4 CAUTI Gap Analysis

A ttachment G: CAUTI Gap Analysis

CAUTI Gap Analysis

The purpose of this assessment is to understand current indwelling catheter-associated urinary tract infections (CAUTI) prevention practices, policies, and procedures on your unit in order to identify areas of strength and opportunities to focus team actions. This assessment can be repeated over time to monitor any changes and support continued actions. Changes that might initiate a repeat of the assessment include an increase in CAUTI events, reduced compliance with urinary catheter insertion or maintenance process measures, or significant staff turnover.

This form should be completed by the individuals from your CUSP team (or unit patient safety team) who are or will be leading CAUTI prevention initiatives. This should include at least the physicians/advanced practice practitioner lead(s), nurse lead(s), and the infection preventionist assigned to the unit. This form will take approximately 60 minutes to complete.

Current Infection Prevention Practice

For each question below select the appropriate response.

Alternatives to Indwelling Urinary Catheters

Question	Yes	No	Don't Know
Do you have a protocol to determine what patients are candidates for avoiding urinary catheters?	O	O	O
1a. If a protocol exists, is it available at the point of care?	O	O	O
1b. If a protocol exists, is evidence that the protocol is applied to individual patients documented in the medical record?	O	O	O
Do you have non-invasive urinary management products to avoid indwelling urinary catheters in men available for use?	O	O	O
Do you have non-invasive urinary management products to avoid indwelling urinary catheters in women available for use?	O	O	O
Does your unit have a protocol for scheduled toileting?	O	O	O
Does your unit perform toileting rounds?	O	O	O
Does your unit have access to an ultrasound bladder scanner?	O	O	O
6a. If your unit has access to a bladder scanner, do nurses undergo standard training in its use?	O	O	O
6b. If your unit has access to an ultrasound bladder scanner, does your unit have a protocol for intermittent catheterization with periodic bladder scanning?	O	O	O
6c. If your unit has access to a bladder scanner, does your unit have a protocol to confirm urinary retention before placing or replacing urinary catheter?	O	O	O
6d. If your unit has access to an ultrasound bladder scanner, it is adequately cleaned and disinfected in between patients?	O	O	O

Insertion Equipment

Question	Yes	No	Don't Know
Is an all-inclusive urinary catheter insertion kit stocked in your unit	O	O	O
Is antiseptic solution for cleaning the urethral meatus prior to catheter insertion stocked in your unit?	O	O	O
Does your unit provide the smallest bore catheter possible pre-attached to a drainage bag with tamper-evident seal?	O	O	O
Does your unit provide the smallest bore catheter with a separately packaged drainage bag?	O	O	O
Are urimeters stocked in your unit?	O	O	O
Are catheter securement devices stocked in your unit?	O	O	O

Insertion Steps

Question	Yes	No	Don't Know
Is a procedural checklist customized to your indwelling urinary catheter insertion protocol available at the point of care (e.g., paper form, form in the electronic health record)?	O	O	O
Is the checklist used for every urinary catheter insertion?	O	O	O
Is completion of the checklist documented in the medical record?	O	O	O
Are nursing staff empowered to question colleagues who are not following appropriate procedures for indwelling urinary catheter insertion?	O	O	O
Is hand hygiene embedded as a step in your urinary catheter insertion checklist?	O	O	O
Do you have a protocol to ensure use of the smallest bore catheter that meets clinical needs to minimize bladder neck and urethral trauma?	O	O	O
Are all indwelling urinary catheters inserted using aseptic technique?	O	O	O
Are all indwelling urinary catheters inserted using sterile equipment?	O	O	O
Are all indwelling urinary catheters secured to prevent movement and urethral traction at the time of placement?	O	O	O
Is the date of insertion of the urinary catheter documented?	O	O	O

Maintenance Steps

Question	Yes	No	Don't Know
Are nursing staff empowered to question colleagues who are not following appropriate procedures for indwelling urinary catheter maintenance?	O	O	O
Is hand hygiene embedded in training materials for indwelling catheter maintenance?	O	O	O
Do staff use standard precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system?	O	O	O
Is a closed drainage system maintained in patients with indwelling catheters in > 95% of cases?	O	O	O
Is unobstructed urine flow maintained in patients with indwelling catheters in > 95% of cases?	O	O	O
Is the urine collection bag below the level of the patient’s bladder in > 95% of cases?	O	O	O
Is the urine collection bag emptied at regular intervals?	O	O	O
Is changing indwelling urinary catheters or drainage bags at routine, fixed intervals avoided?	O	O	O
If breaks in aseptic technique, disconnection, or leakage occur is the catheter and collecting system changed using aseptic technique and sterile equipment?	O	O	O
Is cleansing of the meatal surface with a non-antiseptic solution performed daily?	O	O	O
Is securement of the urinary catheter maintained throughout the time it is in place?	O	O	O
Do you allow urine cultures to be collected from the collecting bag?	O	O	O
Do you allow urine cultures to be collected from the catheter drainage port?	O	O	O
Do you change urinary catheters before collecting urine cultures?	O	O	O

