The Pennsylvania Patient Safety Authority recruited Pennsylvania long-term care (LTC) facilities to participate in a 14-month national catheter-associated urinary tract infection (CAUTI) collaborative led by the Health Research & Educational Trust, an affiliate of the American Hospital Association, funded by the Agency for Healthcare Research and Quality (AHRQ). High-level project goals were to develop and adapt evidence-based CAUTI elimination and safety practices for LTC facilities, to reduce CAUTI rates, and to improve safety culture through improved teamwork and communication in the LTC setting. In December 2015, 10 of the 15 LTC facilities completing the project participated in an online survey to assess whether the AHRQ tools designed for the national project were useful in meeting project goals. The survey results revealed that the project tools were valuable to the majority of respondents by improving CAUTI identification, process and outcome measurement, CAUTI case root-cause analysis, and CAUTI prevention and control measures.
In 2015, Pennsylvania long-term care (LTC) facilities reported 1,079 catheter-associated urinary tract infections (CAUTI) through the Pennsylvania Patient Safety Reporting System (PA-PSRS).1 The Pennsylvania Patient Safety Authority recruited Pennsylvania LTC facilities to participate in a 14-month national CAUTI collaborative led by the Health Research & Educational Trust (HRET), an affiliate of the American Hospital Association, funded by the Agency for Healthcare Research and Quality (AHRQ). The project’s goals were to develop and adapt evidence-based CAUTI elimination and safety practices for LTC facilities, to reduce CAUTI rates, and to improve safety culture through improved teamwork and communication in the LTC setting.
The national project team developed tools to help facilities implement prevention and control measures, structure surveillance activities and identification of CAUTI cases, track and measure performance and outcomes, perform a simple root-cause analysis, and provide robust education and support to participant and facility staff and clinicians. At the project’s end in December 2015, the 15 participants of the Pennsylvania cohort were encouraged to participate in an online survey to evaluate the impact of specific tools and practices used by individual LTC facilities to implement project tasks.
The Authority designed the survey to measure the usefulness and application of practice improvement tools developed by the HRET national project team for the AHRQ Safety Program for Long-Term Care: HAIs/CAUTI. The tools were grouped into five categories: (1) prevention and control measures, (2) process and outcome measurement, (2) root-cause analysis, (4) CAUTI identification, and (5) staff education and support. Survey questions for each practice tool provided two response options. The first response option instructed the respondents to answer “yes” or “no” to specific practice and outcome questions for each of the tools. The second response option instructed the respondents to comment on use of the tools or barriers to implementing the tools or to make any other comments. The survey was sent to the team leaders of each of the 15 facilities that completed the AHRQ safety program. Team leaders functioned in various roles in their facilities and were directors and assistant directors of nursing, infection preventionists, and nurse managers.
Of the 15 LTC facilities that completed the CAUTI project, 11 responded to the survey, and 10 of 11 respondents answered all the questions.
All 11 respondents agreed overall use of the program tools increased staff knowledge about infection control, and helped the infection prevention designee’s job performance; 10 of 11 respondents agreed that the program tools helped identify specific areas to direct infection-control resources and contributed to a decrease in CAUTI. The respondents’ comments included the following:
“The tools were useful visual reminders about all aspects of CAUTI prevention, helpful in staff education, transferrable to myriad other areas, and supplemented corporate tools.”
“Staff let me know how much was learned by sharing bits of information along the way on a one-on-one basis, in morning standup meeting, and small groups.”
Prevention and Control Measures
The HRET National Project Team developed colorful mnemonic infographic posters to display and enhance staff recall of multiple CAUTI prevention practices and team building processes.
Figures 1 and 2 summarize responses to four outcome questions aimed at identifying improved systems and outcomes as a result of using eight CAUTI prevention practices and four team building practices listed in the mnemonic infographic posters. The questions asked whether the tools: (1) were used to change practice, (2) led to improved culture and teamwork, (3) led to decreased catheter utilization, and (4) led to decreased CAUTI.
C.A.U.T.I. Intervention. All of the 10 survey respondents used the C.A.U.T.I. intervention tool to implement all prevention and control strategies. Survey responses to usefulness of the C.A.U.T.I. intervention show effectiveness of the components in all four outcomes, the most impressive being that 80% to 100% of the respondents who used the C.A.U.T.I. intervention tool said implementing one or more practices in the intervention tool led to a decrease in CAUTI (see Figure 1). The definition of the C.A.U.T.I. and the T.E.A.M.S. mnemonic is listed with figures 1 and 2 and in the companion
Pennsylvania Patient Safety Advisory article,
Participating in a National Project, Pennsylvania Nursing Homes Reduce CAUTIs.
