Form 1 Attachment A ICU Assessment

AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Appendix A. ICU Assessment of Current Clinical and Safety Practices

The purpose of this assessment is to understand current HAI prevention practices, policies, and procedures to tailor the educational program to meet your needs. A similar assessment should be administered at the end of the program to monitor any changes in practices, policies, and procedures after program participation.

This form should be completed by the unit project team leader in collaboration with individuals with strong knowledge of current clinical and safety practices in the ICU, such as the ICU manager, infection preventionist, quality leader, clinical educator, or clinical nurse specialist.

About Your Unit

1. Who was involved in the decision for your ICU to participate in this CAUTI and/or CLABSI prevention initiative? Select all that apply.

• ICU manager

• Director of quality

• Chief executive officer

• Chief nursing officer

• Chief quality officer

• Chief medical officer

• Chief financial officer

• Medical director

• Infection preventionist

• ICU staff

• Outside partner organization (e.g., state hospital association)

• Other (please specify): ________________________________________________________

2. How many quality improvement initiatives is your ICU currently working on?

• None

• 1-2

• 3-5

• More than 5

3. Does your ICU experience resource limitations for participating due to competing quality improvement initiatives?

• Yes

• No (→ proceed to question 4)

1. (If Yes) Please describe the resource limitations:

4. For each of the categories below, indicate how many staff members who provide direct patient care in your ICU are part-time or full-time. Enter the number of individual staff members in each category. If you do not have any staff members in a particular category, enter zero (0).

	Number of Part-Time Staff	Number of Full-Time Staff
Registered nurses (RNs)
Licensed practical nurses (LPNs)
Certified nursing assistants (CNAs)
Clinical or medical technicians
Other staff

5. For each of the categories below, please indicate whether staff members perform direct patient care, leadership tasks, or both. Select all that apply.

	Direct Patient Care	Leadership Tasks
Nurse practitioner(s)		
Clinical nurse specialist(s)/clinical nurse leader(s)		
Physician assistant(s)		
Resident physician(s)		

6. What is your unit’s usual registered nurse-patient ratio?

• 1:1

• 1:2

• 1:3

• 1:4 or greater

7. During the last 12 months, what was the average length of stay for patients in your unit? Include only the time patients were in your unit, not the overall hospital length of stay.

Enter the average number of days to two decimal places: _________

8. From the statements below, what would you anticipate will be the top three strengths to implementing this quality improvement initiative in your ICU? Select three.

• Ownership by ICU management

• Ownership by senior leadership

• Ownership by ICU staff

• Standardized processes to affect change

• Team to focus on the project

• Teamwork among team members

• Communication among team members

• Number of physicians in your ICU

• Physician support and/or engagement

• Number of nurses in your ICU

• Nursing support and/or engagement

• Other direct care resources

• Financial resources

• Patient and family engagement

• Integration with other patient safety initiatives

9. From the statements below, what would you anticipate will be the top three barriers to implementing this quality improvement initiative in your ICU? Select three.

• Ownership by ICU management

• Ownership by senior leadership

• Ownership by ICU staff

• Standardized processes to affect change

• Team to focus on the project

• Teamwork among team members

• Communication among team members

• Number of physicians in your ICU

• Physician support and/or engagement

• Number of nurses in your ICU

• Nursing support and/or engagement

• Other direct care resources

• Financial resources

• Patient and family engagement

• Competition with other patient safety initiatives

Current Infection Prevention and Safety Culture Practices - Indwelling Urinary Catheters

10. Are staff in your unit aware of alternatives to indwelling urinary catheters?

• Yes

• No

11. Do staff in your unit use the following alternatives to indwelling urinary catheters? Select one response per row.

	Yes	No	Don't Know
Absorbent pads with scale to weigh urine output	O	O	O
External male catheters	O	O	O
Bedside commode	O	O	O
Scheduled toileting	O	O	O
Toileting rounds	O	O	O
Intermittent catheterization with periodic bladder scanning	O	O	O
Male urinal	O	O	O
Female urinal	O	O	O
Other (please describe below)	O	O	O

1. Please describe other alternatives to indwelling urinary catheters used in your unit:

12. Are the following alternative products to indwelling urinary catheters stocked in your unit? Select one response per row.

