1.
Divide into small groups of 2-3 people.
2.
Groups should work through each part of the case scenario, pausing for discussion before moving to the next section.
You are assigned to take care of Mrs. Smith, an 85 year old transferred from the hospital 5 days ago following a fall and broken hip. She had an indwelling urinary catheter in place at the time of transfer.
The evening shift notes mention that she didn’t eat or drink much at dinner. On your morning visit, you notice that the urine from the catheter is cloudy and foul smelling. Mrs. Smith is awake and states that her pain medication makes her mouth dry and she doesn’t have much of an appetite for breakfast. The charge nurse suggests sending a urine analysis (UA) because her decreased appetite and change in the character of her urine might be early signs of a CAUTI. Discuss within your group.
1.
Do you agree or disagree with the charge nurse and why?
FACILITATOR NOTES:
At this point, the resident doesn’t have any clinical signs or symptoms of a symptomatic catheter – associated urinary tract infection. Therefore, it is not clear that sending a UA would be indicated. In addition, she has an alternate explanation for her change in appetite, side effect of pain medication, and change in urine character, dehydration.
Use this question to review the CAUTI definitions and the criteria listed on the CAUTI surveillance worksheet.
2.
If you were concerned about CAUTI, what additional information about Mrs. Smith would you like to know?
FACILITATOR NOTES:
If a resident is suspected of CAUTI, then staff should perform a clinical history and exam to try to determine if localizing signs or symptoms are present. Actions which could be taken include:

Checking vital signs

Asking about new complaints

Performing an exam of the abdomen and suprapubic area
In addition, this should be an opportunity to evaluate the functioning of the urinary catheter, the duration of time it has been in place, review the indication for its use and consider whether the device is still necessary.
Use this time to explore how well details about the catheter are documented at your facility. When residents are transferred from the hospital with an indwelling urinary catheter, does your facility receive information about indication for use and the date of insertion for the device? If not, how could that information be obtained? Does your facility have consistent documentation of urinary catheter indication and date of insertion when the device is placed in the long-term care facility? If not, how could that be improved?

3.
Who else should be notified about the concerns that you and the charge nurse are having?
FACILITATOR NOTES:
Talk about the communication process in your facility when a CAUTI or UTI is suspected. Does your facility use a standard communication tool (e.g., SBAR) for sharing information with providers (e.g. physicians, physician assistants, nurse practitioners)? Discuss how information might impact provider decisions.
The charge nurse calls the physician to discuss Mrs. Smith’s condition. The physician decides to follow the advice of the charge nurse and send a UA and urine culture.
1.
Is it likely that the UA results will demonstrate presence of WBCs in the urine (e.g. positive for leukocyte esterase)? Is it likely that the urine culture will grow bacteria?
ANSWER: YES
Explanation: Given the presence of the urinary catheter, it is highly likely that the UA will be abnormal and the urine culture will be positive.
2.
Will the findings on the UA and culture help decide if Mrs. Smith has a CAUTI? Why or why not.
ANSWER: NO
Explanation: The presence of pyuria and bacteriuria are NOT enough to define a symptomatic CAUTI. The presence of pyuria and asymptomatic bacteriuria (ASB) are very common in individuals with indwelling urinary catheters. Remember, signs and symptoms are key to distinguishing ASB from CAUTI.
3.
Are there other measures that the charge nurse or physician could have considered in the management of Mrs. Smith?
FACILITATOR NOTES:
Perhaps the physician could have evaluated the current pain medication she is receiving to see if that may be contributing to her loss of appetite. Oral hydration may have helped improve the volume and character of her urine output. Close monitoring of vital signs and ongoing evaluation for other signs and symptoms while hydrating would ensure that if her status declined, it would be detected quickly. The UA and culture is often an easy first step in our assessment, but it could prevent us from identifying the true cause of a resident’s problem.
4.
How would you recommend monitoring Mrs. Smith given what you’ve been told so far? Would the results of the urine testing change your management plan?
FACILITATOR NOTES:
As discussed above, it would be very reasonable to review Mrs. Smith’s pain medication regimen.
Encourage her to increase oral hydration and food intake and monitor her closely for new signs or symptoms.
The UA results were positive for pyuria and also showed evidence for bacteria (positive nitrites). The culture is still pending. When Mrs. Smith’s usual physician was notified of the UA results, she requested vital signs be checked and Mrs. Smith have increased fluid intake in case she was becoming slightly dehydrated. She also recommended that Mrs. Smith have more frequent vital sign monitoring and screening for any new signs or symptoms that were suggestive of a catheter-related complication for the next 24 hours.
Case Scenario 1: Mrs. Smith 2

Mrs. Smith had normal vital signs and seemed to be at her baseline until she was checked in the afternoon following physical therapy (PT). During her transfer from the wheelchair to her bed, her urinary catheter collection bag, which had been hooked to the arm of her wheelchair for transport, became tangled with the wheel. As she moved over to the bed, she developed acute pain, which then subsided. About 30 minutes later, her collection tube has not drained any fresh urine and she has begun complaining of lower pelvic discomfort whenever the catheter is handled.
1.
Could Mrs. Smith be developing new signs of a CAUTI? Are there any other explanations for her signs/symptoms?
FACILITATOR NOTES:
Acute lower pelvic pain could be a symptom of CAUTI, but given the history of catheter trauma during her transfer from the wheelchair to bed, this is more likely due to dislodgement of the catheter. Given that the catheter has not been draining urine, you have to consider whether the tubing has become kinked or the balloon has been pulled out of place.
2.
What might be steps to address Mrs. Smith’s new situation?
FACILITATOR NOTES:
It would be important to exchange the catheter (if she still requires it) given that the current device is not working. She should continue to be monitored for signs/symptoms of CAUTI given that the urine flow was obstructed for a period of time.
3.
Were there issues with her catheter’s handling during and after PT which might have contributed to her symptoms?
FACILITATOR NOTES:
While there may not be adequate information in this clinical scenario to know what was done with the catheter during PT, knowing that someone thought it was okay to raise the collection bag above the level of the bladder during transport to the room, raises the concern that some of the therapists and/or nursing staff may not know how to correctly handle this device. Raising the collection bag above the bladder allows urine to flow backwards into the body. This can increase risk of CAUTI. Also, allowing the tubing to get tangled and pulled during care activities can cause serious injury and discomfort for residents and disrupt the functioning of the device.
Use this time to review the catheter maintenance and insertion checklists. Discuss opportunities to educate all staff about safe catheter handling, including hand hygiene and gown/glove use for insertion and emptying collection bags.
Case Scenario 1: Mrs. Smith 3