Safety Teams and Organizational Structure
    Access to Information
    Facility Expectations
    Engagement of Patient/Client/Resident and Family












Key Items

Road Map to a Comprehensive Healthcare-Associated Infections (HAI) Prevention Program. Complete the HAI road map prior to beginning the gap analysis.

Catheter Associated Urinary Tract Infections (CAUTI) Prevention Strategies - Gap Analysis. Complete this gap analysis to identify where you need to develop action plans.

Catheter Associated Urinary Tract Infections (CAUTI) - a priority healthcare-associated infection

CAUTI Gap Analysis

The Catheter Associated Urinary Tract Infections (CAUTI) Prevention Strategies - Gap Analysis includes a checklist of core and enhanced prevention strategies. Core prevention strategies should always be in place. Examples include:

  • Provide patient/family education.
  • Ensure appropriateness of catheter placement.
  • Insertion practices.
  • Catheter maintenance practices.
  • Removal practices.
  • Documentation practices.
  • Education specific to urinary catheter use.

Enhanced prevention strategies should be considered in addition to core strategies when there is evidence of:

  • Core strategies not being implemented and adhered to consistently
  • Ongoing transmission of CAUTI
  • CAUTI rates not decreasing
  • Change in CAUTI pathogenesis (e.g., increased morbidity/mortality among CAUTI patients)








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You'll notice that some sections of this website lack supporting materials. We're asking CHAIN participants to share tools and resources to add to this site. Sharing knowledge will help us all provide better care to people in Minnesota.

Send us your tool and resource suggestions.

Be an active member of CHAIN. Together, we can reduce HAI rates.

Tools for CAUTI Road Map Topics -

Supporting CAUTI Reduction

Use these sample tools as templates and to take action in your organization.

Patient and Family Education


  • Alternatives to urinary catheters
  • Appropriate use of indwelling catheters

Insertion - Insertion practices

Maintenance - Catheter maintenance practices

Removal - Removal practices

Documentation - Documentation practices

CUSP CAUTI Data Collection Tool. Use this data collection tool to track catheter use, including documenting appropriate and inappropriate indications and actions taken. (2-worksheet Excel doc)

General Resources

Sample Tools - Apply/Take Action

Dialysis Safety. Resources and tools for preventing HAIs in dialysis clinics from the Centers for Disease Control and Prevention. Viewed 8/30/12.

Foley Catheter Tracking Tool. A tool to use for catheter utilization quality tracking.

How-to Guide: Prevent Catheter-Associated Urinary Tract Infections. Prevent catheter-associated urinary tract infections by implementing the four components of care recommended in this Institute for Healthcare Improvement guide. (28-page PDF)

How to Report Zero CLABSI or CAUTI Events for a Month. In order to fully comply with NHSN and CMS reporting requirements, facilities that include Device-Associated Module surveillance (CLABSI and CAUTI) in their monthly reporting plan must indicate when they have zero infection events to report for each NHSN location and event in the plan for a given month. Doing this provides a “true zero” for your facility. (4-page PDF)

Jerri’s Story. An interruption in an elder's happiness. Use this patient story as an educational tool for staff. The story demonstrates how a patient’s urinary tract infection lead to a serious surgical site infection with devastating consequences.

Sample Policy & Procedure for CAUTI. Addresses how to implement best practices for prevention of CAUTI using evidence-based guidelines to prevent and eliminate these infections and comply with zero tolerance for preventable HAIs. Lifecare Medical Center, April 2010. (2-page Word doc)

Professional Education and Training

Introduction to National Healthcare Safety Network (NHSN) CAUTI. Defines resources and methods for CAUTI surveillance, reviews requirements for CAUTI reporting to CMS through NHSN, defines key terms, criteria and application, and how to collect and enter data. Presented by Angela Antilla-Bivens, RN, MSN, NP-C, CIC CDC DHQP. December 2011. (48-minute video) 

NHSN CAUTI Case Studies. These 11 case studies help to understand NHSN definition August 2011. They highlight common errors and difficult issues. Presented by Angela Antilla-Bivens, RN, MSN, NP-C, CIC CDC DHQP. December 2011. Minnesota Department of Health (24-minute video) 


Catheter-Related Bloodstream Infection Prevention Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. Centers for Disease Control and Prevention (CDC) guidelines to reduce the incidence of intravascular catheter-related bloodstream infections (CRBSI).

Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009. CDC guideline for the prevention of catheter-associated urinary tract infections (CAUTI) in all healthcare facilities caring for patients that require urinary catheterization.

Patient Education

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CHAIN is an effort lead by the Association for Professionals in Infection Control and Epidemiology-Minnesota (APIC MN), Minnesota Department of Health, Minnesota Hospital Association, and Stratis Health, which represents Lake Superior Quality Innovation Network in Minnesota.