1. Onboarding Webinar #2 for LTC Facility Team Leads and Core Team
Catheter Associated Urinary Tract Infection (CAUTI) Definitions and Reporting
Onboarding Webinar #2 for LTC Facility Team Leads and Core Team
October 22, 2015
Welcome to today’s webinar titled Catheter-Associated Urinary Tract (CAUTI) . This is the second Onboarding Webinar for the fifth cohort of the Agency for Healthcare Research and Quality’s (or AHRQ’s) Safety Program for Long-Term Care: Healthcare-acquired Infections (HAIs)/CAUTI. This webinar is designed with the team leads and members of the core team in mind as the intended audience. Hopefully this webinar will provide you with some valuable information regarding CAUTI definitions and reporting and how you can share this information with your facility staff.
Sharon Bradley RN, CIC
Senior Infection Prevention Analyst
Pennsylvania Patient Safety Authority

2. Learning Objectives
Upon completion of the webinar, core team members will be able to:
demonstrate a working knowledge of the signs, symptoms, and lab tests appropriate for identifying a CAUTI using the NHSN criteria;
use the train-the-trainer materials to cascade content to facility front- line staff;
provide specific examples of how every team member can help reduce healthcare-associated infections and provide safe care; and
understand the importance of their role in connecting CAUTI identification to their facility’s overall safety plan for residents and staff.
We have a lot of information to cover today and it is my hope that upon completion of the webinar, participants will be able to:
demonstrate a working knowledge of the signs, symptoms, and lab tests appropriate for identifying a CAUTI using the NHSN criteria;
use the train-the-trainer materials to cascade content to facility front-line staff;
provide specific examples of how every team member can help reduce health care- associated infections and provide safe care; and
understand the importance of their role in connecting CAUTI identification to their facility’s overall safety plan for residents and staff.
As you learned in onboarding 1, these modules are designed to help facility team leaders better understand their role in the LTC Program and to have a detailed working knowledge of the CAUTI definitions and identification. We will review in today’s webinar the materials we have developed to help leaders not only share this education with all staff in your facility, but to engage all staff in identifying and reporting signs and symptoms of a CAUTI.

3. What is a Catheter-Associated Urinary Tract Infection (CAUTI)?
An infection occurs when a resident with an indwelling urinary catheter:
Manifests one or more symptoms localized to the urinary tract
AND
Symptoms have no alternative source
Clinical signs and symptoms are combined with laboratory verification of an infection
NHSN LTC
For the LTC Program it is crucial for core team members, as well as front-line staff, to understand what a CAUIT is and the criteria used to identify and diagnose one. It is also essential that everyone is using the same criteria. For this project, an infection is considered a CAUTI when a resident with an indwelling urinary catheter, sometimes called a Foley, manifests one or more symptoms localized to the urinary tract AND these symptoms have no alternative source AND clinical signs and symptoms are combined with laboratory verification of an infection.
This definition can sometimes seem a little confusing, so here are four easy questions to help you and all staff in your facility understand and identify CAUTIs…

4. What Does CAUTI Surveillance Require?
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 the resident’s symptoms?
Does the resident have a urine culture that fits the criteria?
THEN 1 2 3 4
YES
YES
YES
These are four questions you should use to identify CAUTI for surveillance purposes.
If you suspect that your resident has a CAUTI, ask yourself:
Does the resident have an indwelling urinary catheter connected to a drainage device? [CLICK]
Does the resident have one or more CAUTI symptoms? [CLICK]
Is there no other explanation for this resident’s symptoms? [CLICK]
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.
These questions may also be used to help in diagnosing a UTI.
then YES…
the resident has a CAUTI!

