Emergency Department Improvement Intervention

Onboarding Webinar

June 12, 2013

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On the CUSP: Stop CAUTI

Today’s PresentersMohamad Fakih, MD, MPH

St. John Hospital and Medical Center

Marlene Bokholdt, MS, RN, CPENEmergency Nurses Association (ENA)

Jeremiah Schuur, MD, MHS, FACEP Brigham and Women’s Department of Emergency Medicine

Mariana Lesher, MSHealth Research & Educational Trust (HRET)

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Reducing Unnecessary Urinary Catheter Use in the Emergency Department:

Why and How to Implement the Process

Mohamad Fakih, MD, MPHAssociate Professor of Medicine

Wayne State University School of MedicineMedical Director, Infection Prevention and ControlSt. John Hospital and Medical Center, Detroit, MI

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ED Improvement Intervention Objectives

• Improve the compliance with the appropriate indications for UC placement in the emergency department for: 1. Physicians2. Nurses

• Improve the compliance with proper technique for placement.

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Case Scenario: “John”An 85-year-old male with dementia

• John was transferred from the nursing home to the hospital because of a non-functioning gastrostomy (PEG) tube. In the ED, the nurse noted he was incontinent and placed a urinary catheter (UC).

• John was admitted and the PEG tube was changed. That night, he became more confused and pulled on his UC, leading to severe hematuria and a urologic evaluation.

• Within 24 hours, John spiked a fever and blood cultures were positive.

• John was treated for CAUTI and required a prolonged hospital stay.

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Case Scenario: “Jane” An 82-year-old woman admitted for

congestive heart failure

• Jane had a urinary catheter (UC) placed and was started on diuretics. She appeared frail. In the ED, the physician and nurses felt that keeping the catheter in place would make her more comfortable.

• On the 5th day of admission, Jane started complaining of chills, had a fever of 102°F, and her BP dropped to 90 systolic. Blood cultures and urine cultures grew Escherichia coli.

• Jane was diagnosed with symptomatic CAUTI and had to be treated with intravenous antibiotics.

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How to Improve Urinary Catheter (UC) Use in the ED?

• Establish clear guidelines for UC insertion in the ED.

• Engage physicians (significant role in UC use).• Engage nurses (significant role in UC use).

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Prepare for the ED Program

1. Obtain leadership support:– Administrative– Clinical

2. Identify the team:– ED physician champion (leader)– ED nurse champion (leader)– Project Manager: point person to facilitate

implementation of the program and be accountable for data collection.

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Prepare for the ED Program

3. Establishing Institutional Guidelines:– The proper indications for UC placement in the

ED are based upon the CDC HICPAC guidelines. – It is acceptable to consider having alternate

institutional guidelines (or additional agreed upon indications) for UC placement for the ED.

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2009 Prevention of CAUTI HICPAC Guidelines

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Appropriate Indications: Acute Urinary Retention or Obstruction

• Outflow obstruction: examples include prostatic hypertrophy with obstruction, urethral obstruction related to severe anasarca, urinary blood clots with obstruction

• Acute urinary retention: may be medication-induced, medical (neurogenic bladder) or related to trauma to spinal cord

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Appropriate Indication: Accurate Measurement of Urinary Output in the Critically Ill Patients

• CDC HICPAC definition of “critically ill” is not very clear.

• In the ED, we may consider placement for patients likely to be admitted to ICU and will require fluid monitoring.

• Discontinue the UC if patients improve with treatment in ED, and it is no longer necessary.

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Appropriate Indication: Perioperative Use in Selected Surgeries

• Anticipated prolonged duration of surgery, large volume infusions during surgery, or need for intraoperative urinary output monitoring

• Urologic surgery or other surgery on contiguous structures of the genitourinary tract

• This indication will be more applicable to the surgical team evaluating the patient

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Appropriate Indication: Assist Healing of Perineal and Sacral Wounds in Incontinent Patients

• This is an indication when there is concern that urinary incontinence is leading to worsening skin integrity in areas where there is skin breakdown.

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Appropriate Indication: Hospice/Comfort Care/Palliative Care

• Patient comfort at the end-of-life• Check with the patient before placing UC.

What provides most comfort to the patient.

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Appropriate Indication: Required Immobilization for Trauma or Surgery

Including:

1. Unstable thoracic or lumbar spine

2. Multiple traumatic injuries, such as pelvic fractures

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Questionable Indications: Chronic Indwelling Urinary Catheter upon Admission

• Chronic indwelling UC is defined as present for >30 days.

• Difficult to find the reason for initial placement when assessed.

• We suggest that these patients represent a special category and may need a further assessment for the appropriateness of catheterization.

• Considered to have an acceptable indication for UC use until more information is available (primary care physician evaluation).

