Frequently Asked Questions

• Getting Started
• Data Collection
• Indications for Catheter Placement
• Care and Removal of Catheters
• Key Contacts

Getting Started

1. How can I join On the CUSP: Stop CAUTI? — State level coordinators initiate and manage participation of hospital teams in On the CUSP: Stop CAUTI. If you are a member of a hospital team and have an interest in joining the initiative, contact the coordinator for your state. A list of state coordinators can be found here. If you are with a state organization such as a state hospital association, state health department, or a QIO, contact Deborah Bohr at dbohr@aha.org to learn more about how to get involved.

2. Who is eligible to participate? — All adult and pediatric acute care, critical access, and long-term acute care hospitals are eligible to participate. A primary goal of the initiative is to improve safety culture, which is specific to individual units. Therefore, all participating teams should be unit-based, and cross-unit team formation is discouraged.

3. Does the national On the CUSP: Stop CAUTI project team collect data, or does each participating state collect data and submit results? — Each participating hospital unit team is responsible for data collection on their unit. Data is then submitted to the MHA Care Counts database on a monthly basis.

4. In what format are data collected? — Monthly data elements are entered into the web-based data portal, MHA Care Counts. At the start of the project, a readiness assessment is administered through SurveyMonkey. Data collection tools are available to help unit teams streamline and organize data collection and submission processes.

5. How much time is required for participation? — Approximately 10 percent of a project team leader’s time should be committed to the initiative. Team leaders are usually nurse managers, but may also be frontline nurses, physician champions, or quality and safety improvement leaders. Two to four hours per month of a physician champion’s time and five percent of a data coordinator’s time should be committed to the project as well. All unit team members should participate in on-boarding calls, regular monthly content and coaching calls, and in three one-day learning sessions that occur at the beginning, middle, and end of the project.

6. Who should be on our unit team? — At a minimum, all hospital unit teams should include: a physician champion, nurse champion (if the project leader is not a nurse), data coordinator, and hospital executive champion.

7. How many people from each hospital team should travel to the state-hosted, face-to-face educational meetings? — A minimum of two or three members from each hospital unit team should attend the state-level, face-to-face learning sessions, as the learning sessions are intended to support team development and interaction. It is recommended that at least one physician, one nurse, and one infection control practitioner attend from each team.

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Data Collection

1. Which reason for having a catheter today should be recorded in Care Counts if a nurse documented “I&O Critical Illness” as reason for Foley continuation for a patient on a general surgical unit? — If you have a formally approved hospital policy that allows the continuation of catheters outside of the intensive care unit for intake and output monitoring, then the “hospital approved indication” would be appropriate. We still encourage you to assess the continued need for the catheter in these cases and explore alternatives such as measuring urine from a bedpan using a graduated cylinder, condom catheters for male patients, or daily weights.

2. Do we include our swing bed, OB and hospice patients in patient and catheter day counts? — As long as 80 percent of the patients on any unit are of the type described for that location type (see chapter 15 of the NHSN manual http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf ) there is no need to exclude any patients from the patient count nor their catheter days from the catheter day count. This means that if there are a few swing beds on the unit, but these account for less than 20 percent of the patients on the unit, these patients will be included in the count. If hospice and OB patients are part of the unit that is participating in the project, then these patients should be included in the count.

3. How should suprapubic catheters that are hooked to Foley bags and draining be counted? — Suprapubic and condom catheters are not counted in the study for catheter days or infections.

4. Should patients with continuous bladder irrigation be counted? — Those with bladder irrigation have a urological problem that is being managed (usually hematuria, clots so possible conditions that may cause urinary obstruction). These catheters are counted like other indwelling urinary catheters (Foleys) for the study. Infections related to these catheters are also counted.

5. If our hospital collects HSOPS data at a different time than the project requests it, can we use the data we submitted to our hospital? — Yes, you can, but it might delay the state level reports. The data must be survey level, unit specific, response rate >60% and have discipline identifiers.

6. Why is it necessary to have two different methods for counting days? — The population based outcome measure, patient-days denominator, is a better measure for interventions to reduce inappropriate use whereas the NHSN measure is the best to evaluate the proper aseptic placement and maintenance of the device. Because of this, we have chosen to use both methods of counting days.

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Indications for Catheter Placement

1. For a severe CHF patient, is a Foley not considered an appropriate intervention to record I and O? — We do not promote using the urinary catheter for those with CHF in the non-ICU setting. Work with the cardiologists on other ways to assess dieresis such as daily weights.

2. Is catheter placement for chronic UTIs ever an appropriate indication? — Clarify what is meant by chronic UTIs on your unit. Sometimes the term “chronic UTI” is used for patients who have urinary structural abnormalities (either obstruction or leading to neurogenic bladder) that lead to persistent bacteriuria in a person with the same organism. In this situation, the reason for the “chronic UTI” is what should be entered as the indication.

3. If a patient has a complicated urologic surgery and is in an intensive care unit postoperatively with a catheter needed beyond the immediate 24 hour post-op period because of the nature of the surgery, could the indicator “perioperative use in selected surgeries” apply?–It is part of the perioperative appropriate indications, and the limit of use is based on whether the catheter is still needed based on the urology team evaluation. However, if the urologist recommends that the catheter is no longer needed but in the ICU they required fluid monitoring, the indication will change to fluid monitoring in ICU.

4. Should catheters be placed preoperatively for urine analysis/culture and sensitivity on total hip replacement patients? — Urine culture before orthopedic surgery is not evidence-based. The only two indications to test and treat asymptomatic bacteriuria prior to operation are urologic studies and pregnancy.

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Care and Removal of Catheters

1. What is the role of the executive team and physician team in catheter removal? — One key in On the CUSP: Stop CAUTI is to obtain physician staff support. Catheter removal should be ordered by a physician or nurse driven with physician support. The indications need to be agreed on by the medical and nursing staff. Usually urinary catheters placed or followed by urology are not included in the assessment for removal by nurses without physician order. It is easier if the hospital has bladder scanners to assess for retention post Foley removal if patient does not urinate after a period of time. Each hospital needs to have their own process established for removal without physician order.

2. Is it preferred to change Foleys every 72 hours? — Routine change of urinary catheters should not be done. For the hospital setting, Foleys should not be changed unless there is a mechanical problem, a break in the closed system of the catheter, or clinical indications. It may also be considered when treating CAUTI per Category IIC of the HICPAC guidelines.

3. What is best practice for catheters that require irrigation after GU surgery? — This is not easy to do without breaking the system especially if there are clots. There are three-way urinary catheters that can be used, and it should be done very infrequently.

4. How should you accommodate intra-abdominal pressure monitoring if the process requires breaking the system to connect the pressure monitor? — You may need to change the Foley at the same time to prevent introducing organisms up to the bladder.

5. Are silver-impregnated catheters appropriate for routine use or use greater than five days and do you consider them effective in CAUTI prevention? — Given the important clinical and economic consequences of catheter-associated urinary tract infection (CAUTI), researchers have tried novel approaches to prevent this common patient safety problem. Several clinical and economic studies have evaluated antimicrobial urinary catheters. While the studies to date appear to indicate that antimicrobial catheters reduce (or delay) bacteriuria, it remains unclear if these novel catheters will reduce clinically more important endpoints, such as symptomatic infection or urinary tract-related bacteremia. However, in patients at high-risk of CAUTI (e.g., neutropenic and severely immune-compromised patients) or of developing a complication after bacteriuria occurs, or in those hospitals that have unacceptably high CAUTI rates despite adherence to other preventive strategies, antimicrobial catheters may play an adjunctive role in preventing CAUTI. Additional information can be found on CatheterOut.org (http://www.catheterout.org/?q=antimicrobial-catheters).

6. What should I do if the stabilization device is obstructing flow? — The issue may be that the device is positioned in a way that kinks the tubing. Check this and if it appears to be the device, contact the manufacturer about the issues.

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Key Contacts

If you have a specific question about any of the topic areas in the chart below, see the contacts listed in the chart.

For general inquiries to the national project team, contact Paul Tedrick at 312-422-2625, email onthecuspstophai@aha.org,