Removal

Question	Yes	No	Don't Know
Do you have an algorithm available at the point of care to help personnel determine when an indwelling urinary catheter is clinically indicated?	O	O	O
Do you have a standardized workflow for clinical teams to have a daily meaningful conversation about indwelling urinary catheter necessity?	O	O	O
Do you have a protocol for nurse-initiated discontinuance of indwelling urinary catheters?	O	O	O
Do you have automatic stop orders for indwelling urinary catheters?	O	O	O
Do you utilize electronic alerts for removing unnecessary indwelling urinary catheters?	O	O	O
Do you utilize written reminders for removing unnecessary central lines or indwelling urinary catheters?	O	O	O
Do you have a protocol to remove indwelling urinary catheters from operative patients as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use?	O	O	O

Policies, Training, and Feedback

Question	Yes	No	Don’t know
Do you have a hospital policy to avoid indwelling urinary catheters whenever possible that includes your unit?	O	O	O
Do you have a policy to avoid use of indwelling urinary catheters in patients for management of incontinence that includes your unit?	O	O	O
Do you have a policy to use indwelling urinary catheters in operative patients only as necessary, rather than routinely that includes your unit?	O	O	O
Do you have a hospital policy (or policies) for indwelling urinary catheter insertion that outlines roles, responsibilities, and the requirements for urinary catheter placement?	O	O	O
Do you have a hospital policy (or policies) for indwelling catheter maintenance that outlines roles, responsibilities, and requirements?	O	O	O
Do you have standardized training for healthcare personnel who insert indwelling urinary catheters?	O	O	O
49a. If Yes, when is this training required? Select all that apply.	At orientation To gain insertion privileges Annually Other (please specify): _______________
Do you have standardized training for healthcare personnel who maintain indwelling urinary catheters?	O	O	O
50a. If Yes, when is this training required? Select all that apply.	At orientation Annually Other (please specify): _______________
Do you conduct competency assessments for staff who perform insertion of indwelling urinary catheters to ensure proper aseptic technique? Select all that apply.	At orientation Annually No Don’t know Other (please specify): _______________
51a. If Yes, when do these assessments occur? Select all that apply.	At orientation To gain insertion privileges Annually Other (please specify): _______________
Do you conduct competency assessments for staff who care for indwelling urinary catheters to ensure proper maintenance procedure? Select all that apply.	At orientation Annually No Don’t know Other (please specify): _______________
52a. If yes, when do these assessments occur? Select all that apply.	At orientation Annually Other (please specify): _______________
Do you require that staff must be trained before inserting an indwelling urinary catheter?	O	O	O
Do you have a comprehensive program to monitor hand hygiene that involves your unit?	O	O	O
Do you have a comprehensive program to operationalize daily chlorhexidine treatment that involves your unit?	O	O	O
Do you have a dedicated team that inserts, manages, and removes indwelling urinary catheters?	O	O	O
Do you have a standardized workflow for a member of the infection prevention team and a unit member to observe and audit indwelling urinary catheter insertion regularly?	O	O	O
When you have elevated CAUTI rates, do you implement standardized workflows for a member of the infection prevention team and a unit member to observe and audit indwelling urinary catheter insertion monthly?	O	O	O
Do you have urinary catheter device rounds at least monthly?	O	O	O
Do you systematically review each CLABSI to determine gaps in evidence-based practice and opportunities for improvement?	O	O	O
Does your team meet at least once a month to discuss progress towards CAUTI goals?	O	O	O
In the past 30 days, has a senior leader/executive conducted patient safety rounds on the unit?	O	O	O
Do you systematically review each CAUTI to determine gaps in evidence-based practice and opportunities for improvement?	O	O	O
Does your team meet at least once a month to discuss progress towards CAUTI goals?	O	O	O
Does your unit receive regular reports from the infection prevention and control program on your CAUTI rates?	O	O	O
Does your unit receive regular reports from the infection prevention and control program on process measures related to CAUTI prevention?	O	O	O
With whom do you share your CAUTI surveillance data? Select all that apply.	Stakeholder Hospital board members Senior leaders/executives Unit managers All unit nursing staff All physicians providing care to patients Patients and family members Other unit within your healthcare system None of these Don’t know
Are patient education handouts about CAUTI quality improvement efforts available in your unit (e.g., on paper or in EHR or another website readily available for download)?	O	O	O
Is a safety climate survey completed at least annually by individual healthcare providers on your unit?	O	O	O
In the past 30 days, has a senior leader/executive been present at a CUSP activity on your unit?	O	O	O
Has your unit experienced > 25% nursing staff turnover in the past year?	O	O	O
What is your unit’s usual registered nurse-to-patient ratio?	1:1  1:2  1:3  1:4 or greater

Self-Reported Change in HAI Rates and HAI Prevention Processes will be administered with the endline Gap Analysis. One unit lead and one infection preventionist will self-report change in HAI rates and HAI prevention processes per unit at the end of implementation.

• “Since the beginning of the implementation, have your units' HAI rates improved?"

• “Since the beginning of the implementation, have your units' HAI prevention processes improved?"

Public reporting burden for the collection of information is estimated to average 60 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, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

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.