The Emergency Department & Catheter Insertions On the CUSP: Stop CAUTI The Emergency Department & Catheter Insertions September 10, 2013 11:00 AM CT / 12:00 PM ET

Today’s Presenters Mohamad Fakih, MD, MPH St. John Hospital and Medical Center Lisa Wolf, PhD, RN, CEN, FAEN Emergency Nurses Association (ENA) Jeremiah Schuur, MD, MHS, FACEP Brigham and Women’s Department of Emergency Medicine

Session Objectives Understand how to improve the compliance with the appropriate indications for UC placement in the emergency department for nurses and physicians Improve the compliance with proper technique for placement Review the points of impact for the emergency nurse in CAUTI prevention Review ED physicians’ role in urinary catheter placement

Could this happen at your hospital? The Story of Mr. Smith (1) Mr. Smith is 82 year old and gets admitted because of mild congestive heart failure. In the Emergency Department, a urinary catheter is placed (although he can use the urinal), and he is transferred to the floor but could not sleep. He is prescribed a sleeping pill. He gets more restless, gets out of bed, trips on the catheter and falls. He is found to have a left hip fracture, and undergoes surgery. Post-operatively, the staff notes that his left leg is swollen and he is diagnosed with deep venous thrombosis. He is started on blood thinners.

Could this happen at your hospital? The Story of Mr. Smith (2) Because of his immobility, he develops a pressure ulcer on his sacrum. His physician removes the catheter, but now he is having urinary retention related to pain medications. The urinary catheter is placed again. The procedure results in hematuria with the difficulty in insertion and being on blood thinners. Few days later, he develops fever and his blood pressure drops. Blood cultures and urine cultures grow Escherichia coli and he is diagnosed with CAUTI and septicemia. After 6 weeks in the hospital and many complications, Mr. Smith is no longer the same.

Different harms are connected! Patient: Urinary Catheter Harm CAUTI Increased Length of Stay Patient discomfort Trauma Immobility Pressure ulcers Falls Partnership for patients Venous thrombo-embolism Adverse drug events Different harms are connected!

Why the Emergency department (ED)? More than half of the hospitalized patients are admitted from the ED Decision to place urinary catheter often made in the ED Avoiding unnecessary placement would prevent exposure (complications) during hospitalization, especially for the most vulnerable patients

Elderly Women: High Risk for Unnecessary Use (Fakih et al, Am J Infect Control 2010;38:683-8) Evaluated urinary catheter (UC) placement for all admissions from ED for 12 weeks. 532/4521 (11.8%) patients had a UC placed, 69.7% indicated. Women ≥80 years: half had a UC placed without indication. UC without appropriate indication: Women: twice more likely than men Very elderly (≥80 years): 3 times more likely than those 50 or younger A study performed at St John Hospital & Medical Center in Detroit, Michigan evaluated urinary catheter placement for all admissions from the emergency department. Of the 4,521 patients, 532 (11.8%) had a urinary catheter placed. Of those, nearly 70% were appropriately indicated, but only 60% had a physician order documented. Inappropriate placement was higher in the elderly population, and half of the women aged 80-years-old or greater who had catheters placed did not have an appropriate indication. Inappropriate placement: older (mean age 71.3 vs. those with indication 60.0 years, p<0.0001, and patients with no UC placed 56.2, p<0.0001).

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

Effect of Establishing Institutional Guidelines in ED (Fakih et al, Acad Emerg Med 2010; 17:337–340) Established institutional guidelines for UC placement in ED Compared the rate of placement before and after guidelines ED physician champion involved Minimal nursing education/ intervention Pre- and post-intervention: 3 months baseline, and 9 months intervention/ sustainability (sampled 5 days per quarter)

Physician Intervention ED (Fakih et al, Acad Emerg Med, 2010; 17:337–340) UC utilization dropped significantly after starting the physician intervention from 14.9% pre-intervention to 10.6% post-intervention (p=0.002) Physicians ordered fewer UCs post-intervention 4.3% compared to pre-intervention 7.5% (p=0.002) Only 47.0% UCs initially placed in the ED had a physician order documented Post-intervention: more compliance with indications for catheters placed with physician order, no change for those without