Figure 1. Survey Responses: Effectiveness of CAUTI Prevention and Control Measures
Note: Ten of 10 survey respondents used the C.A.U.T.I. tool and responded to each practice question. The components of the C.A.U.T.I. mnemonic infographic are seven prevention and control interventions (some have subcategories): Catheter removal, Aseptic insertion, Use regular assessments, Training for catheter care, and Incontinence care planning.
T.E.A.M.S. Intervention. All 10 survey respondents used the T.E.A.M.S. intervention to implement all team and culture building strategies. Although there was some progress, the low improvement responses to the survey questions on implementation of the T.E.A.M.S. intervention demonstrate the struggle the project participants experienced in improving facility-specific culture and teamwork (see Figure 2).
Figure 2. Survey Responses: Use of the T.E.A.M.S. Intervention to Improve Teamwork And Culture
Note: Ten of 10 survey respondents used the T.E.A.M.S. tool and responded to each practice question. The T.E.A.M.S. mnemonic infographic includes team and culture building interventions: Team formation, Excellent communication, Assessment of what's working, Meeting monthly, and Sustaining efforts.
Four project tools were provided to participating LTC facilities to identify CAUTI, review CAUTI events, perform surveillance, and calculate outcome rates (Table).
Number of Respondents Who Use Tool|
Pre-set Survey Questions
Survey asked users to check "yes" or "no" for each of the following questions:
CAUTI identification tools
|CAUTI case review form |
6 of 11
|Did the case review form help your facility identify resident care issues, barriers to care?||5 of 6|
|Were the results of the CAUTI case review discussed at Quality Assurance Process Improvement Committee meetings?||5 of 6|
|Did the case review result in a change in practice/policy/procedure?||5 of 6|
|Were the case
review results addressed and shared with clinicians and administrators?||5 of 6|
|Did the case review aid in decreasing repeat occurrences of CAUTI?||5 of 6|
|NHSN Definition CAUTI criteria pocket cards |
7 of 10
|Was the CAUTI criteria tool easily accessible for staff use?|| 7 of 7|
|Did the CAUTI criteria tool help staff appropriately identify residents with signs/symptoms of a CAUTI?||7 of 7|
|Did the CAUTI criteria tool help educate staff on appropriate/inappropriate urine culture testing||7 of 7|
CAUTI outcome data definitions
7 of 10
|Did the tool improve your staff's knowledge about outcome data definitions?||6 of 7|
|Was the outcome data definitions tool easy to understand and apply?||6 of 7|
|Did your staff feel more confident the CAUTI definitions are hardwired into practice?||6 of 7|
|Long-term care CAUTI surveillance worksheet ||7 of 10||Did the tool make it easy to identify residents that met or did not meet NHSN criteria for a suspected CAUTI?||7 of 7|
Process and outcome measurement tools ||Indwelling urinary catheter insertion checklist |
8 of 10
|Did the indwelling urinary catheter insertion criteria assist your staff to identify residents who did not meet catheter insertion criteria?||8 of 8|
|Was the tool used EVERY TIME a new catheter was initiated for a resident?||2 of 8|
Indwelling urinary catheter maintenance checklist
5 of 10
|Did you use the indwelling urinary catheter maintenance checklist to standardize indwelling catheter maintenance?|
5 of 5
|Was the use of the indwelling urinary catheter maintenance checklist associated with helping decrease CAUTIs?||4 of 5|
|Has the use of the indwelling urinary catheter maintenance checklist helped educate staff and residents?||5 of 5|
|Has the use of the indwelling urinary catheter maintenance checklist aided in timely catheter removal when applicable?||5 of 5|
Sustainability assessment tool and action plan
|5 of 10 ||Did the sustainability tools help you identify areas of weakness that may impede the future progress of your hard work during this project?||5 of 5|
|Did the sustainability action plan assist you in creating a realistic plan to overcome barriers and continue support and momentum for the project?||4 of 5|
Root-cause analysis tools ||Learn From defects tool ||10 of 10 ||Did the Learn from Defects tool help identify catheter care issues?||10 of 10|
|Did the Learn from Defects tool help you understand the systems/processes behind an identified defect?||9 of 10|
|Did the Learn from Defects tool lead to a change in practice/policy/procedure?||7 of 10|
|Staff safety assessment ||6 of 10 ||Has this tool helped identify potential or actual safety issues?||5 of 6|
|Has your facility encouraged staff to use this tool and follow up with concerns?||4 of 6|
Source: These materials, provided on the Agency for Healthcare Research and Quality (AHRQ) Web site, are government works and are in the public domain only in the United States.
