Indwelling Urinary Catheter is NOT:
a drainage tube inserted into the urinary bladder through the urethra;
left in place and connected to a closed collection system; and
sometimes called a “Foley” catheter.
an in-and-out catheter;
a suprapubic catheter, nor
a nephrostomy tube.
Lets look at the topics addressed by these questions in more depth. The first question is about indwelling catheters; understanding what is considered an indwelling catheter is the first step to understand a CAUTI diagnosis.
An indwelling urinary catheter is:
a drainage tube inserted into the urinary bladder through the urethra;
it is left in place and connected to a closed collection system, such as a bag;
and is sometimes referred to as a “Foley” or “Foley Catheter.”
An indwelling urinary catheter is NOT:
an in-and-out catheter;
a suprapubic catheter; nor
a nephrostomy tube.
Additional Facilitator Notes
Why might a resident have a catheter? The criteria for a resident to have a catheter are from the CDC and the LTC regulation based on scientific studies. While you will hear about this in more detail in other onboarding webinars, it is important to know the criteria so we do not have residents with catheters who don’t need them, which can unnecessarily expose them to CAUTI.
Urinary retention, bladder outlet obstruction, assist in healing perineal /sacral wounds, prolonged immobilization, end of life comfort, accurate output measurement in critically ill, and perioperative for selected surgical procedures of the genitourinary tract or long procedures are accepted criteria for residents to have an indwelling catheter.

5. Question 2: What are the Signs and Symptoms of CAUTI?
ONE or MORE of the following:
CAUTI Signs and Symptoms
Fever
Rigors
New confusion or functional decline
(with NO alternative diagnosis AND leukocytosis)
New suprapubic pain or costovertebral angle pain or tenderness
New onset hypotension
(with no alternate site of infection)
Acute pain, swelling or tenderness of the testes, epididymis or prostate
Purulent (pus) discharge from around the catheter
The second question asks “Does the resident have one or more CAUTI symptoms?” The following signs and symptoms are the CDC accepted symptoms associated with CAUTI:
Fever
Rigors
New onset confusion or functional decline
There must be no other diagnosis to explain this decline AND the resident must have leukocytosis (an increased white blood cell count for this to qualify as a CAUTI associated symptom.)
New onset of suprapubic pain or costovertebral angle pain or tenderness
New onset hypotension
There must be no other site of infection, for new onset hypotension to count as a CAUTI symptom
Acute pain, swelling or tenderness of the testes, epididymis or prostate gland
Purulent discharge or pus from around the catheter
The resident MUST have one or more of these signs and symptoms to qualify as having a CAUTI.
All levels of staff involved in direct resident care should be familiar with these signs and symptoms and understand how to observe, report and document them. In the next couple of slides we will describe how to identify these signs and symptoms in greater detail.

6. Fever
Single oral temperature greater than 100 ºF OR Repeated oral temperatures greater than 99 ºF Repeated rectal temperatures greater than 99.5 ºF Single temperature greater than 2 ºF over baseline for either oral or rectal
During training you may have learned when a temperature becomes a fever. Identifying a fever in the elderly can be difficult because they often have a normal temperature below 98.6 ºF. So clinical experts have clarified acceptable definitions of fever. For residents to have a fever, one of the following must be true.
They must have a:
Single oral temperature greater than 100 ºF OR
Repeated oral temperatures greater than 99 ºF
Repeated rectal temperatures greater than 99.5 ºF
Single temperature greater than 2 ºF over baseline for either oral or rectal.
What do we mean by baseline temperature? For the purpose of this project, it is an average of the resident’s previous documented temperatures.

7. Rigors Sudden, paroxysmal chill with high temperature.
Followed by a sense of heat and profuse perspiration.
Commonly called “fever and chills.”
It is important to understand what rigors are, especially if this is the resident’s only symptom of an infection.
Commonly called chills and fever, you would observe the resident for sudden, paroxysmal chill with high temperature.
This would then be followed by a sense of heat and profuse perspiration.

