Manager Review Date: _____________
UBC Review Date: ________________
Date due to IP Team:
CAUTI Prevention Case Review-Unit Level Assessment
Nurse Sensitive Outcome Indicators
Investigating Unit:
Date admitted to Unit:
Date UA collected (from IP report):
Pt Account #:
Location of Patient day before UA/C&S:
(NHSN tool for IP use to determine correct unit designation)
Date indwelling urethral catheter (IUC) inserted:
Number of days after insertion date was infection identified?
Dept where IUC inserted:
Organism Identified:
Record the highest value from 2 days before urine collection date to 2 days after (infection window)
Highest Temp:
Highest WBC:
Same organism & same sensitivity identified from other site within 48 hr?
Yes  No 
List other site(s): ______________________________________________________________________
Date IUC removed: _____________
Type of urethral catheter:
Urethral Indwelling  Coude’ 
Other (Specify) __________________
3-Way Indwelling Urethral 
Temperature Sensing Indwelling Urethral 
Standardized Procedure (SP 115) used every shift by registered nurse:
Yes  No 
MD documentation for reason to continue IUC found (Specify): _____________________________
If IUC present, Physician orders present and rationale for IUC documented (Specify): ______________________
Proper size used for appropriate gender:
Female (14 French) Yes  No 
Male (16 French) Yes  No 
Peri care documented: Yes  No 
Other, per MD order (specify)______________
Securement Device documented? Yes  No 
Direct observation of patient (if still on unit) OR select another patient with an IUC
No dependent Loops 
Bag off floor 
Bag below bladder 
Interview with (any) RN on date of investigation. Discuss knowledge of:
Aseptic Insertion  Catheter & Perineal Care 
Describe SP.115 implementation 
What risk factors were present at the time of the CAUTI?  loose stools   extended stay  >65yrs  Female
 immune suppressed  recent urological procedure  multiple co-morbidities  Other: describe
CUSP Questions for UBC:
Was this event preventable? Did we do everything possible to prevent? (Yes or No is required)
 Yes: _____________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
 No: State what measures were implemented for prevention: _________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What can we do differently to improve patient safety and outcomes? _________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
UBC action plan (must include measurable dates): ________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Date action plan reported/scheduled for staff meeting discussion (must be within 30 days of UBC meeting): ________________
UBC Chair signature: _____________________ Date: _______ Manager signature: _______________________Date: __________
Fax to:
Infection Prevention: 713-2471
Please submit on or prior to due date listed on this form