Note: Of the 15 long-term care facilities completing the project, 11 responded to the survey, and 10 of 11 answered all the questions.
CAUTI, Catheter-associated urinary tract infection; NHSN, National Healthcare Safety Network.
CAUTI case review form. Six of 11 respondents used the case review; 5 of 6 users indicated it helped identify resident care issues, facilitated sharing case-review results with staff and the Quality Assurance/Process Improvement (QAPI) Committee, resulted in change in practice, and decreased CAUTI.
NHSN definition CAUTI criteria pocket cards. Seven of 10 respondents used pocket cards that list the National Healthcare Safety Network (NHSN) definitions of CAUTI; all 7 users agreed that the pocket cards helped educate staff on appropriate and inappropriate urine-culture testing and to appropriately identify residents with signs and symptoms of a CAUTI.
CAUTI outcome data definitions. Seven of 10 respondents used the definitions; 6 of 7 users agreed it improved staff knowledge about outcome data definitions and was easy to understand and apply.
Long-Term Care CAUTI Surveillance Worksheet. Seven of 10 respondents used the surveillance worksheet; all 7 users agreed that the surveillance tool facilitated identification of residents who met the (PA-PSRS) criteria for a suspected CAUTI.
Additional respondents’ comments about usefulness of the CAUTI identification tools included the following:
“[The tools] showed me I was incorrectly defining CAUTI.”
“Good comprehensive guidelines for review of each CAUTI case and was beneficial in completing QI [quality improvement] projects for reducing CAUTI.”
Process and Outcome Measurement
The project participants were introduced to three project tools designed to measure compliance with appropriate, aseptic catheter insertion and maintenance best practices and outcomes and sustainability of program improvements (see Table).
Indwelling urinary catheter insertion checklist. Eight of 10 respondents used the tool; all 8 used it to identify residents who did not meet national guidelines for needing an indwelling urinary catheter, but only 2 of 8 used it for
every catheter insertion.
Indwelling urinary catheter maintenance checklist. Five of 10 respondents used the tool; all 5 agreed that the checklist helped standardize indwelling catheter maintenance, educate staff and residents, and aided timely catheter removal when applicable; 4 of 5 users agreed that the tool helped reduce CAUTI.
Sustainability assessment tool and action plan. Five of 10 respondents used the sustainability assessment tool and action plan; all 5 users agreed that the tools identified areas of weakness that may impede the future progress of project work and 4 of 5 users agreed that the tools assisted in creating a realistic plan to overcome barriers and continue support and momentum for the project. Survey respondents’ comments about usefulness of the process and outcome measuring tools included the following:
“[The tools] helped update policies and develop a facility specific checklist.”
“Managers used the tools to determine if practices were consistent with facility policy.”
“The action plan helped to set goals and evaluate outcomes.”
The program provided two tools to the project participants: one to perform a simple root-cause analysis on CAUTI cases and a second to anonymously ask staff whether they believed another person could be harmed from a CAUTI and how to prevent it (see Table).
Learn from Defects tool. All 10 respondents used this tool to help identify catheter care issues; all 10 users agreed the tool helped them identify catheter care issues, 9 agreed it helped them understand the systems or processes behind an identified defect, and 7 agreed that use of the tool led to a change in practice or policy and procedure.
Staff safety assessment. Six of 10 respondents used this tool; 5 users agreed that it helped identify potential or actual safety issues and 4 users encouraged staff to use this tool and follow up with concerns.
Survey respondents’ comments about the usefulness of the root-cause analysis tools included the following:
“The tools helped me concisely communicate the importance of reviewing infections with my staff.”
“A simple method to work on system problems.”
“The information was used in QI projects and safety committee meetings.”
Education and Support
Participating facility teams were offered essential live one-on-one support in the form of coaching calls and on-site visits. Onboarding and educational webinars and live learning and collaborative sessions enhanced the implementation of project goals. Education and support details are discussed in the companion
Advisory article “Participating in a National Project, Pennsylvania Nursing Homes Reduce CAUTIs.”
On-site visits. All 10 respondents agreed that the authority staff visits to each individual facility improved project participation, supported progress and administrative engagement, and provided personalized assistance. Respondents’ comments about the usefulness of the site visits included the following:
“Personalized review of how we measure up to like facilities.”
“Knowledge sharing with administration to see the importance of the project and to present at board meetings.”
“Was the pep talk needed to get on track and realize positive outcomes.”
Coaching calls. Eight of 10 respondents who participated in monthly coaching calls with the Authority staff described helpful takeaways, as follows:
“Evidenced-based research to support practice changes.”