Pilot Work: Ascension and Michigan Hospital Association More than 30 EDs involved Engaged both ED physicians and nurses Encouraged establishing institutional guidelines Looked at change in placement rate and appropriateness

Indications Based on CDC HICPAC Guidelines (Gould, et Indications Based on CDC HICPAC Guidelines (Gould, et. al, Infect Control Hosp Epidemiol 2010; 31: 319-326) Alt text: Examples of Appropriate Indications for Indwelling Urethral Catheter Use. Source: Gould, et. al, Infect Control Hosp Epidemiol 2010; 31: 319-326.

Pilot work: 18 EDs in Ascension Health Results: less catheters placed, in some instances up to 50% drop, average about a third, and increased appropriateness of use Physician order documentation for placement increased More noticeable improvement in hospitals who started with a higher baseline use In the ED, both physician and nurse support of the process are important. Having clarity regarding the acceptable indications for urinary catheter use will help both physicians and nurses when they evaluate whether a patient needs to have a catheter in. Finally, identify nurse and physician champions who are enthusiastic, passionate, patient safety advocates to gain peer support.

Ascension Pilot of 18 EDs Reduction in catheter use by a third! The results were sustained for more than 6 months Catheter avoidance translates into preventing exposure to the catheter for thousands of patients About 5,000 patients avoided catheter placement (total pts admitted per year about 160,000; drop from 9% to 6% if sustained over 1year)

How to Improve Appropriate Urinary Catheter (UC) Use in the ED? Establish clear guidelines for UC insertion in the ED. Engage nurses (significant role in UC use). Engage physicians (significant role in UC use).

Nursing Considerations in the Emergency Department Lisa Wolf, PhD, RN, CEN, FAEN Emergency Nurses Association

Problem The emergency nurse at both the initial patient encounter and throughout the trajectory of care makes clinical decisions that affect patient safety, efficacy, efficiency and cost-effectiveness of care involving Problem identification Acuity assignation Need for resources Patient advocacy

Problem Clinical decision-making takes place in a social context. The attitudes and biases of each participant can affect the decision-making process. The overall culture of an emergency department can challenge or enhance good clinical decision-making.

Who is driving patient care in emergency settings? Nurses? Physicians? Hospitalists? Intensivists? Patients?

What’s different about ED nursing? Rapidly shifting priorities Quick turnover of patients Chaotic environment Potential for rapid deterioration of patients Range of ages/developmental stages Unclear diagnosis/etiology of symptoms

EDs as a unique setting Higher levels of autonomous practice Nurse-driven environment Use of protocols/care guidelines Collaborative practice

The Framework An integrated, ethically-driven environmental model of clinical decision-making The model is an open environmental model with each element influencing the others. Core elements knowledge base critical application moral agency Immediate elements unit leadership nurse-provider relationship Influential elements institutional leadership environment of care 

An integrated, ethically-driven environmental model of clinical decision-making (Wolf, 2011) Influential elements Immediate elements Core elements Core elements exert influence on accuracy in problem identification and decision-making. Immediate elements of the practice environment can be influenced by the core elements of leaders Influential elements will also reflect the core attributes of leaders, managers and administrators in the health care environment.

Elements of the individual Knowledge base – what does the provider know? Moral reasoning – what drives questioning and assessment? Drive to act – able to operationalize moral agency?

What are the elements in the environment? Environmental structure Standards – what is expected of each level of provider? Communication – how does information and concern get transmitted between providers? Teamwork – are all providers working with the same agenda and goals? Autonomy of practice – who is able to make decisions about acuity and resources and under what circumstances?