8. New Onset of Confusion Has the resident had an acute change
In order to standardize definitions, clinical experts have agreed to use the detailed definitions about new onset confusion and function decline as described in the Minimum Data Set (MDS). The MDS assessment is already required by LTC regulations, so you may already be familiar with these descriptions.
A symptom of confusion meets the definition of a CAUTI if the resident’s symptoms meet all three of the criteria in the top blue boxes, which are confusion without an alternate diagnosis and leukocytosis, fluctuating behavior that comes and goes or changes in severity, and difficulty focusing and an inability to maintain attention. In addition, the resident must meet at least one of the criteria in the lower green boxes, which includes disorganized thinking making it hard to follow or not making sense, or the resident is sleepy, lethargic or unarousable.
Finally, you must have observed these changes in a resident’s acute mental status over the last 7 days for this onset of confusion or functional decline to indicate a CAUTI.
Has the resident had an acute change
in their mental status over the last 7 days?

9. New Onset Functional Decline
Observe each Activity of Daily Living (ADL) for most dependent episode in last 7 days:
ADL
Functional Level
Dressing
Personal Hygiene
Eating
Transfer
Bed mobility
Toilet use
Walk in room /corridor
Locomotion on/off unit
*Bathing
0 Independent
*Supervision
Limited Assistance
*Physical help limited to transfer
Extensive Assistance
*Physical help in part of bathing
*Total Dependence
* = levels that are used to determine bathing level of assistance
The criteria for functional decline also mirrors those of MDS.
Observe how much help the resident needs from the staff over the last 7 days, even if the most dependent level of support occurred only once. Make sure you report these changes every day, every shift and that any changes in function are recorded. This will help the person doing surveillance determine if the resident's symptoms meet the criteria for a CAUTI.
On your contacts with residents look for evidence of an acute/new decline in any of these ADLs from their baseline or usual ability in the last 7 days.
Note that bathing has different functional levels that are marked with an asterisk.
Each functional level has a number attached to it so that the person doing surveillance can determine if the change in function fits the criteria.

10. Leukocytosis White Blood Cell (WBC) Differential
Leukocytosis is an elevation in the total white blood cell (WBC) count found in the complete blood count (CBC) and differential blood test.
Neutrophilia
Greater than 14,000 leukocytes OR
Left shift (>6% bands or ≥1,500 bands/mm3)
Elevation in immature WBC (bands)
Normal values
WBC (x103)
Bands %
Neut/segs %
Eos
Baso
Lymph
Mono %
5-10
3-6
50-62
0-3
0-1
25-40
3-7
Shift to the left
WBC (x103)
Bands %
Neut/segs %
Eos %
Baso %
Lymph %
Mono 15 10 65 1 20 3
Both an acute onset of confusion and functional decline will fit the CAUTI criteria only if the symptoms are accompanied by leukocytosis.
Many times a complete blood count (CBC) with differential is ordered as a screening test to detect infection.
Leukocytosis is identified by looking at the lab results for the number of white blood cells (WBC) in the CBC and for the type of WBC –in this case neutrophils. This criteria would be determined by the nurse, physician’s assistant or physician who reviews the lab test.
Additional Facilitator Notes
Leukocytosis is determined by Neutrophilia with greater than 14,000 leukocytes or elevation in immature white blood cell count bands, a left shift with greater than 6% bands or greater than or equal to 1,500 bands per millimeter cubed.
Less mature neutrophils - those that have recently been released from the bone marrow into the bloodstream - are known as "bands." The term "shift to the left" means that the bands or stabs have increased, indicating an infection in progress.
For example, a resident with acute CAUTI might have a "WBC count of 15,000 with 65% of the cells being mature neutrophils and an increase in stabs or band cells to 10%". This report is typical of a "shift to the left", and will be taken into consideration along with history and physical findings, to determine how the resident's CAUTI will be treated.
Source: eHow. What is a shift to the left in blood testing? Table by WC Lockwood (replicated for 508 compliance) Accessed from on 04/03/15.

11. Suprapubic Pain or Costovertebral Angle Pain
New onset of:
Suprapubic pain OR
Costovertebral angle pain or tenderness
The area where the vertebral column, or spine, intersects the lower ribs is known as the costovertebral angle.
It is an important area because it marks the spot where the kidneys are typically found.
Because of the referred pain pathways, even a simple lower UTI may be accompanied by flank pain and costovertebral angle tenderness.
Percussion of the kidneys, as demonstrated here by a licensed nurse helps assess pain or tenderness, and is important if it is the only symptom of a CAUTI.
Source:

12. Questions 3: Could Something Else Cause These Signs and Symptoms?
The signs and symptoms just described are only indicative of a CAUTI if there are no other explanations for the signs and symptoms.
The signs and symptoms just described are only indicative of a CAUTI if there are no other explanations for the signs and symptoms.