“Came away with feeling of making progress and the time and effort was well worth it.”
“Helped to stay focused and learn from others’ success.”
Onboarding webinars. Eight of 10 respondents participated with their staff in webinars on team building and CAUTI definitions; 6 of 10 respondents participated in webinars on safety culture and surveillance for CAUTI. One facility commented that the education provided information on new technology and offered insight and support.
Live learning sessions. Six of 10 respondents attended one or more of the live learning sessions; 4 of 6 attended the first two sessions; 3 of 6 attended the final learning session (lower participation was because the distance to the event was too far for some). Responses to the question about which session was the most helpful and why included the following:
“It was an opportunity to network with like-minded nurses and use the project tools.”
“The information participants provided helped me to see that other facilities encountered challenges and gave me ideas of how to circumvent some of the challenges this facility encountered.”
The generally positive responses from the practice survey suggest that project tools and individual support from the Authority staff were beneficial to the participants in CAUTI prevention and team building. The responses to the practice survey demonstrated the value of the unique project tools to: (1) evaluate CAUTI prevention and control practices, (2) identify practice changes instituted as a result of the project, (3) identify CAUTI, (4) monitor outcome and process measures, (5) facilitate root-cause analysis of CAUTI events, and (6) improve team culture.
Several of the tools can improve outcomes in myriad other resident safety areas. For example, the T.E.A.M.S. intervention can be applied to any QAPI project, and root-cause analysis can facilitate investigation and elimination of resident safety problems other than CAUTI.
Participating clinicians and administrative teams became more engaged after the personalized on-site visits. Authority staff worked with each facility on the best methods for applying the interventions using their available resources and demonstrated the advantages to their investment, including resident safety, regulatory compliance, and fiscal savings.
Survey respondents shared challenges to implementing one or more of the project tools including: (1) changes in nursing, infection control, and administrative staff, (2) time required to complete some tools, (3) requirement to use a corporate tool rather than a tool provided by the project, (4) lack of buy-in from colleagues, (5) competing priorities, and (6) new administration or upper-level management failing to follow up on concerns. Barriers to use of the indwelling urinary catheter insertion checklist include staffing and time challenges, unavailability of a reviewer in the room at the time of the procedure to observe technique, and lack of staff training, competency, or approved policies and procedures. Some survey respondents commented that implementing team building practices was compromised because of the inability to develop a CAUTI team or to engage administrators in safety rounds. Lack of time was cited as a barrier to attending webinars and coaching calls; prohibitive distance was the most frequent barrier to attending live learning sessions. Engagement of the entire facility team was problematic for some participants because of changes in nursing directors and administration’s disinterest in the project. The specific barriers listed in the survey comments identify specific areas to direct infection-control resources.
Results of the CAUTI prevention practice survey demonstrated that facilities found the project tools valuable to improve CAUTI-prevention systems and practices, improve teamwork, reduce device use, and reduce the rate of CAUTI. The Authority continues to evaluate sustained improvement through review of CAUTI numbers, rates, and device use reported through PA-PSRS, and one-on-one ongoing contacts with participants as needed. Project details are discussed in the companion
Participating in a National Project, Pennsylvania Nursing Homes Reduce CAUTIs.
The tools developed for this national program were unavailable to the public during the course of the program. However, AHRQ selected project tools for release to the
AHRQ Safety Program for Long-Term Care public website after the conclusion of the project in September 2016.2 This practice survey demonstrates that respondents shared successes and suggests that implementing a facility-specific, structured CAUTI-prevention program in a supportive collaborative structure using evidence-based practices and standardized tools to improve systems and teamwork can lead to decreased resident harm from CAUTI.
Christine Roper, MSN, RN, CPEN, of Children’s Hospital of Philadelphia Clinical Documentation Improvement Team, assisted in developing the survey and in presenting data outcomes at the third learning session. Christina M. Hunt, MBA, MSN, RN, HCM, CPPS, Director of Collaborative Programs at the Pennsylvania Patient Safety Authority, and JoAnn Adkins, BSN, RN, CIC, Infection Prevention Analyst at the Pennsylvania Patient Safety Authority, contributed feedback on the survey before its administration.
Pennsylvania Patient Safety Authority. 2015 Pennsylvania Patient Safety Authority annual report. 2016 Apr 29. 98 p. Also available: http://patientsafetyauthority.org/PatientSafetyAuthority/Documents/annual_report_2015.pdf
AHRQ safety program for long-term care: preventing CAUTI and other HAIs. [internet]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2016 Sep [accessed 2016 Oct 05]. Available: