CAUTI

• Patient Name

• Room number

• MRN

• Personnel

• Conducted on

  Date

• Prepared by

• Location
  Address

EMR

• Order in place

  Yes

  No

  N/A

• Protocol in place

  Yes

  No

  N/A

• Peri care documented every 12 hours

  Yes

  No

  N/A

• Peri care last documented

  Date

Visualization

• Is Foley bag not full

  Yes

  No

  N/A

• Where is Foley bag located

  Select On floor Hanging on bed appropriately Laying in bed with patient If ambulating, hanging below bladder level If ambulating. Hanging on walker/ wheelchair above bladder level If in wheelchair, hanging on side of it below bladder level If in wheelchair. Above bladder level

  • On floor
  • Hanging on bed appropriately
  • Laying in bed with patient
  • If ambulating, hanging below bladder level
  • If ambulating. Hanging on walker/ wheelchair above bladder level
  • If in wheelchair, hanging on side of it below bladder level
  • If in wheelchair. Above bladder level

• Dependent loop absent

  Yes

  No

  N/A

• Green sheet clip utilized

  Yes

  No

  N/A

• Securement device in use

  Yes

  No

  N/A

• Red seal intact

  Yes

  No

  N/A

• Reason to maintain foley

  Select Pt does not meet criteria, discontinue Foley within 2 hours Accurate I/O in critically ill patient Assist healing open perineal/sacral wound in incontinent patients Bladder irrigation or drug instillation Epidural catheter or intrathecal still in place, or in effect Gross he matures or continued irrigation Immobilized pt due to unstable fractures Neurogenic bladder dysfunction Palliative care for terminally ill Pt is hemodynamically unstable Recent bladder or urinary surgery Recent pelvic surgery (I.e.Gyn & colorectal) Urinary obstruction

  • Pt does not meet criteria, discontinue Foley within 2 hours
  • Accurate I/O in critically ill patient
  • Assist healing open perineal/sacral wound in incontinent patients
  • Bladder irrigation or drug instillation
  • Epidural catheter or intrathecal still in place, or in effect
  • Gross he matures or continued irrigation
  • Immobilized pt due to unstable fractures
  • Neurogenic bladder dysfunction
  • Palliative care for terminally ill
  • Pt is hemodynamically unstable
  • Recent bladder or urinary surgery
  • Recent pelvic surgery (I.e.Gyn & colorectal)
  • Urinary obstruction

Nurse observation

• Did nurse use sterile technique to place Foley.

  Yes

  No

  N/A

• Did Nurse use appropriate wipes for q 12 hour pericare<br>Pericare wipes provided. Uses pkg of 5 not large bag of comfort bath<br>

  Yes

  No

  N/A