Reducing Unnecessary Urinary Catheter Use in the Emergency Department

1. Reducing Unnecessary Urinary Catheter Use in the Emergency Department Margarita E. Pena, MD, FACEP Karen Jones, RN, BSN St. John Hospital and Medical Center

2. 3 Keys to Our Success Establish clear guidelines for ED urinary catheter (UC) placement: • Collaborative effort between Infectious Disease (ID) and the Emergency Department (ED) • Indications based on CDC HICPAC guidelines Physician engagement and buy-in: • Identify ED physician champion • Educate ED attending and resident physicians Reflect and Review • Look for other opportunities • Re-educate periodically

3. Establish Clear Guidelines • ED physician champion identified • ID and ED physician champions collaborate to establish guidelines: both invested in improving UC placement in ED • They agree on a list of acceptable indications for UC use that areclearly identified • Any other reasons (beyond CDC HICPAC appropriate indications) for UC placement in the ED are addedto the hospital-specific guidelines • We suggest limiting the additional acceptable indications to a minimum

4. Physician Engagement • The ED champion educates attending staff on the importance of appropriate ED UC use • Collaborative UC guidelines are presented and discussed • A successful intervention relies on the ED attending staffs’ adherence to the guidelines

5. How to Spread the Message • Pocket cards • Posters • Lectures • Algorithms

6. How to Spread the Message

7. How Did We Do? • Fakih MG, Pena ME, Shemes S, et al. Effect of Establishing Guidelines on Appropriate Urinary Catheter Placement. Acad Emerg Med 2010; 17:337–340

8. UC Placement in the ED Pre/Post-Intervention: Impact of Physician Order

9. Compliance with UC Indications Pre/Post-Intervention

10. Reflect & Review • Reasons for noncompliance with guidelines identified • Opportunities identified, guidelines altered • The team worked with Radiology to remove UC requirement for emergent pelvic ultrasounds • Removed indication for acute mental status changes with agitation Fakih MG, Shemes S, Pena ME, et al. Urinary catheters in the emergency department: Very elderly women are at high risk for unnecessary utilization. Am J Infect Control 2010;38:683-8

11. Facilitators • Collaboration with other departments (e.g., radiology) • Involvement of all ED staff • Resident education: Identify a resident champion! Dyc N, Pena ME, Shemes S, et al. The effect of resident peer-to-peer education on compliance with urinary catheter placement indications in the emergency department. Postgrad Med J 2011 Dec;87(1034):814-8

12. Resident Peer-to-Peer Education • Significant improvement in test scores occurred immediately after education which remained 3 months post-education consistent withpre-education (9.43+/-1.17, 10.81+/-1.46, 10.43+/-1.28) • Improved resident knowledge did not translate to less UCs placed (p.0.76), nor did it improve the proportion of indicated UCs placed (p.0.71) in admitted ED patients. • Attending physician and staff nurse influence is needed for multidisciplinary approach.

13. Opportunities identified • Guideline revision • Vulnerable populations (e.g., very elderly females) • ED staff education • Physician orders • Multidisciplinary collaboration between physicians and nurses

14. Polling Question #1 • Which do you believe would be the biggest barrier to a successful ED CAUTI reduction intervention? CHOOSE ONE • Lack of leadership support • Lack of ED physician engagement • Lack of ED nursing engagement • Lack of collaboration between physician and nursing • Lack of time/resources to implement and sustain

15. Reducing Unnecessary Urinary Catheter Use in the Emergency Department Margarita E. Pena, MD, FACEP Karen Jones, RN, BSN St. John Hospital and Medical Center

16. Nurses Are Key Players • Focused on appropriate indications that had already been determined • Pocket cards and posters to reinforce the message • ED Nurse Champion • Responsible for peer-to-peer coaching and education • Consider an approachable person who is well-versed in ED functions and is available as a resource • Focused on working with physicians to determine UC necessity and required an accompanying written order. • Patient-focused

17. How We Started • Nursing staff discussions • Reinforced that avoiding UC use should not be seen as “more work” for the nursing staff • Highlighted risks associated with UCs (especially after leaving the ED) • Encouraged collaboration among physicians and nursing staff • Empowered each patient care nurse to be a “champion” for his/her patient • Performed accurate and periodic data collection

18. Useful Tools to Reinforce

19. Things to Consider • Nurse engagement • Obtain support from ED nurse director, nurse manager, and nurse educator • Learn in tandem with ED physicians/residents • Seek out alternatives to UCs • Promote straight-catheter for sample collection • Consider use of bladder scanner • Nurse champion held several instructional bladder scanner in-services, incorporating appropriate use of urinary catheters • Promote use of urinal or condom catheter for males • Increase vigilance with skin care, frequent turning and repositioning

20. Polling Question #2 • Does your nursing staff have a yearly competency on the insertion and/or maintenance of urinary catheters? (CHOOSE ONE) • Yes, for insertion and maintenance • Yes, for insertion only • Yes, for maintenance only • No yearly competency for urinary catheter insertion or maintenance • I don’t know

21. Process for Urinary Catheter Placement Engage both physicians and nurses!

22. Continue to Evaluate Progress Nurse driven removal of unnecessary UCs (med-surg units). Institutional guidelines for the ED established. • Inpatient nursing rounds with nurse manager and case management. • Twice-weekly point prevalence. Urinary Catheter Prevalence (%) SJHMC, Detroit, MI

23. Ongoing Process Evaluation • Aseptic insertion process • Ensure all necessary items are available • Documentation • Indicate if UC is present upon admission • Chart the actual insertion • Presence of physician order • Address pushback from other units • Maintenance issues (bag below the bladder, securement) • Keep the system closed! • Use pre-connected urine meter device

24. Sustainability of Program • 2012 • SJHMC was part of a UC-reduction project, involving many Ascension Health EDs • ED nurses created posters with key messages for indications • ED nurses voluntarily assisted in data collection and provided feedback to ED nurse manager

25. Rate of Urinary Catheters Placed in ED

26. UC placed based for appropriate indication

27. Physician Order present for UC

28. Conclusions • A successful ED nurse champion must be: • Aware of how the ED functions • Approachable • Available as a resource • Also: • Have clear indications • Provide feedback to staff • Consider processes to sustain the hard work!

29. Polling Question #3 • For your ED, what do you think is the most important factor to prevent unnecessary catheter use? (CHOOSE ONE) • Physician support • Nurse support • Collaboration between physician and nurse • The physicians and nurses being aware of the indications for appropriate use • The availability of tools to prevent placement: bladder scanners, urinals, adequate numbers of restrooms

30. Acknowledgement • Arlene Boelstler MA RN BSN, Manager, Emergency Department, St. John Hospital & Medical Center

31. Emergency Nurses Association Lisa Wolf PhD, RN, CEN, FAEN Director, Institute for Emergency Nursing Research Marlene Bokholdt, MS, RN, CPEN, CCRN-Ped Nursing Association Editor

32. Discussion Questions • From whom do you need support for the CAUTI initiative? • Is nursing management on board? • What barriers are there to the support you need? • What have you done to gain that support? • What is the state of communication between emergency nurse and emergency physician? Between emergency nurse and inpatient nurse? • What communication barriers exist? • What have you done to overcome those barriers? • What is the nature of collaboration between emergency nurse and emergency physician regarding decision making and urinary catheter use?