Fostering excellence in clinical decision-making Needs to address all aspects of the model Individual Knowledge and critical application Moral agency Drive to act Environmental Context in which decision making occurs and is acted upon Unit level Institutional level

Urinary Catheter Utilization About 15 - 25% of patients will have a urinary catheter placed during their hospitalization. Many are placed in: ICU ED OR Urinary catheterization is a common procedure with up to 25% of admitted patients undergoing placement. The most common areas where patients have catheters placed are the emergency department, the intensive care unit, and the operating suite. Because of this prevalence, the emergency nurse plays a significant role in the reduction of CAUTI.

Reducing CAUTI Avoid use if no indication Remove as soon as possible When looking at ways to reduce the incidence of CAUTI, there are 2 main decision points First, is the decision to insert, be sure there is a strong indication for use and identify the reasons for placement as that will help at the second decision point. Second, is to remove the catheter as soon as possible. If the indication is clear, the point at which it has served its purpose and is ready for removal will also be clear. This helps prevent the catheter remaining in place until discharge, because no one has considered why it is there, so there is no clear indication for removal.

Why we think putting in a catheter is a good idea – but it’s not Facilitates I/O measurement Keeps patients from having to get up to urinate, protecting them from injury Protects skin in the incontinent patient. Saves time for the bedside nurse. Traditional reasons for catheter placement may seem logical, but many are not, or at least not in every case. A catheter facilitates intake and output measurement and in the critically ill patient, a urinary catheter may be indicated, but there are many patients who require accurate I & O measurement that can be accomplished with less invasive measurement devices. We traditionally thought that a catheter was helpful in preventing falls because patients didn’t have to get up to the bathroom. However, the catheter doesn’t eliminate the urge to urinate and the tubing can cause tripping and falling in the patient who may be confused and try to get up. We thought that it would protect the skin in the incontinent patient, and a catheter may prove useful in advanced stage pressure ulcers, but to protect intact skin, there are many other products that can create a barrier. Finally, we thought it would save time, but clearly, with extended length of stay, infection complications, and other risks, it does not save time in the long run.

Indications for catheterization Patient is critically ill and will require accurate output measurement Urinary retention/obstruction Bladder scanner or bedside ultrasound 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 HCPAC Guidelines Current recommendations for identifying patients who would benefit from a urinary catheter include: The patient who is critically ill and will require accurate output measurement This does not mean every patient who is admitted to the ICU is critically ill. Confirmation of lack of other options for measurement should be clear and documented. Urinary retention/obstruction Use a bladder scanner or bedside ultrasound first to identify retention and amount retained Consider straight catheter use instead of an indwelling catheter to limit exposure Immobilization needed for trauma or surgery Inquire the length of the surgical procedure before placement or communicate with the OR staff to see if they would prefer to place the catheter and then remove it immediately after the surgical procedure. Incontinent with open sacral/perineal wounds Consult with wound care End of life/hospice Be sure it is what the patient wishes prior to inserting for hospice care Chronic or existing catheter use Some patients may present with a catheter in place and each one is evaluated for continued use upon arrival. Re-evaluate need and discuss with provider

“Not” indications for catheterization Substitute for frequent toileting To obtain a specimen if the patient can void freely Patient preference Dementia Obesity A catheter should not be used for convenience and many of the contraindications are related to those convenient reasons. It is not a substitute for frequent toileting. Toileting schedules promote continence and the use of a catheter instead can interfere with that continence training process. There may be patients who will ask for a catheter, but that cannot be the only reason. Dementia is a contraindication, because as we saw in the initial case study, catheter placement in the patient with dementia may increase the agitation as confusion worsens with nightfall or illness. Obesity can limit movement and the obese patient may require additional staff to get up to toilet, but a catheter is not a solution for this.

Patients at high risk for inappropriate catheterization Elderly Women Incontinent Obese Immobile Non-critically ill cardiac and renal patients Monitor does not necessitate catheter Elderly women seem to be at the highest risk for catheterization with no documented indication for placement. Others at risk for inappropriate placement include those who are incontinent, obese, immobile, and patients with cardiac or renal problems that require monitoring for urine output, but have other options.

Reducing inappropriate placements reduces Infection rates Cost Antibiotics use Length of stay Morbidity Patient discomfort What are the benefits to reducing the inappropriate placement of a urinary catheter? There are many; Infection rates; CAUTI rates will drop with fewer catheters and eliminating those procedures that are unnecessary will eliminate the risk of infection for those patients. It seems simple, because it is. In many cases it is not just the UTI that is avoided, but risk of urosepsis is also avoided. With decreased infection rates, costs for extended stays and additional treatment is also decreased. The use of antibiotics is scrutinized more than ever and every time we can avoid the need to give antibiotics the better all of our patients are. Finally, catheters are uncomfortable and the resulting urinary tract infection even more so.

Attributes of the Individual Emergency Nurse Knowledge base: Assessment skills Indications for placement/non-placement of catheter Critical application Under what circumstances catheter is placed Autonomy of practice Moral agency Ability to advocate for safe patient care Promotes beneficence and non-maleficence

Putting systems in place Environmental: Context in which decision making occurs and is acted upon Unit Leadership Must set standards of practice Must maintain ‘sunnum bonum’ for patients Must promote collaborative clinical decision-making and care

Nurse-Provider relationships and communication Central to decision-making and action Assess for mutual respect and autonomy of practice Institutional level – foster teamwork, autonomy and control over practice. Ethical standards drive practice Interdisciplinary training, governance, practice committees

Communication with providers Clear understanding of indications Commitment to nonmaleficence (doing no harm) Patient focused care In the emergency department, clear, concise, and frequent communication is necessary for efficient and safe care. In prevention of CAUTI, this communication is vital. Discuss the indications. Identify and document the indication to promote early removal. Think beyond the patient’s needs within the emergency department, but what will the needs and indications be upon admission. If the indication for the catheter was present, but conditions and status have changed prior to admission, and the need no longer exists, remove the catheter. Make sure there is a written order to reflect that communication.

Implications Environment: In settings with problematic decision-making or change process implementation, the attributes of the practice environment should be examined and managed as well as the skill level of individual nurses who practice in that environment. Administrative support Nurse-physician relationships Practice culture

The take home Clinical decision-making is not a matter of information in, decision out Elements that encompass both characteristics of the individual as well as the context in which the individual functions are crucial to fostering excellence in decision-making

The take home Commitment at the unit and institutional levels is required to support and facilitate excellence. Both physicians and nurses need to model ethically-driven, patient focused, collaborative care The environment of care must change to afford behavioral change

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

Objectives Review ED 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 reduce catheter use

Role of ED Physician Champion to Reduce CAUTI Promote reduction of catheter use by championing appropriateness Encourage interdisciplinary conversation around catheter use Engage with other services around patterns of catheter use

Improving Appropriateness Review appropriate indications for catheters with medical staff CDC/HICPIC 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

Physician Task 1: Champion Appropriateness Have ED physician champion work with nursing to develop / review ED policy addressing appropriate indications for urinary catheter placement Start with CDC/HICPAC guideline Define both indication and contraindications Consider any ED specific modifications Have reviewed by infection control  Implement

Physician Task 1: Champion Appropriateness Have ED physician champion work with nursing to implement ED policy Require order for placement of catheter Require documentation of indication with order Include prompts of indications/contraindication Possible in EHR or on paper form Have ED physician speak ED to physician group about CAUTI and policy

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 50

Physician Task 2: Address Specific Clinical Patterns Have ED physician champion work with nursing and other services to address local patterns of care Identify specific clinical conditions where catheters are used, but can be avoided Liaison with Physician leaders from other services around patterns of care Develop context specific improvement plans

Identify Common Patterns of ED Catheter Use Measuring urine output in stable patients CHF Assessing bladder volume Urinary retention from possible spinal injury Protocolized care for trauma Incontinence without open sacral or perineal wounds Pre-operative placement, outside other indications Specific Conditions Small bowel obstruction

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 RN not junior resident

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

Physician Task 3: 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

Ongoing Physician Champion Roles Share data on catheter use with medical staff Break out by physician if possible Circulate descriptive summaries of any CAUTI cases that are attributed to ED placement Communicate with other medical services about specific patterns of care

Questions

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