Integrating Teamwork Tools into CUSP Efforts

1. Integrating Teamwork Tools into CUSP Efforts Shannon Davila, RN, MSN, CIC, CPQH New Jersey Hospital Association Slides adapted from original source: Barbara Edson, RN, MBA, MHA VP, Clinical Quality, Health Research & Educational Trust (HRET)

2. Learning Objectives • Describe teamwork and communication tools from TeamSTEPPS. • Describe opportunities and CAUTI scenarios in the ED in which TeamSTEPPS tools can be used.

3. 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

4. Barriers to Team Performance Inconsistency in team membership Lack of time Lack of information sharing Hierarchy Defensiveness Conventional thinking Varying communication styles Conflict Lack of coordination and follow-up Distractions Fatigue Workload Misinterpretation of cues Lack of role clarity

5. TeamSTEPPS & CUSP http://teamstepps.ahrq.gov/

6. What is TeamSTEPPS? • A way to address the barriers to team performance • An evidence-based program based on more than 30 years of research and evidence • A roadmap to creating high-performing, multidisciplinary teams in any setting

7. TeamSTEPPS Core Teamwork Skills

8. Leadership Tools • Briefs • Short session prior to start • Assign roles, establish expectations, anticipate outcomes • Huddles • Ad hoc planning to reestablish/reinforce and assess or adjust plans • Debriefs • Information exchange after the action

9. Communication • SBAR • Situation • Background • Assessment • Recommendation • Call-out • Check-back • Handoffs

10. Situation Monitoring Tools Situation Monitoring=Scanning and assessing what is going on around you and with you • Cross Monitoring • Watching each other’s backs • Ensuring mistakes/oversights are caught • STEP checklist • I’M SAFE checklist

11. Mutual Support Tools • Task Assistance=protecting each other from work overload • Feedback • Advocacy and Assertion • Two-Challenge rule • CUS (I’m Concerned, I’m Uncomfortable, This is a Safety Issue) • DESC Script • Collaboration

12. CUSP: CAUTI

13. CAUTI Example

14. CAUTI Scenario An ED nurse is assigned to an 87 year old female patient being seen for possible wrist fracture after a fall. The ED physician is a family friend of the patient’s daughter, and orders a urinary catheter after the family’s request for one, due to their concerns the patient is unsteady and not safe to ambulate to the bathroom. The nurse knows that the patient does not need a catheter and that there are alternatives that would be more appropriate and safe. Despite concerns, the nurse places the catheter because the physician made it clear that the family wants it and he does not think it a big deal since, in his words “the patient won’t be here that long” and it will allow her to “rest”.

15. CAUTI scenario continued X-rays show the patient does not have a fractured wrist, but does have nodules on a chest x-ray that look suspicious. Orders are written to admit the patient. Due to high census, the patient is held in the ED and over the next 24 hours, the patient repeatedly pulls at the catheter, attempting to remove it. Additionally, the patient makes several attempts to climb out of the bed, and is found on the floor at one point in the night. To rule out any injuries, the patient is sent for a head CT along with a chest CT for the nodules. During the transport and test, the care technician places the urinary catheter collection bag on top of the patient while the patient is on the stretcher. The nurse notices this but does not move the bag. The patient is later admitted, and 2 days later a urine specimen is collected and a culture shows the patients has an E. coli urinary tract infection. The patient is started on IV antibiotics that extend her admission at least 3 more days.

16. Opportunities? • Huddle- ED team to make a fast plan on how to best care for the patient, assign roles, express concerns • Task Assistance- ED team work together to toilet this patient • CUS or Two Challenge Rule- question the need for catheter • Cross Monitoring- RN to remind the CT tech the urine collection bag should be lowered below the bladder

17. Discussion Questions • Have team members experienced situations in which any of these tools would have been beneficial? • What is the biggest area of need for your team? Leadership, Communication, Situation Monitoring or Mutual Support? • Does your Emergency Department staff have formal teamwork training program? • If so, how can CAUTI prevention be integrated into the program?

18. Thank you! Questions?

19. Funding Prepared by the Health Research & Educational Trust of the American Hospital Association with contract funding provided by the Agency for Healthcare Research and Quality through the contract,“National Implementation of Comprehensive Unit-based Safety Program (CUSP) to Reduce Catheter-Associated Urinary Tract Infection (CAUTI), project number HHSA290201000025I/HHSA29032001T, Task Order #1.”