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How Do We Achieve Agreement on Acceptable Indications?

• Each institution may have additional reasons (beyond CDC HICPAC appropriate indications) for UC placement in the ED.

• Indications should be clearly identified during program preparation.

• We suggest limiting the additional acceptable indications to a minimum.

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Common Conditions where the Catheter is Placed Inappropriately

Physician and Nurse Practice

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Examples of Common Conditions where the Catheter May Be Placed Inappropriately

Who is Critically Ill? Unconsciousness versus Agitation

• Admitted to ICU• Requiring high amounts of Oxygen (e.g., >4

liters, >6 liters, or on 100% O2 non-rebreather)?

• Agitated patients may have a higher risk of trauma related to UC, if placed.

• Evaluate whether you have any standing orders for UC placement as a part of the treatment of acute stroke.

Emergent Pelvic Ultrasound for Pregnancy? Frail and Immobile patients

• Placing UC would increase the risk for introducing bacteria to the bladder.

• Patients can drink fluids and will have a full bladder without risk.

• It is usually an issue with workflow in the ED.

• The UC reduces mobility, and makes patients at a higher risk for pressure ulcers.

• Frail patients may become more deconditioned with a UC and infectious complications (CAUTI) may result in poor outcomes.

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The Measurement Phases of the ED Improvement Intervention

• Baseline• Intervention

– Pre-implementation– Implementation

• Sustainability

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ED Improvement Intervention Timeline

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Intervention

Defining the ED Measurement Phases

• Baseline: assess the proportion of those UCs placed (evaluate the magnitude of the problem of inappropriate use)

• Intervention: assess whether the placement of UCs has dropped, and inappropriate use

• Sustainability: continued reduction in placement rate will reflect whether the program effect persists

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How to Spread the Message• Pocket cards, posters,

lectures, and algorithms describing the appropriate indications.

• Make sure the information is shared with nurses and nursing assistants, staff physicians, physicians-in-training, and mid-level providers

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For Patients Requiring a UC

1. Ensure your policies for placing the UCs are up to date.

2. Ensure the staff placing UCs are evaluated for competency (i.e., know proper insertion technique).

3. Consider using a catheter insertion kit that includes all the elements required for insertion.

4. May use simplified insertion checklist for periodic audits.

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Simplified Insertion Checklist for UC Placement

Components of ChecklistCompliant

Yes Yes, after correction

Hand hygiene before and after procedure?

Sterile gloves, drapes, sponges, aseptic sterile solution for cleaning, and single use packet lubricant used?

Aseptic insertion technique (no contamination during placement)?

Proper securement of urinary catheter post-procedure?

Closed drainage system and bag is below patient post-procedure?

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What is the UC Evaluation Process?

Physician and nurse evaluate patient.

Decision to place a UC based on

appropriate indication.

Patient’s ED nurse

reevaluates need for UC and reason

for use before transfer to

unit.

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UC Evaluation: Data Collection in the Emergency Department

• A form is completed by the ED nurse transferring the patient to the hospital unit:1. Patient with or without catheter2. Reason for use of catheter (for internal

evaluation)3. If no appropriate reason, nurse to evaluate

removal

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ED Intervention Urinary Catheter (UC) Data Collection Form Patient #__________________ Date:_____________________ UC (Foley) placed in ED: Yes No If yes, physician order present* Yes No If placed in ED, reason*

Appropriate Indications Inappropriate Reasons for Placement

Urinary flow obstruction or retention (e.g., prostatic hypertrophy, hematuria with clots, urethral stricture, trauma to urethra, neurogenic bladder, including paraplegia/quadriplegia if unable to straight catheterize)

Incontinence

Morbid obesity

Immobility not related to trauma

Dementia/chronic confusion

Debility (very frail patients)

Perioperative use in selected surgeries (e.g., urologic procedures, surgeries contiguous to genitourinary tract, emergency surgery with anticipated large fluid resuscitation or extended duration, or if needed for intraoperative urine output monitoring)

Monitoring fluids in non-critically ill patients

Urine specimen collection

Patient request

Need for immobilization because of trauma with multiple fractures (e.g., pelvic fractures, hip fractures with risk of displacement) or unstable spine

If other, please state:

Monitoring fluids in critically ill patients

Assist healing of sacral and perineal wounds in those with incontinence

To improve comfort for end of life care (eg, hospice, palliative care, comfort care)

Acceptable conditions per institutional guidelines:

*Data recommended for internal evaluation only.

UC Evaluation: Data Collection Form• Example of the

form that may be used for those collecting data in the emergency department (ED)

• Used during intervention and sustainability periods.

