Emergency Department Improvement Intervention Onboarding Webinar

1. On the CUSP: Stop CAUTI Emergency Department Improvement Intervention Onboarding Webinar June 12, 2013

2. Today’s Presenters Mohamad Fakih, MD, MPH St. John Hospital and Medical Center Marlene Bokholdt, MS, RN, CPEN Emergency Nurses Association (ENA) Jeremiah Schuur, MD, MHS, FACEP Brigham and Women’s Department of Emergency Medicine Mariana Lesher, MS Health Research & Educational Trust (HRET)

3. Reducing Unnecessary Urinary Catheter Use in the Emergency Department: Why and How to Implement the Process Mohamad Fakih, MD, MPH Associate Professor of Medicine Wayne State University School of Medicine Medical Director, Infection Prevention and Control St. John Hospital and Medical Center, Detroit, MI

4. ED Improvement Intervention Objectives • Improve the compliance with the appropriate indications for UC placement in the emergency department for: • Physicians • Nurses • Improve the compliance with proper technique for placement.

5. 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.

6. 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.

7. 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).

8. Obtain leadership support: Administrative Clinical 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. Prepare for the ED Program

9. Prepare for the ED Program • 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.

10. 2009 Prevention of CAUTI HICPAC Guidelines

11. 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

12. 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.

13. 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

14. 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.

15. 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.

16. Appropriate Indication: Required Immobilization for Trauma or Surgery Including: • Unstable thoracic or lumbar spine • Multiple traumatic injuries, such as pelvic fractures

17. 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).

18. 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.

19. Common Conditions where the Catheter is Placed Inappropriately Physician and Nurse Practice

20. Examples of Common Conditions where the Catheter May Be Placed Inappropriately

21. The Measurement Phases of the ED Improvement Intervention • Baseline • Intervention • Pre-implementation • Implementation • Sustainability

22. ED Improvement Intervention Timeline Intervention

23. 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

24. 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

25. For Patients Requiring a UC Ensure your policies for placing the UCs are up to date. Ensure the staff placing UCs are evaluated for competency (i.e., know proper insertion technique). Consider using a catheter insertion kit that includes all the elements required for insertion. May use simplified insertion checklist for periodic audits.

26. Simplified Insertion Checklist for UC Placement

27. 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.

28. UC Evaluation: Data Collection in the Emergency Department • A form is completed by the ED nurse transferring the patient to the hospital unit: • Patient with or without catheter • Reason for use of catheter (for internal evaluation) • If no appropriate reason, nurse to evaluate removal

29. 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.

30. UC Evaluation: Metrics to Evaluate Improvements

31. 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.

32. The CAUTI Emergency Department Improvement Intervention Marlene Bokholdt, MS, RN, CPEN Nursing Education Editor Emergency Nurses Association

33. 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

34. 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

35. Decision to Insert • Responsibility • Communication • Team • Patient and family • Provision of care • Documentation prompts

36. CAUTI Myths

37. Is the patient critically ill and will require accurate output measurement? No Yes • Other indications for urinary catheter: • Urinary retention/obstruction? • Use bladder scanner first • Immobilization needed for trauma or surgery? • Incontinent with open sacral/perineal wounds? • End of life/hospice? • Chronic or existing catheter use? • Re-evaluate need and discuss with provider • Insert catheter and treat signs of shock: • Hypotension • Decreased cardiac output/function • Decreased renal function • Hypovolemia • Hemorrhage • Re-assess after intervention No Yes Do NOT insert Explore alternatives Still critically ill, requiring accurate output measurement? Yes No Insert or maintain catheter Remove catheter prior to admission

38. 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

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

40. 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)

41. 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

42. 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

43. ED Nursing Education Presentation 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

44. ED Physician Champions for CAUTI Jeremiah D. Schuur MD, MHS, FACEP Brigham and Women’s Hospital American College of Emergency Physicians

45. Learning Objectives Review physicians’ role in urinary catheter placement Identify strategies for improving appropriateness Review role of physician champion in CAUTI project

46. 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)

47. 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

48. 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

49. 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

50. Is the patient critically ill and will require accurate output measurement? No Yes • Other indications for urinary catheter: • Urinary retention/obstruction? • Use bladder scanner first • Immobilization needed for trauma or surgery? • Incontinent with open sacral/perineal wounds? • End of life/hospice? • Chronic or existing catheter use? • Re-evaluate need and discuss with provider • Insert catheter and treat signs of shock: • Hypotension • Decreased cardiac output/function • Decreased renal function • Hypovolemia • Hemorrhage • Re-assess after intervention No Yes Do NOT insert Explore alternatives Still critically ill, requiring accurate output measurement? Yes No Insert or maintain catheter Remove catheter prior to admission