AN EVIDENCED-BASED PROTOCOL TO REDUCE URINARYCATHETER USE IN SKILLED NURSING FACILITIES Murthy Gokula, M.D.,CMD Phyllis M. Gaspar, Ph.D., RN Thotakura, Sreekiran, M.D., MPH Rubeen, Shafia, M.D.,MPH University of Toledo, Department of Family Medicine Toledo,Ohio

Acknowledgement of funding from the AMDA Foundation/ Pfizer QI Award

Background Use of indwelling urinary catheters (IUC) in skilled nursing facilities (SNF) persists even though CMS requires a valid medical justification for use. Gap in knowledge EXISTS regarding long term indwelling catheters continued need, proper maintenance, managing complications of urinary catheters in SNFs and its effect on reducing catheter associated UTIs (CAUTIs) Important: – CAUTIs are a major cause of UTIs, leading to acute hospitalization of elders from SNFs – UTIs contribute to the problems of urinary incontinence, falls and delirium – IUCs are an added concern as they are one point restraints

Purposes Purposes of this study were to: 1) describe the current use, care, and CAUTIs related to IUC in SNFs; and 2) determine the effects of the implementation of the FIRM (Foley Insertion Removal and Maintenance) protocol on these same aspects of IUC use.

FIRM Protocol 2 Components FIRMS (Foley Insertion Removal and Maintenance Sheet) – Order Sheet that documents rationale for order and maintenance care Education Component – to provide evidence based content to nursing staff and providers

FIRM Protocol: Education Component Education Program – Content included: Introduction to the FIRMS Significance of problems associated with IUCs Criteria for appropriate use of IUCs Appropriate approaches for insertion, maintenance and of IUCs Presented to staff nurses and providers at the 3 settings.

Settings 3 SNFs served as settings for this study. Following the initial data collection one setting (#3) was dropped from the follow up analysis as the policy for admission included the need to remove an unnecessary IUC prior to admission.

Characteristics of 3 Facilities

Methods Retrospective review (10 months prior to implementation of protocol) and monthly review (6 months following implementation) of charts of residents identified as having an IUC was conducted to determine: – Length of time in place, – Documentation of reason for use and care, and – Occurrence of CAUTI.

Results A comparison of the data prior to implementation with data following implementation of the protocol related to: Number of IUCs Length of time IUCs were in place Documentation of reason for placement Relevant outcomes

Comparison of Use of IUC Use Prior to and Following Implementation of Protocol FacilityPrior to Implementation (10 months) Following Implementation (6 months) # of IUCMean Length of Time IUC in Place (days) (SD) Rate of IUCs per Month* # of IUCMean Length of Time IUC in Place (days) (SD) Rate of IUCs per Month* (23.15) (50.84) (37.80) (76.70) (2.12)-NA- Total (69.17)11.3

Documentation of IUC Reason Documentation of reason for placement prior to and following implementation Documentation of a Reason for UIC Placement Prior to Implementation Number of IUCs Following Implementation Number of IUCs No Reason Documented15 (28%)1 (1.5%) Reason Documented and Meets CMS Criteria 37 (69%)67 (98.5%) Reason Documented but Does Not Meet CMS Criteria 2 (4%)0 Total5468

Documented Reasons Prior to and Following Protocol Implementation Documented Reason for Catheter Order Prior to Protocol Implementation (N=54) Following Protocol Implementation (N= 68) Urinary Incontinence17 Urinary retention030 Hematuria04 Obstruction173 Pelvic Fracture01 Comfort Care212 Neurogenic Bladder65 Bladder irrigation12 Wound Healing03 Other110 No Reason Documented 151

Outcome: Attachment of IUC Number of IUCs attached for security increased dramatically after implementation with 100% documented as attached following implementation compared to only 20% prior to implementation.

CAUTI Rates Prior to and Following Protocol Implementation FacilityCAUTI/month Rate prior to Implementation CAUTI/month Rate Following Implementation Total2.38.8

Limitations Limitations of the study contributed to findings of the study: – Initial chart review was retrospective and retrieval of data difficult. – Identification of residents with IUC difficult prior to implementation. – Lack of protocol champion at one facility.

Conclusions FIRM Protocol is advocated even though the number of documented IUC increased and the length of time IUCs were in place increased following implementation. Documentation of order for IUC placement, indication for placement, and secured attachment of catheter to thigh improved dramatically following implementation of the protocol.

Recommendations FIRM Protocol is advocated even though the number of documented IUC increased and the length of time IUCs were in place increased following implementation. The implementation of a policy that incorporates the FIRM protocol is advised. The policy needs to include the following: – Criteria for appropriate use of catheters – Removal within 1-3 days following placement unless absolutely indicated – Continuous education and surveillance – Facility champion