On the CUSP: Stop CAUTI ED Intervention National ED Office Hours Co Hosted by: Emergency Nurses Association & Health Research and Educational Trust Moderated by: Shannon Davila, New Jersey Hospital Association September 10, 2014 at 10 CT/ 11 ET

ED Office Hours Agenda General Overview ED Success Story Presentation Neel Pathak, HRET ED Success Story Presentation Deborah Cioffi, Barnabas Health, NJ Discuss Utilization Rates and Barriers Specific to the ED Environment Tina Adams, Clinical Content Development Lead, HRET Marlene Bokholdt, Nursing Education Editor, ENA Karen Jones, Infection Prevention and Control, St. John Hospital & Medical Center ED CAUTI Data Collection: Tips for Success Shannon Davila, Clinical Quality Improvement Manager, New Jersey Hospital Association Discuss General Questions/Concerns National Project Team

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 American College of Emergency Physicians (ACEP) Emergency Nurses Association (ENA)

ED Improvement Intervention Goals Learning 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

Decreasing Catheter Use in the Emergency Department Deborah Cioffi, RN, MSN, MSA Administrative Director, Emergency Services Monmouth Medical Center

CAUTI A Call to Reverse the Trend in Emergency Departments

Barnabas System ED’s Joined the- On the Cusp: Stop CAUTI National initiative with AHA/HRET to implement a proven culture change model-Comprehensive Unit –Based Safety Program (CUSP) and Intervention to Prevent Catheter Associated Urinary Tract Infection (CAUTI)

ED Project Timeline BASELINE: Sept 17- 30, 2013 Collect urinary catheter initial placement prevalence. Number of admissions from the ED Number of admissions from the ED with a newly placed indwelling catheter PRE-IMPLEMENTATION: Oct 1 – Nov 16, 2013 Prepare for the implementation. Create staff awareness and excitement about the program. Begin emergency physician and nursing staff education. IMPLEMENTATION: Nov 17 – 30, 2013 (14 consecutive days) Education on proper (aseptic) insertion technique and maintenance, as well as removal of catheters placed prior to transfer to inpatient units if appropriate. Number of admissions from the ED with newly placed indwelling catheter. SUSTAINABILITY: Quarterly, any 14 days of the following months: Feb 2014 May 2014 Aug 2014 Nov 2014

MMC ED Team Deborah Cioffi, RN, MSN, MSA Victor Almeida, DO, FACEP Administrative Director, Emergency Services Victor Almeida, DO, FACEP Chairman, Emergency Services Jean Straker-Darbeau, RN, DNP ED Educator Caitlin Mahoney, RN Staff Nurse Kathy Rivera, RN Performance Improvement Coordinator Carolyn Korotky, RN, BA, BSN, RN-BC, CIC RN Infection Control

Baseline Data Reporting Number of ED catheter insertions Number of Admissions Did patient present to ED with a catheter in place? Was an order present for insertion?

Challenges Intervention Keeping education on the forefront Instituted catheter topics with daily huddle Yearly competency did not include visual / tactile urinary catheter insertion ED observation and “hands on” insertion practices as annual competency RN completion of mandatory field in the Electronic Health Record Staff champion and educator to conduct audit of documentation Staff unaware of how much urine is in bladder. Bladder scanner in house not readily available ED presented a request to foundation. Foundation purchased the bladder scanner Urinary Catheter Kit did not contain all necessary equipment. Kit was not user friendly Reached out to our catheter kit representative to look at new catheter insertion kits Alternatives were not readily available for staff to choice from Added straight catheter to equipment bundle Placed straight catheter as an alternative choice next to catheter kits in ED storeroom. Other options were explored. New condom catheter being trialed. Proper placement of urinary catheter bag during transport to prevent UTI ED champion and fellow staff committee members looking at hooks to place on equipment to identify proper placement of catheter bag Brightly colored wipeable sticker to apply to equipment that indicates proper placement

Our Next Steps Recognized that urimeters are needed for inpatients Adding urimeters in the storeroom so that they are available to be used to avoid having to Mechanism to be implemented to ensure proper placement of catheter system on stretchers and wheelchairs to prevent backflow which can lead to a urinary tract infection Barnabas Health systemwide committee was formed. Meets biweekly. Pat McNamee, Deb Cioffi All 7 Barnabas Health Hospitals have formed Hospital Based Committee that report up to the Systemwide Steering Committee The Nurse driven protocol for Catheter insertion and removal was implemented across the system

Polling Question 1 How is urinary catheter insertion competency in staff assessed in your emergency department? (CHOOSE ONE) a)      Observation during insertion on patient(s) b)      Simulation c)       Written test and/or computerized module d)      There is no competency for ED staff

Polling Question 2 2. What is your data source for tracking urinary catheter insertions in your emergency department? (CHOOSE ONE) a) Nursing insertion documented on paper or electronic medical record b) Physician order documented on paper or electronic medical record c) Supply/stock records d) Laboratory results  

Polling Question 3 3. Which component of CAUTI prevention strategy would you like to focus on for your emergency department? (CHOOSE ONE) a)  Insertion practices (i.e., sterile technique, 2-person insertion) b)  Improving communication among ED staff to ensure UCs are placed only when appropriate c) Improving communication among ED and inpatient staff to ensure UCs are placed only when appropriate d) Developing more involved, more visible CUSP CAUTI leaders (physicians & nurses) in the ED

Utilization Rates & Barriers Discuss Utilization Rates and Barriers Specific to the ED Environment

ED CAUTI Data Collection Tips for Success Shannon Davila Clinical Quality Improvement Manager, NJHA

Let’s Review the Measures Required ED metrics: Number of admits from the ED, including observation patients Number of admits from the ED, including observation patients with a newly placed indwelling catheter in the ED Additional recommended ED metrics: Catheter appropriateness Total number of indwelling catheters placed in the ED

Potential Data Sources Paper Chart Electronic Health Record Nursing documentation Physician Order Entry Supply Log QI checklist/log Laboratory data

Review Potential Data Sources Where do nurses document? Do they chart urinary catheter insertion? Where do physicians place their orders? Do they routinely and consistently order urinary catheters? Are catheters a charged item? Can you access billing lists or supply records? Do you collect UA’s on all patients that receive a urinary catheter? Can you isolate those ED pts from lab data records?

Get to know your IT friends! Find out who in is charge of your ED EHR system Get this report request in the queue as soon as possible Be very clear what data points you want to capture (example: indwelling NOT straight cath insertions) May use this an opportunity to update the ED documentation (add insertion criteria)

Don’t Wait! Collect and enter data as soon as possible Know your data collection schedule

Benefit of Collecting Both Measures Gives a multi dimensional view of what is going on Will help to show the impact of interventions Helps to create consistency across hospital units

Share the Wealth Have a co- lead or data collector Look for alternative options for data collection Review data with your team on a regular basis Share your report template with others

Questions? Other Suggestions?

General Questions/Concerns? ED Office Hours General Questions/Concerns?

Quarterly ED Office Hours Access slides, recording, and transcript of today’s webinar on the national project website: http://www.onthecuspstophai.org/on-the-cuspstop-cauti/educational-sessions/ed-improvement-intervention-educational-sessions/ Upcoming Office Hours: Wednesday, December 10, 2014 at 11 ET/10 CT Wednesday, March 11, 2015 at 11 ET/10 CT Wednesday, June 10, 2015 at 11 ET/10 CT

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