5. Question 1: What is an Indwelling Urinary Catheter?
An Indwelling Urinary Catheter IS:
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.
Indwelling Urinary Catheter
An Indwelling Urinary Catheter is NOT:
Now that we have talked about why reducing and preventing CAUTI’s are important, lets take a deeper look at the four questions for identifying CAUTIs and the information to which each is alluding. The first question is about indwelling catheters; understanding what is considered an indwelling catheter is the first step in understanding a CAUTI diagnosis.
For this project we are using the Center for Disease Control (CDC) National Health Safety Network (NHSN) definition of an indwelling catheter. By these standards 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.”
It is important to note that this differs from the long-term care Minimum Data Set (MDS) definition, which includes all types of urinary catheters in the CAUTI definition.
Examples of non-indwelling urinary catheters are:
an in-and-out catheter;
a suprapubic catheter; nor
a nephrostomy tube.
If you suspect that a resident with a suprapubic or nephrostomy tube has a urinary tract infection, you would use the NHSN /McGeer Criteria for a symptomatic urinary tract infection WITHOUT an indwelling catheter.
Indwelling urinary catheters can increase the resident’s risk of getting an infection. Urinary catheters connect the heavily colonized perineum with the normally sterile bladder, providing a route for bacterial entry. The bacteria’s basic survival strategy is to colonize the surfaces of the urinary catheter and grow as a community of organisms. This collection of bacteria on the top of the catheter is embedded in a gel-like substance known as biofilm.
Most microorganisms that cause CAUTIs derive from the patient's own colonic and perineal flora. Female residents have a higher risk for CAUTI compared to males because they have a shorter urethra which is in closer proximity to the anus. However, CAUTI bacteria can also originate from the hands of health care personnel during catheter insertion or maintenance of the catheter collection system.
an in-and-out catheter;
a suprapubic catheter, nor
a nephrostomy tube.
Photograph from NHSN LTC

6. Question 1: Recent Catheter Removal and CAUTI
If the indwelling urinary catheter was removed within 2 calendar days prior to the development of CAUTI signs and symptoms, then it’s a CAUTI as long as the urine culture criteria is met
Day of catheter removal = day 1
All signs/symptoms + positive urine culture must be available within a close timeframe (NHSN Infection Window Period is defined as the 7-days)
NHSN LTCF; CDC-NHSN
A resident can be diagnosed with a urinary tract infection that is considered a CAUTI if they have recently had an indwelling urinary catheter removed. If a resident develops CAUTI signs and symptoms and meets urine culture criteria within 2 days of having the catheter remove they are considered to have a CAUTI.
When documenting such cases it is important to note that the day the catheter is removed is day 1 and all signs and symptoms and positive urine culture must be available within a closed timeframe. For this project we will be using the NHSN infection window period which is defined as 7-days. As of January 2015, this 7-day infection window period includes the day the first positive diagnostic test was obtained, the 3 calendar days before and the 3 calendar days after.
For infection criteria that do not include a diagnostic test, the first documented localized sign or symptom should be used to define the window (e.g., rigors, site specific pain, purulent discharge, etc.).
The introduction of the Infection Window Period, or “gap days”, used in 2014, will no longer be used to determine fulfillment of infection criteria.

7. 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
If a resident with an indwelling catheter (or one removed in the last 2 days) has just one of these symptoms and a positive urine culture it will count as a CAUTI.
All levels of staff involved in direct resident care should be familiar with these symptoms and understand how to observe, report and document them. Giving antibiotics to residents who do not meet these criteria, ergo do not have a CAUTI, increases antibiotic resistance, the emergence of multi-drug resistant organisms (MDROs) and the prevalence of C. Diff infections. You will learn more about the importance of avoiding antibiotic overuse in Training Module 4.
In the next couple of slides we will describe how to identify these symptoms in greater detail to assure everyone is using the same criteria.

8. Fever
Single oral temperature greater than 100°F OR Repeated oral temperatures greater than 99°F Repeated rectal temperatures greater than 99.5°F Single temperature greater than 2°F over baseline for either oral or rectal
Identifying a fever in the elderly can be difficult because they often have a normal temperature below 98.6 ºF. In 2008, the Infectious Disease Society of America (IDSA) updated the Clinical Practice Guideline for the evaluation of fever and infection in older adult residents at long-term care facilities. 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
If using the baseline definition, then you should use an average of the resident’s previous documented temperatures, making sure the same method used for baseline is used for fever assessment:
An oral temperature is 0.5°F (0.3°C) to 1°F (0.6°C) lower than a rectal or ear (tympanic) temperature.
A rectal temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature.
An ear (tympanic) temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature.

9. 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. Staff should become comfortable using this term for sudden, uncontrollable or spastic movement accompanied by a fever, especially if this is the only symptom that fits the CAUTI criteria.