	Yes	No	Don't Know
Absorbent pads with scale to weigh urine output	O	O	O
External male catheters	O	O	O
Bedside commode	O	O	O
Intermittent catheter kits	O	O	O
Bladder ultrasound	O	O	O
Male urinal	O	O	O
Female urinal	O	O	O
Other (please describe below)	O	O	O

1. Please describe other alternative products stocked in your unit:

13. Are the following urinary catheter insertion and/or maintenance products stocked in your unit? Select one response per row.

	Yes	No	Don't Know
All-inclusive urinary catheter insertion kit	O	O	O
Hand hygiene supplies: alcohol-based waterless product or antiseptic soap and water	O	O	O
Sterile gloves	O	O	O
Antiseptic solution for cleaning the urethral meatus prior to catheter insertion	O	O	O
Smallest bore catheter possible pre-attached to drainage bag with tamper-evident seal	O	O	O
Smallest bore catheter and separately packaged drainage bags	O	O	O
Urimeter	O	O	O
Catheter securement device	O	O	O
Patient education handout	O	O	O
Procedural checklist customized to your indwelling urinary catheter insertion protocol	O	O	O
Bladder ultrasound scanners to confirm urinary retention before placing or replacing urinary catheters	O	O	O

14. Does your unit have a policy and/or procedure regarding indications for indwelling urinary catheters that incorporates at a minimum the following recommendations from the Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee (CDC HICPAC) Guidelines for Prevention of Catheter-associated Urinary Tract Infections, 2009¹?

	Yes	No	Don't Know
Inserting catheters only for appropriate indications	O	O	O
Minimizing indwelling urinary catheter use in all patients, particularly those at higher risk for CAUTI or mortality from catheterization such as women, the elderly and patients with impaired immunity	O	O	O
Avoiding use of indwelling urinary catheters in patients for management of incontinence	O	O	O
Using indwelling urinary catheters in operative patients only as necessary, rather than routinely	O	O	O
Removing the indwelling urinary catheter from operative patients as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use	O	O	O
Considering the use of a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions	O	O	O
When ultrasound bladder scanners are used, including a step to ensure that - indications for use are clearly stated	O	O	O
When ultrasound bladder scanners are used, including a step to ensure that - nursing staff are trained in the use of the device	O	O	O
When ultrasound bladder scanners are used, including a step to ensure that - equipment is adequately cleaned and disinfected in between patients	O	O	O

15. Does your unit have a policy and/or procedure for inserting indwelling urinary catheters that includes at a minimum the following recommendations from the CDC HICPAC Guidelines for Prevention of Catheter-associated Urinary Tract Infections, 2009?

	Yes	No	Don't Know
Performing hand hygiene immediately before and after insertion or any manipulation of the catheter device or site	O	O	O
Ensuring that only properly trained persons who know the correct technique of aseptic catheter insertion are given this responsibility	O	O	O
Ensuring insertion of indwelling urinary catheters using aseptic technique	O	O	O
Ensuring insertion of indwelling urinary catheters using sterile equipment	O	O	O
Ensuring proper securement of indwelling urinary catheters after insertion to prevent movement and urethral traction	O	O	O
Ensuring that unless otherwise clinically indicated, the smallest bore catheter possible is used, consistent with good drainage, to minimize bladder neck and urethral trauma	O	O	O

16. 16. Does your unit have a policy and/or procedure for maintenance of indwelling urinary catheters that includes at a minimum the following recommendations from the CDC HICPAC Guidelines for Prevention of Catheter-associated Urinary Tract Infections, 2009?

