Applying the NHSN CAUTI Criteria to Case Studies National Content Series for All Staff July 16, 2015 Welcome to today’s content webinar for all LTC facility staff on how to apply the NHSN CAUTI criteria to case studies. This webinar is part of the Agency for Healthcare Research and Quality’s (or AHRQ’s) Safety Program for Long-term Care that addresses healthcare-associated infections (or HAIs) and catheter associated urinary tract infections (or CAUTI).

Learning Objectives Upon completion of this webinar, all long-term care facility staff will be able to: apply CAUTI signs and symptoms as defined by the NHSN criteria in long-term care to case studies; identify how they can help reduce healthcare-associated infections and provide safer resident care; and explain the importance of different team member's role in connecting CAUTI identification to their facility's overall safety plan for residents and staff. Upon completion of this webinar, all Long-term Care facility staff will be able to: apply CAUTI signs and symptoms as defined by the NHSN criteria in long- term care to case studies; identify how they can help reduce health care-associated infections and provide safer resident care; and explain the importance eahc team member's role in connecting CAUTI identification to their facility's overall safety plan for residents and staff.

Why Should We All Care About Surveillance? Essential component of the infection prevention program Protects the resident & employee’s health Part of the facilities’ performance improvement plan; provides feedback for your infection prevention program Information may be useful for residents and family members CMS regulatory requirements Whether you know it or not surveillance projects are underway at your facility. Performing surveillance activities allows facilities to study and measure resident care. Surveillance activities are an essential component of any infection prevention program. They help protect the residents and employee’s health, provide feedback for your facility’s infection prevention program, informs customers (like residents and families) and helps facilities achieve CMS regulatory requirements. Essentially, surveillance helps facilities set priorities. And remember, resident safety and infection prevention is everyone's responsibility.

Preventing CAUTI is a Team Sport All health care personnel, regardless of their discipline, are important with ongoing resident awareness and assessing for CAUTI and other changes in condition Make this part of your facility safety plan! All health care personnel, regardless of their discipline, should be involved in ongoing resident awareness and assessment for changes in condition. This type of surveillance should be part of your facility’s safety plan.

Four Questions to Identify a CAUTI Does the resident have an indwelling urinary catheter connected to a drainage device? Does the resident have one or more CAUTI symptoms? There is no other explanation for this resident’s symptoms? Does the resident have a urine culture that fits the criteria? In order to have a successful CAUTI surveillance program and incorporate it into your facility’s safety plan, all staff need to be familiar with the CAUTI signs and symptoms. And staff involved in direct resident care should also be familiar with how to observe, report and document these symptoms. So, we are going to take a few minutes and review the CAUTI definition we learned in onboarding 2. If you suspect that a resident has a CAUTI, there are four simple questions you should ask yourself: Does the resident have an indwelling urinary catheter connected to a drainage device? Does the resident have one or more CAUTI symptoms? There is no other explanation for this resident’s symptoms? Does the resident have a urine culture that fits the CAUTI criteria? [Click] If you answered “YES” to all of these questions, then the resident does indeed have a CAUTI. YES YES YES YES then the resident has a CAUTI!

What are the Signs and Symptoms of CAUTI? ONE or MORE of the following: CAUTI Signs and Symptoms Fever Rigors (chills and sweats) 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 Now lets review the NHSN signs and symptoms that could indicate a CAUTI. These signs and symptoms include: Fever Rigors New onset confusion or functional decline : (with NO alternative diagnosis AND leukocytosis) New onset of suprapubic pain or costovertebral angle pain or tenderness New onset hypotension Acute pain, swelling or tenderness of the testes, epididymis or prostate gland Purulent discharge or pus from around the catheter And remember 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 that meets the NHSN criteria it will count as a CAUTI. If you need to refresh yourself on the details of how to identify these symptoms, review the onboarding 2 video for all staff. See Onboarding 2: CAUTI Definitions and Reporting video for all LTC staff for further details

Urine Odor Urine odor may result from: Dehydration Medications e.g. antibiotics Foods e.g. asparagus, onions, garlic Total Parenteral Nutrition (TPN) Alcohol, coffee Urinary tract infection Urine odor or smell, by itself, does not predict a UTI You may have noticed that urine odor was not on the list as a symptom that indicates a CAUTI. This is because odorous, or foul smelling urine, is NOT a CAUTI sign or symptom. There are many different conditions that could contribute to a resident’s smelly urine. These include: Dehydration Resident’s medications, e.g. antibiotics Certain foods such as asparagus, onions and garlic Total Parenteral Nutrition (TPN) Alcohol, coffee Urinary tract infection Urine odor or smell, by itself, does not predict a UTI. Instead, carefully assess the resident’s condition and share your findings with the appropriate team members.

