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

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)

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

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.

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.

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.

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).

Prepare for the ED Program 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 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.

2009 Prevention of CAUTI HICPAC Guidelines Alt text: Examples of Appropriate Indications for Indwelling Urethral Catheter Use. Source: Gould, et. al, Infect Control Hosp Epidemiol 2010; 31: 319-326.

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

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

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

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.

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.

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

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).

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.

Common Conditions where the Catheter is Placed Inappropriately Inappropriate Catheter Placement Elderly (especially women) Incontinence Debility Use in non-critically ill cardiac and renal patients Morbid obesity? Immobility Alt text: The diagram represents the relationship between inappropriate UC use and its common conditions. Physician and nurse practice influences this relationship greatly. Physician and Nurse Practice

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.

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

ED Improvement Intervention Timeline Alt text: The Project timeline is broken down into the four components of the program: baseline (weeks 1 and 2), pre-implementation (week 3), implementation (weeks 4 & 5), and sustainability (quarterly). Baseline: Collect urinary catheter initial placement prevalence; number of ED admissions as well as ED admissions with newly-placed indwelling catheter (14 days). Pre-implementation: Prepare for the implementation. Create staff awareness and excitement about the program. Begin ED physician and nursing staff education. Implementation: Educate on proper (aseptic) technique and maintenance, as well as removal of UCs placed prior to transfer to inpatient units if appropriate. Collect number of ED admissions, as well as ED admissions with a newly-placed UC (14 days). Sustainability: Collect UC initial placement prevalence (total of 14 days per quarter). Data review and feedback should occur during implementation and sustainability periods.

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

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

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.

Simplified Insertion Checklist for UC Placement Components of Checklist Compliant 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?

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.

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

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. Alt text: Example of a standard UC data collection form in Microsoft Word format. The form collects patient’s name, date, whether or not a UC was placed in the ED, if a physician order was present, and asks the user to select the reason for placement. Reasons fall into two columns, appropriate of inappropriate, based on the institution’s guidelines.

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) (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) (Total number of UCs placed in the ED) Mathematical equations for calculating rates.

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. http://www.onthecuspstophai.org/on-the-cuspstop-cauti/educational-sessions/ed-improvement-intervention-educational-sessions/

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

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

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

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

CAUTI Myths Perception Facts Facilitates 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

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? 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? Competencies Hygiene then sterility Competencies Review catheter insertion technique Two-person procedure Because you can do it alone, doesn't mean you should Checklists Supplies

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

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)

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

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

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

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

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

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)

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

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

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

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? Insert or maintain catheter Remove catheter prior to admission Is the patient critically ill and will require accurate output measurement? 50

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 Give feedback to medical staff on catheter appropriateness

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

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

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

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

Emergency Department Data Mariana Lesher, MS Senior Data Analyst Health Research & Educational Trust

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 All items in RED are required for ED registration State Hospital name Unit name Principal data person’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 3

Entering Data in CDS is Simple! Log into CDS with login ID and password https://www.hretcds.org Select the measure, then click “enter data”* *Data entry dates will vary per cohort and unit

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 unit

Enter These Three Simple Items Was data collected (yes or no)? If YES, enter numerator & denominator SAVE or SUBMIT

Upcoming Events & Next Steps 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

Take the ED Recruitment Questionnaire We Want to Hear from You Take the ED Recruitment Questionnaire https://www.surveymonkey.com/s/5VGX6FX (email coming soon from ENA)

Questions?

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