    	Yes	No	Don't Know
    Maintaining a closed drainage system	O	O	O
    Maintaining unobstructed urine flow	O	O	O
    Ensuring that only properly trained persons who know the correct technique of aseptic catheter maintenance are given this responsibility	O	O	O
    Using standard precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system	O	O	O
    Performing daily cleansing of the meatal surface with a non-antiseptic solution (example: soap and water)	O	O	O
    Avoiding changing indwelling urinary catheters or drainage bags at routine, fixed intervals	O	O	O
    Performing daily assessment of ongoing need for the indwelling urinary catheter	O	O	O
    If breaks in aseptic technique, disconnection or leakage occur, replacing the catheter and collecting system using aseptic technique and sterile equipment	O	O	O
    Removing indwelling urinary catheters within 24-48 hours of admission unless there are appropriate indications	O	O	O

17. For each statement below, please indicate whether your ICU conducts audits of the items at least monthly. Note: An audit is defined as an assessment, typically by direct observation, either hospital-wide or ICU-specific, of health care personnel compliance with facility policies.

	Yes	No	Don't Know
Indwelling urinary catheter appropriateness	O	O	O
Date of insertion	O	O	O
Date of removal	O	O	O
Adherence to proper aseptic technique during indwelling urinary catheter insertion	O	O	O
Adherence to proper indwelling urinary catheter maintenance procedures - Maintaining a closed system	O	O	O
Adherence to proper indwelling urinary catheter maintenance procedures - Maintaining unobstructed urine flow	O	O	O
Adherence to proper indwelling urinary catheter maintenance procedures - Securing the catheter to avoid urethral trauma	O	O	O
Adherence to proper indwelling urinary catheter maintenance procedures - Positioning the urine collection bag below the level of the patient’s bladder	O	O	O
Adherence to proper indwelling urinary catheter maintenance procedures - Emptying the collecting bag regularly using a separate collecting container for each patient	O	O	O

18. Please indicate whether your ICU currently uses any of the following:

	Yes	No	Don't Know
Electronic alerts for removing unnecessary indwelling urinary catheters	O	O	O
Written reminders for removing unnecessary indwelling urinary catheters	O	O	O
A dedicated team that inserts, manages and removes indwelling urinary catheters	O	O	O
Guidelines or algorithms for appropriate indwelling urinary catheter management	O	O	O
Multidisciplinary indwelling urinary catheter “rounds”	O	O	O
Nurse-initiated discontinuance of indwelling urinary catheters	O	O	O
Automatic stop orders for indwelling urinary catheters	O	O	O
Routine process to review all CAUTIs with frontline staff, including root cause and possible solutions for prevention	O	O	O

1. If selected above, please indicate who participates in the multidisciplinary indwelling urinary catheter rounds.

	Yes	No	Don't Know
Nurse	O	O	O
Physician	O	O	O
Other	O	O	O

Current Infection Prevention and Safety Culture Practices - Central Lines

19. For each question below, select the appropriate response.

	Yes	No	Don't Know
Is an all-inclusive central line insertion kit stocked in your unit?	O	O	O
Is alcohol-based waterless product stocked in your unit?	O	O	O
Is antiseptic soap and water stocked in your unit?	O	O	O
Are masks, caps, sterile gowns, and sterile gloves to be worn by all health care personnel involved in the procedure stocked in your unit?	O	O	O
Are large (full-body) sterile drapes to cover the patient stocked in your unit?	O	O	O
Is alcohol chlorhexidine antiseptic for skin preparation stocked in your unit?	O	O	O
Are central line dressing change kits stocked in your unit?	O	O	O
Are chlorhexidine-impregnated dressings or patches/discs stocked in your unit?	O	O	O
Are positive displacement needleless connector valves for central venous catheters stocked in your unit?	O	O	O
Are patient education handouts stocked in your unit?	O	O	O
Is a procedural checklist customized to your central line insertion protocol stocked in your unit?	O	O	O
Do staff use ultrasound scanners to guide internal jugular vein line placement as appropriate?	O	O	O
If a central line cart is used, is there a clear process for assembling and restocking the central line cart?	O	O	O

20. Does your unit have a current policy and/or procedure for insertion and maintenance of central lines that includes the following?