NHSN Definitions Pocket Cards CAUTI Criteria - NHSN Definitions Pocket Cards The NHSN definition pocket cards, available on the ltcsafety.org project website, can also help you understand and remember the CAUTI criteria. The definition pocket cards are especially helpful with CAUTI identification during routine resident care. They detail the signs and symptoms of a CAUTI and can aid in ongoing assessment of residents with urinary catheters. Nursing and nursing assistive staff can use the pocket cards while rounding to evaluate residents for possible signs and symptoms of CAUTI; and physicians and clinicians may use them to evaluate residents with signs and symptoms of CAUTI before prescribing antibiotic treatment. Remember, that any change in a resident’s condition, should be promptly reported to the appropriate clinical staff

Preventing CAUTI is a Team Sport Role Scene Observation CNA Morning care Purulent discharge around the catheter PT Physical therapy session New onset of confusion Unit secretary Speaking with resident Pain RN Care Flushed appearance Dietary Staff Dining room Shaking/chills Here are some examples of the types of observations different staff members might make related to CAUTI surveillance: Maybe a CNA notices purulent discharge around the catheter during resident morning care The physical therapist detects a new onset of confusion while working with the resident Perhaps the unit secretary notices that the resident appears to be having pain while when he/she stops by to chat All staff being on the look-out for such signs and symptoms helps contribute to the facility surveillance program. [CLICK] In your facility, do all team members, who clearly play a role with resident safety, feel comfortable with relaying this information to the appropriate staff? [Pause for Discussion] Do all team members, who clearly play a role with resident safety, feel comfortable with relaying this information to the appropriate staff?

Wrap-up Infection prevention should be part of your facility’s resident safety plan All team members should continually assess the residents for possible CAUTI, other infections and changes in condition All team members need to promptly report any changes in condition to the appropriate clinical team members Training materials offer additional opportunities to review case scenarios to better equip the team with assessing the residents for possible CAUTI, other infections and changes in condition To summarize today’s training, remember that infection prevention should be part of your facility’s resident safety plan. Take time to discuss with your team how you keep residents safe and prevent infections. Remember that all team members should continually assessing the residents for possible CAUTI, other infections and changes in condition. By promptly reporting changes in a resident’s condition to the appropriate clinical team members, you are keeping the resident safe. Identify who on your clinical staff team you would report this to if you haven’t already. The training materials provided offer you with an opportunity to review case scenarios to better equip you with assessing residents with indwelling urinary catheters for a possible CAUTI, other infections and changes in condition.

Stay Updated with Useful Resources NHSN Criteria—CAUTI Definition Pocket Cards CAUTI Surveillance Worksheet CAUTI Case Review Form As we wrap up today’s discussion, I’d like to thank you for viewing this presentation. We need all staff’s input to reduce HAIs and CAUTIs in long-term care facilities. The following resources are available to you as participants in the AHRQ Safety Program for Long-term Care: HAIs/CAUTI project. Resources: The first resource is a link to the 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. The second resource is a link to the TeamStepps for Long-term Care web page. 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. The third resource is a link to NHSN Criteria CAUTI Definition Pocket Cards. The final resource is a link to the CAUTI surveillance worksheet, designed to assist teams in reviewing a resident’s chart for a suspected CAUTI. The final resource is a link to the CAUTI Case Review Form, designed to identify possible resident care issues that may have contributed to a CAUTI. We hope that these resources will be helpful on your journey to reduce CAUTIs and HAIs and improve your facility’s culture of safety. Thank you for your time and attention.

References Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee (HICPAC) approved guidelines for the Prevention of catheter-associated urinary tract infections, 2009. Available at http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf. Centers for Disease Control and Prevention. Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance (online). Accessible at: http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf. National Healthcare Safety Network (NHSN). Long-term Care Facility (LTCF) Component Healthcare Associated Infection Surveillance Module: UTI Event Reporting [online]. 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):965-977.