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UC Evaluation: Metrics to Evaluate Improvements

Measurement Calculation

Required for reporting to national project:

ED UC Placement

Rate=

(Number of ED admissions with a newly-placed indwelling UC, including observation patients)

X 100(Number of ED admits from the ED, including

observation patients)

Optional recommended to internal evaluation:

Inappropriately Placed UC Rate =

(Number of UCs placed in the ED without appropriate indication) X 100

(Total number UCs placed in the ED)

Documented Physician Order

to Place UC Rate

=

(Number of UCs placed in the ED without a documented physician’s order) X 100

(Total number of UCs placed in the ED)

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ED Intervention Checklist for Success

• Select physician and nurse champions.• Establish agreed upon ED institutional

guidelines.• Create a mechanism to ensure data collection

(and feed the data back to different stakeholders).

• More ED resources available here on our project website.

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The CAUTI Emergency Department Improvement

Intervention

Marlene Bokholdt, MS, RN, CPENNursing Education Editor

Emergency Nurses Association

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Learning Objectives

• Identify why the ED is getting involved in CAUTI prevention

• Review the points of impact for the emergency nurse in CAUTI prevention

• Define how the Emergency Nurses Association, and other national organizations can support ED involvement

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Why the Emergency Department?

• Most urinary catheters placed• Emergency environment and team• Intuitive vs. analytic decision making• Three points of impact

– Decision to insert– Insertion technique– Maintenance– Decision to remove

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Decision to Insert

• Responsibility• Communication

– Team– Patient and family

• Provision of care • Documentation prompts

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CAUTI Myths

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Perception FactsFacilitates I/O measurement

Alternatives are available with less risk (e.g., urinals, daily weights)

Prevents falls from getting up to urinate

Increases risk to fall, especially in the confused patient

Protects skin in the incontinent patient

Increases risk of skin breakdown from immobility, muscle loss, and catheter-related trauma

Saves time for the bedside nurse

Extended LOS, infection complications, and other risks, it does not

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Other indications for urinary catheter:Urinary retention/obstruction?

o Use bladder scanner firstImmobilization needed for trauma or surgery?Incontinent with open sacral/perineal wounds?End of life/hospice?Chronic or existing catheter use?

o Re-evaluate need and discuss with provider

Insert catheter and treat signs of shock:HypotensionDecreased cardiac output/functionDecreased renal functionHypovolemiaHemorrhage

Re-assess after intervention

Do NOT insert

Explore alternatives

Still critically ill, requiring accurate output measurement?

Insert or maintain catheter Remove catheter

prior to admission

Is the patient critically ill and will require accurate output measurement?

Insertion Technique

• Emergency vs. sterility?– Hygiene then sterility

• Competencies– Review catheter insertion technique

• Two-person procedure– Because you can do it alone, doesn't mean you should

• Checklists• Supplies

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Decision to Remove

• Re-evaluation prior to admission• Not an ED issue…Maybe, maybe not

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The CAUTI Emergency Department Improvement Intervention

What is the On the CUSP: STOP CAUTI ED Improvement Intervention?

• Expanding the reach of the On the CUSP: STOP CAUTI national collaborative

• Instilling a culture of partnership between emergency departments and in-patient units

• Broadening exposure to national experts Emergency Nurses Association (ENA) American College of Emergency Physicians (ACEP)

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ED Improvement Intervention

Goals: Best practice techniques for CAUTI Prevention

• Technical change (Process): Determine catheter appropriateness

Preventing unnecessary placement Promoting compliance with institutional guidelines

Promoting proper insertion techniques

•Culture change (CUSP): Teamwork and communication amongst frontline staff Identify nurse and physician champions for leadership and buy-in Collaboration with in-patient units

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ED Improvement Intervention

National project support includes:

•Comprehensive ED Tool Kit with customizable resources

•Educational events: National expert presentations Coaching support by the National Project Team In-person training opportunities

•Data collection and analysis

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ED Nursing Education Presentation

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Case Scenario: “John”An 85-year-old male with dementia

•Brought to the ED with a nonfunctioning PEG tube. •Noted to be incontinent and a urinary catheter is placed.•Admitted for a PEG change. •Overnight he became more confused; pulling on his catheter. •Developed severe hematuria; urology evaluation.•Within 36 hours

– Febrile– Positive blood cultures– Treated for CAUTI – Required a prolonged hospital stay

ED Physician Champions for CAUTI

Jeremiah D. Schuur MD, MHS, FACEPBrigham and Women’s HospitalAmerican College of Emergency

Physicians

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Learning Objectives

• Review physicians’ role in urinary catheter placement

• Identify strategies for improving appropriateness

• Review role of physician champion in CAUTI project

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Physician Role in Urinary Catheter Placement