	Yes	No	Don't Know
Use of line insertion checklist	O	O	O
Routine use of alcoholic chlorhexidine antiseptic for skin preparation prior to insertion	O	O	O
Use of chlorhexidine-impregnated dressing/patch or disc	O	O	O
Avoidance of the femoral site for central venous access	O	O	O
Empowerment of staff to stop a non-emergent central line insertion if proper procedures are not followed	O	O	O
Use of ultrasound for central line placement	O	O	O
Use of a vascular access team to insert PICC lines	O	O	O
Performance of hand hygiene prior to central venous catheter insertion or manipulation	O	O	O
Daily audits for central line necessity	O	O	O
Daily audits for central line removal	O	O	O
Changing of transparent dressings and performance of site care with a chlorhexidine-based antiseptic every 5-7 days or immediately if the dressing is soiled, loose or damp	O	O	O
Changing of gauze dressings every two days or earlier if the dressing is soiled, loose or damp	O	O	O
Use of a routine flushing and/or locking solution for central venous catheters	O	O	O
When adherence to aseptic technique cannot be ensured (e.g., catheters inserted during a medical emergency), replacement of the catheter as soon as possible, i.e., within 48 hours	O	O	O
Prompt removal of central line if no longer necessary	O	O	O

21. For each statement below, please indicate whether your ICU conducts audits of the items at least monthly. Note: An audit is defined as an assessment, typically by direct observation, either hospital-wide or ICU-specific, of health care personnel compliance with facility policies.

	Yes	No	Don't Know
Central line appropriateness	O	O	O
Central line insertion documentation that includes date of insertion	O	O	O
Central line removal documentation that includes date of removal	O	O	O
Adherence to proper aseptic technique during central line insertion	O	O	O
Adherence to appropriate port antisepsis prior to accessing central line	O	O	O
Adherence to proper central venous blood specimen collection technique	O	O	O
Adherence to proper central line maintenance procedures inclusive of discussions of central line necessity for each patient during patient rounds	O	O	O
Adherence to proper central line maintenance procedures inclusive of assessment of proper hand hygiene used by all personnel involved in central line care for each patient	O	O	O
Adherence to proper central line maintenance procedures inclusive of assessment of dressing integrity at each shift	O	O	O
Adherence to proper central line maintenance procedures inclusive of use of chlorhexidine for skin antisepsis	O	O	O
Adherence to proper central line maintenance procedures inclusive of central line tubing changes as indicated by protocol	O	O	O
Other central line maintenance procedures (describe below)	O	O	O

1. Please describe other central line maintenance procedures audited:

22. Please select the appropriate response for each statement below.

	Yes	No	Don't Know
Our ICU performs root cause analysis on all central line-associated blood stream infections.	O	O	O
Our ICU bathes patients daily with chlorhexidine.	O	O	O
Our ICU uses antiseptic or antibiotic-impregnated or coated central venous catheters.	O	O	O

General Questions

23. A competency assessment is defined as a process of ensuring that health care personnel demonstrate the skills and knowledge to perform a procedure properly and according to facility standards and policies. This may be done through direct observation by trained observers of personnel, performing a simulated procedure on a mannequin or an actual procedure on a patient.²

1. Please select whether your ICU conducts competency assessments of the staff who perform the items listed below upon hire/during orientation.

	Yes	No	Don't Know
Insert indwelling urinary catheters to ensure proper aseptic technique	O	O	O
Care for indwelling urinary catheters to ensure proper maintenance procedures	O	O	O
Care for central venous catheters to ensure proper dressing change procedures	O	O	O

2. Please select whether your ICU conducts competency assessments of the staff who perform the items listed below at least annually.

	Yes	No	Don't Know
Insert indwelling urinary catheters to ensure proper aseptic technique	O	O	O
Care for indwelling urinary catheters to ensure proper maintenance procedures	O	O	O
Care for central venous catheters to ensure proper dressing change procedures	O	O	O

24. Nursing staff feel comfortable questioning colleagues who are not following appropriate procedures for indwelling urinary catheter insertion and maintenance

• Yes

• No

• Don’t know

25. Nursing staff feel comfortable questioning colleagues who are not following appropriate procedures for central line insertion and maintenance

• Yes

• No

• Don’t know

26. Does your unit have an active antibiotic stewardship program/process in place?

• Yes

• No

27. Staff correctly perform hand hygiene greater than 95% of the time based on direct observations

• Yes

• No

• Don’t know

28. When was the last culture of safety survey in your unit? MM/DD/YYY

    1. What type of survey was given?

• Hospital Survey on Patient Safety (HSOPS)