10. New Onset of Confusion Has the resident had an acute change
Behavior change, eg. “the resident seems agitated,” isn’t accurate enough to be considered new onset of confusion and diagnosed as a CAUTI. Rather, it is important to get at confusion criteria that are more often due to an infection. Similarly, an acute change in mental status can be interpreted in a variety of ways.
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.
This diagram can help front-line staff better understand the criteria that need to be met for a resident to have new onset confusion.
A sign 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.
As members of the core team you should be on the lookout for new onsets of confusion.
Ask staff members about their observations, pay special attention to signs and symptoms of delirium;
Review the medical record documentation during the 7-day look-back period to determine the resident’s baseline status, fluctuations in behavior and behaviors that might have occurred during this period; and
Interview staff, family members and others in a position to observe the resident’s behavior during the 7-day look-back period.
Has the resident had an acute change
in their mental status over the last 7 days?

11. Step 1: 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
Similar to New Onset of Confusion clinical experts have agreed to use the detailed definitions to standardize diagnosing Functional Decline. The only current method is in the Minimum Data Set (MDS) 3.0, which is consistent with the NHSN and the Revised McGeer Criteria. Long-term care staff should be familiar with assessing the residents in these terms because they should be completing the MDS assessment, which is required by government regulations.
The first step in determining Acute Functional Decline is for staff to monitor, report and document any decline in the nine Activities of Daily Living (ADLs) during every contact with the resident. 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.
Documenting these changes will help the person doing surveillance—that may be you—determine if the resident's symptoms meet the criteria for a CAUTI. 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.
Note that bathing has different functional levels that are marked with an asterisk. You will use the same level of self-performance for Independent (0), Supervision (1) and Total Dependence (4). But the two assistance categories are different from the other ADLs.
Limited Assistance becomes “Physical help limited to transfer” and
Extensive Assistance becomes “Physical help in part of bathing”
It is important to remind staff of this difference and make sure it is appropriately reported and documented.
Let’s take a look at how much help the resident with a catheter needs to perform their ADLs on a daily basis to understand how to score the functional level.

12. Step 2: New Onset Functional Decline
Did activity occur 3 or more times in a 7-day period?
Assistance
Explanation
Score
Independent
No help or staff oversight any time
Supervision
Needs oversight, encouragement , cueing 1
Limited Assistance
Resident highly involved in activity
Staff provide guided maneuvering of limbs or other non-weight bearing assistance 2
Extensive Assistance
Resident involved in activity
Staff provide weight bearing support 3
Total Dependence
Full staff performance every time during entire 7 day period 4
Besides knowing which categories of activities of daily living must be monitored, reported and documented, staff must monitor how much help the resident with a catheter needs to perform their ADLs on a daily basis. Only by knowing the baseline can one determine if there has been a decline in function.
As the table highlights there are 5 levels of assistance and each level corresponds with a number score. For example if a resident needs no staff help or oversight at any time for an ADL then they are considered independent and would receive a 0 for that activity. On the other hand if a resident activity requires a staff person every time for the seven day period then the ADL score would be 4.

13. Step 3: New Onset Functional Decline
Monitor for NEW 3-point increase in total ADLs from BASELINE
ADL
Baseline
Code
Now
Bed Mobility
Independent
Supervision 1
Transfer
Limited assist 2
Walk in room/ corridor
Locomotion on/off unit
Dressing
Eating
Toilet use
Personal hygiene
Bathing
Help with transfer
Total ADL score 7 15
Observe the resident’s dependence on staff over the last 7 days, even if the most dependent level of support occurred only once. This example shows a sample of an 8-point decline in the resident’s ADL function over the last 7 days. This decline would meet the CAUTI criteria, which requires at least a 3-point decline.

14. ?
Understanding ADL
Which scenario fits the decline in activities of daily living (ADL) criteria? (Choose one.)
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
Explanation:
Scenario “A” shows an ADL decline from independence to extensive assistance in 3 ADLs. This would equal a 3-point increase in overall assistance, meeting the definition of a functional decline.
Scenario “B” does not meet the criteria, because it is only a 1-point increase in overall assistance.