13. Question 4: What Lab Tests Indicate a CAUTI?
If a urinary catheter is in place:
Positive urine culture with 100,000 colonies or more (105 CFU/ml) of any number of microorganisms indicates a CAUTI.
If a urinary catheter is not in place, but was removed in the past 2 days:
Voided urine culture with 100,000 or more colonies (105 CFU/ml) of no more than 2 species of microorganisms. OR
Positive culture with 100 or more colonies (102 CFU/ml) of any number of microorganisms from a straight in/out catheter specimen.
When the resident has symptoms or complaints the physician may order a urine culture.
It’s important to interpret the culture results correctly if it is suspected that the resident has a urine infection related to having an indwelling urinary catheter.
If the resident has an indwelling catheter the urine specimen must be taken from the port in the tubing designed for specimen withdrawal and the result must show 100,000 colonies of a microorganism (plus symptoms) to be a CAUTI.
If the urinary catheter is in place, the culture must show 100,000 colonies of any number of organisms.
Even if the resident with symptoms does not have a urinary catheter, they may still have a urinary tract infection that is associated with a catheter if the catheter has been removed in the last 2 days.
If the resident had a catheter, but it was removed in the last 2 days before the specimen was taken, a voided urine specimen must show 100,000 or more colonies containing no more than 2 species of microorganism or an in and out specimen must show at least 100 colonies of any number of microorganism to be considered a CAUTI.
Please note that if a void urine culture has more than 2 species of microorganisms or if an indwelling catheter has been in place for more than 14 days, there is a high probability that sample is contaminated and a new urine analysis should be completed.
The revised McGeer criteria recommends that if the current catheter has been in place for 14 days the urinary catheter is replaced prior to obtaining a specimen for culture. This will be covered again in the surveillance onboarding webinar.

14. To Find a CAUTI, Ask 4 Simple Questions
Does the resident have an indwelling urinary catheter connected to a drainage device?
Does the resident have one or more CAUTI signs and symptoms?
Is there no other explanation for the resident’s signs and symptoms?
Does the resident have a urine culture that fits the criteria?
If you can answer “YES” to ALL 4 questions, then you found a CAUTI!
I have just provided you additional information on each of the key questions that helps us determine whether or not a resident has a CAUTI. To review, the key questions are:
Does the resident have an indwelling urinary catheter connected to a drainage device?
Does the resident have one or more CAUTI symptoms?
Is there no other explanation for this resident’s symptoms?
Does the resident have a urine culture that fits the CAUIT criteria?
If you answered “YES” to all of these questions, then your resident does indeed have a CAUTI.
Thanks very much for you time and attention to this program and for working to make your long-term care facility a safer place for the residents that live there.

15. Stay Updated with Useful Resources
CAUTI Criteria NHSN Definitions Pocket Cards
LTC CAUTI Surveillance Worksheet
The following resources are available to you as participants in the AHRQ Safety Program for Long-term Care: HAIs/CAUTI project. We hope that these resources will be helpful on your journey to reduce CAUTIs and HAIs and improve your facility’s culture of safety.
Resources:
AHRQ Safety Program for Long-term Care: HAIs/CAUTI project website. On the website you will find a variety of tools to help you prevent CAUTIs and improve your facility’s culture of safety.
TeamSTEPPS for Long-term Care. TeamSTEPPS is a communication and teamwork system that offers solutions to improving collaboration and communication within health care facilities. The resources on this page are specifically designed for the Long-term Care environment.
CAUTI Criteria NHSN Definitions Pocket Cards. A resource to identify CAUTIs based on NHSN criteria.
LTC CAUTI Surveillance Worksheet . A tool that can be used to review a resident’s chart for a suspected CAUTI to determine if the documented signs and symptoms meet the NHSN criteria for a CAUTI.