• Safety Attitudes Questionnaire (SAQ)

• Manchester Patient Safety Assessment Framework (MaPSaF)

• Other

29. Please respond to the following statements about your ICU in general. In the last year,

	Never	Rarely	Some-times	Often	Always
Staff members anecdotally report having too many quality improvement priorities	O	O	O	O	O
Staff members anecdotally report feeling positively recognized by their manager for their efforts to improve quality in the ICU	O	O	O	O	O
Staff members anecdotally feel supported by senior administration	O	O	O	O	O
Staff members anecdotally feel supported by the physicians practicing in the unit	O	O	O	O	O
Staff members anecdotally report feeling supported by other staff for their efforts to improve quality in the ICU	O	O	O	O	O
Our ICU worked as a team to improve processes and quality care for all patients	O	O	O	O	O
All ICU staff were held equally accountable for improving quality in our ICU	O	O	O	O	O

1. Comments:

30. Does your ICU or organization recognize staff for their efforts to improve quality?

• Yes

• No (→ proceed to question 31)

1. (If Yes) What are some ways your ICU or organization recognizes staff for their efforts to improve quality? Select all that apply.

• Verbal acknowledgement (public or private)

• Formal acknowledgement (such as performance reviews or documentation in employee record, individual recognition program)

• Monetary incentives

• Non-monetary incentives (food, day off, etc.)

• Other (please specify): _________________________________________________

31. Do you have a quality improvement champion(s) for CAUTI within your unit? Note: A champion staff is an individual who will be supporting these quality improvement initiatives.

• Yes

• No (→ proceed to question 32)

1. (If Yes) Who is/are your CAUTI champion(s)? Select all that apply.

• Quality manager

• Infection preventionist

• Nurse

• Physician

• Unit leader

• Other (please specify): __________________________________________________

32. Do you have a quality improvement champion(s) for CLABSI within your unit? Note: a champion staff is an individual who will be supporting these quality improvement initiatives.

• Yes

• No (→ proceed to question 33)

1. (If Yes) Who is/are your CLABSI champion(s)? Select all that apply.

• Quality manager

• Infection preventionist

• Nurse

• Physician

• Unit leader

• Other (please specify): __________________________________________________

33. Does your ICU use specific methods to enhance teamwork and communication?

• Yes

• No (→ proceed to question 34)

1. (If Yes) Please select the methods your ICU uses to enhance teamwork and communication. Select all that apply.

• Briefings

• Huddles

• Daily patient goals

• Multidisciplinary rounds

• Other (please specify): __________________________________________________

34. With whom do you share your CAUTI and/or CLABSI surveillance data?

	CAUTI only	CLABSI only	CAUTI and CLABSI	Neither
Hospital board members	O	O	O	O
Senior leaders/executives	O	O	O	O
ICU managers	O	O	O	O
All ICU nursing staff	O	O	O	O
All physicians providing care to patients	O	O	O	O
Patients and family members	O	O	O	O

35. In the past 30 days, a senior leader has conducted patient safety rounds on the unit

• Yes

• No

• Don’t know

36. Does your project team meet at least once a month to discuss progress towards CAUTI and/or CLABSI goals?

• Yes

• No

• Don’t know

37. Does your ICU share your CAUTI and/or CLABSI surveillance data with frontline staff?

• Yes

• No (→ proceed to question 38)

1. (If Yes) How does your ICU share your CAUTI and/or CLABSI data with frontline staff? Select all that apply.

• TAP reports

• Scorecards

• Daily huddles

• Team meetings

• Other: _______________________________________________________________

1. How frequently do you share your CAUTI and/or CLABSI data with frontline staff? Select one.

• At least daily

• At least weekly

• At least monthly

• At least quarterly

• At least yearly

• Ad hoc (i.e., only when there is an infection to report)

38. Please list titles of the individuals who collaborated in the completion of this form.

	Title

# # # #

1 The CDC HICPAC guidelines are evidence-based practices regarding infection control and prevention. Access at https://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf

2 Competency assessment definition sourced from the WHA fillable CAUTI TAP tool.

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