Appendix Figure A. Flow Diagram of Traditional Surveillance.

Appendix Figure A is a flow diagram demonstrating the ICPs’ protocol for performing traditional CAUTI surveillance without the assistance of the electronic surveillance system. Boxes shaded in light grey indicate electronic or paper records obtained by the ICPs. White boxes and arrows describe steps taken in the ICPs’ workflow. Dark grey boxes indicate stopping points in the workflow (e.g., when a potential CAUTI is “screened out” and discarded or is deemed to be a candidate CAUTI). To begin, on a daily basis, a designated ICP would query the Infection Control Unit’s web-based repository of clinical microbiological data (QC Pathfinder, Vecna Technologies, Cambridge, MA), generating a hospital-wide list of medical record numbers (MRNs) for all patients with urine cultures processed by the microbiology lab within 48 hours. The ICP manually reviewed this list and selected all positive urine cultures, excluding those with “mixed bacteria.” Next, the designated ICP searched the patients’ electronic medical record to determine which positive urine cultures met NHSN criteria for colony growth. For cultures meeting colony growth criteria, the ICP then reviewed the patient’s history in the electronic medical record and paper chart to determine whether or not the patient was in an ICU at the time or within 48 hours of urine culture specimen collection. For all potential CAUTI, the ICP printed separate reports for each ICU and distributed these lists to the staff member covering the unit. Each ICP then provided the list of MRNs and dates to the Infection Control Unit database manager, who accessed the computerized nursing care record and generated a list of dates on which each patient had an indwelling urinary catheter in place. The ICPs then manually cross-referenced the printed lists of positive urine cultures by MRN with the list of patient catheter-days. For all patients with co-occurring indwelling urinary catheters and positive urine cultures, the ICP reviewed the electronic medical record, the microbiological and urinalysis data, as well as the paper chart to determine whether a potential case met NHSN CAUTI criteria. All identified cases meeting CAUTI criteria were reported to the NHSN’s secure internet-based surveillance system.