15. Leukocytosis Neutrophilia OR Elevation in immature WBC (bands)
Leukocytosis is an elevation in the total white blood cell (WBC) count found in the complete blood count (CBC) and differential blood test.
Neutrophilia
>14,000 leukocytes OR
Elevation in immature WBC (bands)
Left shift (>6% bands or ≥1,500 bands/mm3)
White Blood Cell (WBC) Differential
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.
A complete blood count with differential measures the levels of white blood cells (WBC), as well as platelet levels, hemoglobin and hematocrit. Leukocytosis is determined by high numbers of WBC and may indicate that the resident may have inflammation or an infection somewhere in their body. This criteria is likely to be determined by the nurse, physician’s assistant or physician who reviews the lab test.
So the licensed nurse or physician will determine the presence of leukocytosis when neutrophilia are 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.
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.

16. Understanding Changes in Mental Status?
Understanding Changes in Mental Status
Which of the residents below has a change in mental status that fits the confusion criteria? (Choose one.)
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: B
Explanation:
Scenario “A” does not meet the criteria, because the acute change in mental status is not accompanied by the appropriate leukocytosis criteria (>14,000 leukocytes).
Scenario “B” represents a change in mental status because the change in mental status is acute, accompanied by leukocytosis. The resident’s behavior is fluctuating and their thinking is disorganized.

17. 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.
Health care professionals often check for tenderness in this area by tapping a fist on this region of the body. If the maneuver elicits pain, positive costovertebral angle tenderness is said to be present. Typically, a nurse or physician would check for tenderness both on the right and left sides of the body.
Source:

18. Question 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.

19. 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 to correctly identify a CAUTI. Symptoms MUST BE ACCOMPANIED by a POSITIVE URINE CULTURE, so 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.
[Explanation of how to decipher 10 to the 2nd or to the 5th power:
The power of a number says how many times to use the number in a multiplication.
102 means 10 × 10 = 100
(It says 10 is used 2 times in the multiplication IS THIS NEEDED]

20. Knowledge & Skills Transfer
The LTC Program Facility Team Leader and core team are very important to the successful implementation of the program. In general, the facility team leader is expected to promote the project goals, educate staff and encourage team members to commit to interventions that aim to reduce CAUTI and improve the safety culture.
So, for the remainder of this program we’ll provide the team leader and core team with specific examples of how to engage and support the front-line staff.
Knowledge & Skills Transfer

21. Materials and Training Aids
CAUTI Criteria - NHSN Definitions Pocket Cards
The LTC Program has a host of materials and training aids posted to the ltcsafety.org website to assist you with hardwiring the CAUTI definitions into daily clinical practice and surveillance processes.
For example
The NHSN Definitions Pocket Cards are a resource to identify CAUTIs based NHSN criteria.
Nursing/assistive staff can use the pocket cards while rounding to evaluate residents for possible signs and/symptoms of CAUTI.
Physicians/clinicians may use it to evaluate residents with signs and/or symptoms of CAUTI before prescribing antibiotic treatment.
Additionally, these tools are great for printing, laminating and distributing to all direct care providers.

22. Your Role in Engaging Staff in CAUTI Prevention
Share information with all staff/teammates
Include physicians and non-physician providers in the education
Use the CAUTI definition tools to build, encourage and support staff to correctly identify CAUTI signs and symptoms
Explain the signs and symptoms of UTI to residents/families
Monitor and report small changes in a resident's conditions
Recognize staff who accurately observe, report, document and monitor signs and symptoms
Let’s spend the next few minutes examining what the long-term care staff’s role is in identifying and communicating CAUTI signs and symptoms. Each of you will have slightly different roles in your facility. But each of you plays an important part in supporting all staff in being part of the safety team to identify changes in a resident’s condition.
It is important that standardized definitions are second nature to all l staff to be sure you are accurately identifying CAUTI.
Talk with all staff and teammates to share information and discuss what you are learning and how you can apply the new information. Use the CAUTI definition tools to build, encourage and support staff to correctly identify CAUTI signs and symptoms. You can then work as a team to help educate one another about what your facility is doing to prevent infections. When residents and families suggest a UTI or request antibiotics, you can explain the signs and symptoms of a UTI and what you’ve observed to warrant a test or describe what you’re going to monitor for.
Some of you will be involved in providing formal education; others may be involved in reinforcing positive behaviors related to communicating and documenting signs and symptoms.