• All urinary catheters require an order…

• Yet, the decision to place a catheter is not the ED ordering provider’s alone:– ED nurse– Patient & Family– Consultant (e.g. Trauma)– Admitting service (e.g. Cardiology)

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ED Workflow and Culture & Urinary Catheter Placement

• ED workflow requires physicians and nurses to work in parallel

• Nurses often assess a patient and consider a catheter before the ordering provider

• Patterns of ED catheter use have developed over time and reflect local practice patterns

• It will take teamwork from physicians, nurses and others to avoid CAUTI

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Role of ED Physician Champion to Reduce CAUTI

• Promote reduction of catheter use by championing appropriateness

• Encourage interdisciplinary conversation around catheter use

• Engage other services around patterns of catheter use

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Identify Common Patterns of ED Catheter Use

• Measuring urine output in stable patients– CHF

• Assessing bladder volume– Urinary retention from spinal injury

• Protocolized care for trauma

• Incontinence without open sacral or perineal wounds

• Pre-operative

• Existing catheter use

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Other indications for urinary catheter:Urinary retention/obstruction?

o Use bladder scanner firstImmobilization needed for trauma or surgery?Incontinent with open sacral/perineal wounds?End of life/hospice?Chronic or existing catheter use?

o Re-evaluate need and discuss with provider

Insert catheter and treat signs of shock:HypotensionDecreased cardiac output/functionDecreased renal functionHypovolemiaHemorrhage

Re-assess after intervention

Do NOT insert

Explore alternatives

Still critically ill, requiring accurate output measurement?

Insert or maintain catheter Remove catheter

prior to admission

Is the patient critically ill and will require accurate output measurement?

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Improving Appropriateness• Review appropriate indications for catheters

with medical staff– CDC/HICPAC Guidelines– Pathway

• Implement appropriateness criteria in workflow– Ordering process: Computer physician order entry or

Paper order sets– Pathway

• Give feedback to medical staff on catheter appropriateness

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Case Study: Trauma

• Historically most trauma patients received a catheter as part of evaluation & resuscitation– ATLS 8th edition recommends urinary catheters for

assessing hemodynamic status– Often placed by junior trainee

• Identify current practices• Review protocol with ED and Trauma leaders• Set clear criteria for catheter use• Designate appropriate staff to place catheters

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Case Study: Congestive Heart Failure

• Many CHF patients get a catheter to monitor urine output

• Identify motivations for pattern of care– Medical necessity? -- Not if able to regularly void & stable– Patient convenience?– Staff convenience?

• Strengthen protocols for tracking urine output• Meet with Cardiology to examine practice

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Collaboration with Nursing

• Encourage communication at the time of catheter ordering/placement– “Huddle” re: need for catheter– Acknowledge nursing’s deeper knowledge of

patient and ability to care for self

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Champion Roles

• Share data on catheter use with medical staff– Break out by physician if possible

• Circulate descriptive summaries of any CAUTIs that are attributed to ED placement

• Communicate with other medical services about specific patterns of care

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Emergency Department Data

Mariana Lesher, MSSenior Data Analyst

Health Research & Educational Trust

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CDS Registration• Send the following information to Keesha

Mwangangi kmwangangi@aha.org:

• Comprehensive Data System (CDS) Login ID and Password provided by HRET. – Following registration, an email will be sent to the

Principal Data Person

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All items in RED are required for ED registration

State Hospital name

Unit name

Principal data perso

n’s first name

Principal data

person’s Last

name

Principal data

person’s email

Principal data

person’s Phone

Team Lead First

Name

Team Lead Last

Name

Team Lead email

Team Lead

Phone

ED Physician Champion First Name

ED Physician Champion Last Name

ED Physician Champion

email

1

2

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Entering Data in CDS is Simple!

• Log into CDS with login ID and passwordhttps://www.hretcds.org

• Select the measure, then click “enter data”*

*Data entry dates will vary per cohort and unit58

ED Data Entry• Select baseline (first 14 days only) or monitoring

(implementation and sustainability) tab

• Select date*, then click “Go”

*Data entry dates will vary per cohort and unit59

Enter These Three Simple Items

1. Was data collected

(yes or no)?

2. If YES, enter numerator & denominator

3. SAVE or SUBMIT

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Upcoming Events & Next Steps

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• August ED Office Hours: Wednesday, August 14, 2013 at 11 ET/10 CT/9 MT/8 PT

• Review all “Resources” located on the project webpage: http://www.onthecuspstophai.org/on-the-cuspstop-cauti/toolkits-and-resources/emergency-department-improvement-intervention/

• Baseline Data Collection begins in September 17, 2013

We Want to Hear from You

Take the ED Recruitment Questionnaire

https://www.surveymonkey.com/s/5VGX6FX

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Questions?

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Your Opinion Matters!

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please complete our survey using this link:

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