16. References
National Healthcare Safety Network (NHSN). Urinary Tract Infection (UTI) Event for Long-term Care Facilities. [online] Stone ND, Ashraf MS, Calder J. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol 2012;33(10): Centers for Medicare and Medicaid. MDS 3.0 RAI Manual v1.12. October 1, [online] Instruments/NursingHomeQualityInits/MDS30RAIManual.html. George-Gay B, Katherine Parker K. Understanding the Complete Blood Count With Differential. Journal of PeriAnesthesia Nursing, Vol 18, No 2 (April), 2003: pp

17. Engagement Activities
Case Study, Skills Questions
This portion of the training is designed to test your knowledge of the information we have covered and your ability to define a CAUTI using the nationally accepted criteria.
Engagement Activities

18. Skill Question #1 Is this a CAUTI or a non-catheter symptomatic UTI?
Day 1: The resident has an indwelling urinary catheter inserted in the LTC facility for a bladder outlet obstruction.
Day 2: The indwelling urinary catheter remains in place.
Day 3: The resident’s indwelling urinary catheter remains in place. The resident has a single oral temp of 100.2ºF. A urine culture is collected from an indwelling catheter specimen.
Day 4: The indwelling urinary catheter remains in place. No symptoms are documented.
Day 5: The urine culture is positive for Staphylococcus aureus 100,000 CFU/ml.
ANSWER:
This IS a LTC-acquired CAUTI because:
The resident has a urinary catheter placed in the nursing home
The symptoms meet the CAUTI criteria of one symptom and a qualifying culture from the indwelling catheter specimen which are:
An oral temp over 100 ºF
And a positive urine culture with 100,000 colonies of any microorganisms from the indwelling catheter specimen

19. Skill Question #2
Which of the following criteria would confirm a CAUTI?
The resident’s oral temperature is ºF and the indwelling catheter specimen is positive for E. coli 100,000 CFU (105).
The resident has purulent discharge around the suprapubic catheter and the catheter specimen is positive for E. coli 100,000 CFU (105).
The resident has a fluctuating change in mental status, and a voided specimen positive for E. coli 100 CFU (102 ) four days after the indwelling catheter was removed.
The resident has multiple oral temps of 99.2 ºF, chills, sweating and the indwelling catheter specimen is positive for E. coli 100,000 CFU (105).
ANSWER:
1 and 4 confirm a LTC facility-acquired CAUTI.
YES. Fits the fever and the culture criteria.
NO. CAUTI criteria does not include suprapubic catheters.
NO. While the culture fits the CAUTI criteria, it is more than 2 days after the day the catheter was removed. To meet the CAUTI the resident must develop signs and symptoms while having an indwelling urinary catheter in place or “recently in place.” “Recently in place” means an indwelling urinary catheter was removed within the 2 calendar days prior to the date of event. (Day of catheter removal = day 1).
YES. The repeated oral temps of 99 °F, rigors and the catheter urine culture fit the criteria.

20. Skill Question #3
Which of the following scenarios fits the decline in activities of daily function (ADL) criteria?
A resident who was independent with bed mobility, transfers and locomotion last week, now needs extensive assistance with all 3 ADLs with no apparent cause.
A resident who required supervision for eating, personal hygiene and toilet use now needs limited assistance with toilet use.
ANSWER: A
“A“ scenario shows an ADL decline from independence to extensive assistance in 3 ADLs; would equal a 3 point increase in overall assistance, which is the definition of a functional decline.
“B” scenario is not an ADL decline because the change in the one ADL does not fit the criteria for a functional decline.

21. Skill Question #4
Which of the residents below has a change in mental status that fits the confusion criteria?
A resident who is usually able to follow instructions has been unable to focus on activities of daily living or pay attention to instructions for the last couple of days and has a WBC count of more than 10,000 leukocytes.
A resident suddenly has fluctuating difficulty paying attention and is not making sense during conversation, and has a WBC of greater than 14,000 leukocytes.
ANSWER
No. Scenario A does not fit CAUTI criteria because the acute change in mental status is not accompanied by leukocytosis (>14,000 leukocytes).
YES. Scenario B fits CAUTI criteria because the change in mental status is acute, accompanied by leukocytosis, the behavior is fluctuating and has disorganized thinking.