Attachment D - CAUTI Monthly Device Rounds Checklist

A ttachment D: CAUTI Device Rounds Checklist

CAUTI Device Rounds Checklist (Device Checklist Form)

CAUTI device rounds are an opportunity to directly observe patients’ catheter devices to ensure evidence-based best practices are followed to prevent device-associated infections. The device rounds incorporate data collection and real-time discussion, education, and problem-solving to optimize catheter device care measures. You may want to invite the unit CUSP Executive to attend these rounds. Of note, smaller groups tend to be most effective for catheter device rounds.

Complete this checklist one day per month for each patient’s catheter device present in the participating unit at the time of assessment. The assessment may be completed by frontline personnel, infection preventionists, CUSP members, catheter device experts, or others in the unit. Once the month’s assessments are complete, combine the data from each patient’s device checklist form and enter the total count for each of the following items in the data collection program portal (Monthly Aggregated Checklist Form).

For each catheter device, confirm each of the following elements are in place:

• Is the drainage bag below the patient’s bladder?

• Yes

• No

• N/A

• Is the drainage bag off the floor?

  • Yes

  • No

  • N/A

• Is the drainage bag less than 2/3 full?

  • Yes

  • No

  • N/A

• Was the drainage bag emptied in the last 24 hours?

  • Yes

  • No

  • N/A

• Is the tubing off the floor?

  • Yes

  • No

  • N/A

• Is the tubing obstructing urine flow (e.g., no kinks, patient not lying on tubing)?

  • Yes

  • No

  • N/A

• Is the tubing without dependent loops?

  • Yes

  • No

  • N/A

• Is the tubing secured?

  • Yes

  • No

  • N/A

• Is the closed system maintained (red seal intact)?

  • Yes

  • No

  • N/A

• Was the pericare completed and documented in the last 24 hours?

  • Yes

  • No

  • N/A

• Did you review the indication and determine the urinary catheter is/was not appropriate and discussed removal?

  • Yes

  • No

  • N/A

CAUTI Device Rounds Checklist (Monthly Aggregated Checklist Form)

CAUTI device rounds are an opportunity to directly observe patients’ catheter devices to ensure evidence-based best practices are followed to prevent device-associated infections. The device rounds incorporate data collection and real-time discussion, education, and problem-solving to optimize catheter device care measures.

Aggregate data from your monthly CAUTI Device Rounds Checklists by totaling the number of “Yes” responses and enter the total count in the spaces provided below.

Provide the total count for the following with respect to your unit for the month of [MONTH].
	Total count
Total number of central lines assessed
Count of the catheter devices for which the following CAUTI prevention elements were in place. Total number of times where:
Drainage bags were below the patient’s bladder
Drainage bags were off the floor
Drainage bags were less than 2/3 full
Drainage bags were emptied in the last 24 hours
The tubing was off the floor
The tubing was obstructing urine flow (e.g., no kinks, patient not lying on tubing)
The tubing was without dependent loops
The tubing was secured
The closed system was maintained (red seal intact)
Pericare was completed and documented in the last 24 hours
You reviewed the indication and determined the urinary catheter is/was not appropriate and discussed removal
Public reporting burden for the collection of information is estimated to average 90 minutes per response, the estimated time required to complete this assessment. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-XXXX), AHRQ, 5600 Fishers Lane, MS 0741A, Rockville, MD 20857. The confidentiality of your responses is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure.