On the CUSP: Stopping CAUTI at the Front Door NJHA – August 15, 2013 Quality Initiatives: Physician Leadership in the Emergency Department

David J. Adinaro MD, MAEd, FACEP President, NJ-ACEP Chief, Adult Emergency Department, SJRMC EM Residency Research Director, SJRMC

Disclosures I have nothing to report in terms of financial disclosures. My opinions are my own.

Biases I believe  That I have the best job in the world  That I work with the best people in the best profession  That we do noble work

Biases I believe  That I have the best job in the world  That I work with the best people in the best profession  That we do noble work  That we can do better

» ED Physicians role in preventing CAUTI » Identify the opportunities to change physician behavior » Importance of collaboration in ED to change systems and cultures Objectives

» Where the work is done and errors are made\discovered » Real time decisions based on available information » Last line of defense in error prevention » In healthcare made up of doctors, nurses, techs The Sharp End

» Distal to the sharp (work end) » Often remote from real time decisions but contribute to the care given and errors made » ED Exec, Hospital Administration, State regulations, National Policies The Blunt End

Reason’s Model of Normal Accidents Patient develops CAUTI Lack of institutional policy or goal Foley need not reevaluated on floor Family requests ED physician orders Admitting physician does not address

» ED Physician Role in Preventing CAUTI Preventing CAUTI at the Front Door

In theory placement of a foley catheter needs a physician order. Good evidence based indications for placement Preventing CAUTI at the Front Door

– KT (Knowledge Translation) Approach Lack of knowledge about consequences Lack of consequence Prior training Lack of alternatives – Systems approach This is how we do it Changing the easiest pathway Preventing CAUTI at the Front Door

Great summary article from a respected elder of emergency medicine ns/in-my-opinion/rick-bukata-the- high-cost-of-convenience-caths/ ns/in-my-opinion/rick-bukata-the- high-cost-of-convenience-caths/ Preventing CAUTI at the Front Door

Also reviewed the inappropriate indications for catheter placement: Incontinence (without additional indication) Diuresis Frequent, nonessential measurement of UOP Nurse’s concern about patient discomfort Diarrhea (without additional indication) Patient’s preference Preventing CAUTI at the Front Door

» Identify the opportunities to change physician behavior Preventing CAUTI at the Front Door

 “Small Wins” Approach  Academic detailing\Physician Champion  Group responsibility  Monthly or quarterly data  Trend Foleys and infections  Individual responsibility  Audit and feedback  Inclusion in yearly reviews

Preventing CAUTI at the Front Door Small Wins – produce change without confronting the system directly or aggressively. Impact is from examples they provide others. » Through doing something tangible. » Through showing change is possible.

Preventing CAUTI at the Front Door Academic Detailing\Physician Champion Physician Champion Unlikely to be chairman\ED director Tend to have a full plate. Champions need to have ability to focus on the project for at least a year. A younger (training-wise) doc with some stature in department.

Preventing CAUTI at the Front Door  Group responsibility  Tends to be least threatening to individual physician  Monthly or quarterly data  Trend Foleys and related infections

Preventing CAUTI at the Front Door  Group responsibility  Usually a good first step  Will usually get attention of “center of department”  Ineffectual for outliers

Preventing CAUTI at the Front Door  Individual responsibility  Audit and Feedback  Yearly reviews  Best for outliers

Preventing CAUTI at the Front Door  Audit and Feedback methodology:  Mentioned frequently in KT literature  Fits in with Plan, Do, Study, Act cycles  Really just behavioral reinforcement to effect change  Most basic and probably most effective

Preventing CAUTI at the Front Door  Audit and Feedback methodology:  Based on clearly defined guidelines  Must be on-going and as real-time as possible  Should include a mechanism to address systemic (non individual) issues.

Preventing CAUTI at the Front Door  Audit and Feedback methodology:  Real-time feedback (days\weeks not months)  Feedback from consistent source (physician champion)  Feedback is on success and failure  Include alternatives

» Importance of collaboration in ED to change systems and cultures Preventing CAUTI at the Front Door

ED Collaborations PICTURE

Department is made up of physicians and nurses No one group fixes any problem without the other Likelihood of success lower without close integration Unlikely in future medicine will be successful without collaborative leadership and care Proximity is not enough! ED Collaborations

SJRMC Paterson, NJ 150,000 visits 50 physicians, 120+ nurses 2008 – ED Exec Team EDQA Committee ED Collaborations

ED EXEC ED Physician and ED Nurse leadership Formally meets weekly Informally constantly Joint decision making Unified Implementation Message travels separate pathways ED Collaboration

EDQA Off shoot of ED Exec Open meetings Open, “anonymized” referral process Screens used Separate from Audit and Feedback related to quality initiative (STEMI, pneumonia, stroke) ED Collaboration

EDQA Relies on an established worksheet Examines individual care provided and systems involved Key in identifying system\cultural strengths and weakness Forms the basis of many decisions made by ED EXEC ED Collaboration

EDQA To date reviewed over 1,000 cases Majority have no findings\concerns Feedback provided to treating staff CME\contact hours available Highlights excellent care also ED Collaboration

» ED Physician Role in Preventing CAUTI » Identify the opportunities to change physician behavior » Importance of collaboration in ED to change systems and cultures Preventing CAUTI at the Front Door

Thank PatersonER.com (blog) Slides available NJEmergencyDocs.com (acep blog)