23. Educate All Staff to Identify CAUTI Signs and Symptoms
Use slide set with facilitator’s notes
Share recorded session for all staff who interact with residents
Use quiz to assess knowledge gained and encourage team discussion
Provide copies of tools to guide CAUTI identification
Provide Evaluation Form and Certificate of Completion
First lets talk about ways to share the information we discussed during today’s webinar on CAUTI definitions. The team leader can either customize the presentation to focus specifically on elements that effect their facility or play the short 15-minute video geared for the front-line staff. This format allows the trainer to utilize different training modalities for staff who are unable to attend viewings at designated times.
During the education session, whether using the video recording or presenting the information live:
Encourage staff to ask questions and share any concerns throughout the session.
Pause the video as needed to address questions.
Encourage staff to share stories of challenges or barriers to meeting the expectations.
At the end of the video ask staff to answer the case studies and review each question and correct answers with the entire group. Provide additional resources or follow-up as needed based on the responses.
You may want to distribute the quiz before the video or training session starts for staff to consider the answers for, or distribute the quiz afterward to assess knowledge transfer. Use the facilitator’s notes or video recording of the skills questions to explain the correct answer and why the other answers are incorrect.
Thank the staff for attending, have staff complete the evaluation and reinforce the importance of their role in eliminating CAUTI.

24. ?
CAUTI or Not?
Is the following an example of 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.
Now we are going to give you the opportunity to practice identifying CAUTIs. The following is a Case Study from the accompanying training materials for all-staff. It is important that you understand how to answer these questions so you can explain the correct answers to your facility team.
On day 1 the resident has an indwelling urinary catheter inserted in the LTC facility for a bladder outlet obstruction. By day 3 the indwelling urinary catheter is still in place and the resident has a single oral temp of 100.2ºF and a urine culture is collected from an indwelling catheter specimen.
on day 4 the indwelling urinary catheter is still in place and no symptoms are documented.
On day five the urine culture results come back and are positive for Staphylococcus aureus 100,000 CFU/ml.
Does this resident have a CAUTI?
ANSWER: YES, this is a LTC-acquired CAUTI
Explanation:
The resident has an indwelling urinary catheter in place;
The symptoms meet the CAUTI criteria ; An oral fever above 100 oF;
There is no other explanation for the resident’s symptoms; and
The resident has a positive urine culture with 100,000 colonies/mL of one species of microorganism (Staphylococcus aureus).

25. ?
Criteria for CAUTI
Which of the following criteria would confirm a CAUTI? (Select all that apply.)
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).
Here are a couple more case studies for you to practice your CAUTI identification.
ANSWER: A, D are CAUTIs
Explanation:
This is a CAUTI. The resident has an indwelling urinary catheter and their fever and culture fit the criteria for a CAUTI.
This is NOT a CAUTI. The CAUTI criteria do not include suprapubic catheters.
This is NOT a CAUTI. While the urine culture and symptom fit the criteria for a CAUTI, the indwelling urinary catheter was removed 4 calendar days before the symptoms were observed. To count as a CAUTI the indwelling urinary catheter must have been removed within 2 calendar days of observing the symptoms.
This is a CAUTI. The repeated oral temperature of 99.2oF and rigors (chills and sweating) along with the positive indwelling catheter urine specimen of 100,000 CFU (105) of E. coli meet the CAUTI criteria.

26. Stay Updated with Useful Resources
CAUTI Criteria NHSN Definitions Pocket Cards
LTC CAUTI Surveillance Worksheet
LTC Safety Toolkit
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.

27. References
National Healthcare Safety Network (NHSN). Long-term Care Facility (LTCF) Component Healthcare Associated Infection Surveillance Module: UTI Event Reporting [online]. National Healthcare Safety Network (NHSN). Urinary Tract Infection (UTI) Event for Long-term Care Facilities [online]. National Healthcare Safety Network (NHSN). Catheter-Associated Urinary Tract Infection (CAUTI) Event. Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee (HICPAC) approved guidelines for the Prevention of catheter-associated urinary tract infections, Available at Centers for Disease Control and Prevention. Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance (online). Accessible at: 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): George-Gay B, Katherine Parker K.. Understanding the Complete Blood Count With Differential. Journal of PeriAnesthesia Nursing, Vol 18, No 2 (April), 2003: pp

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