1. On the CUSP: Stop CAUTI in ICU National Content Webinar
Today’s Topic:
Defining “Critically Ill” in the ICU; Alternatives to Catheters; Using the CUSP Staff Safety Assessment and the Learning from Defects Tools to Improve Safety Culture
Access slides and the audio recording of today’s webinar on the national project website:

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3. Today’s Presenters
Randy Garnett Jr., MD PCCM Physician, Sentara Medical Group Chairman, Sentara Norfolk General Critical Care Committee Medical Director, Sentara Lung Transplant Out Patient Program Norfolk, Virginia Sheryl Sheriff, RN Greenville Hospital System Greenville, South Carolina Emily Pasola MSN, RN, CNL Clinical Nurse Leader Surgical Intensive Care Unit Saint Joseph Mercy Hospital Ann Arbor, Michigan

4. INDWELLING URINARY CATHETER USE IN THE ICU CRITICALLY ILL PATIENTS
Randy Garnett Jr., MD PCCM Physician, Sentara Medical Group Chairman, Sentara Norfolk General Critical Care Committee Medical Director, Sentara Lung Transplant Out Patient Program Norfolk, Virginia

5. ICU Characteristics (Complex Interactions, May Effect indwelling urinary catheter Utilization)
Medical vs. Surgical
Acuity level of patients
Arena from which patient comes from to the ICU- OR, ED, floor SNF
Who put the indwelling urinary catheter in?
ICU culture RN MD
Leadership/admin support
Other

7. Potentially Critical Illness Clinical Observations
Sweaty, anxious, pale
Agitated or confused
Responds to moderate stimulation only – loud voice, physical prodding
Accessory muscle use and RR or RR < 8
HR > 100
SBP < 90
UO < 0.5 ml/kg/hr

8. The Critically Ill Patient Clinical Observations
Looks ill – poorly perfused
Unresponsive or poorly responsive neurologically
Resp Rates < 8 or > 30
HR < 50 or > 150
SBP < 60 to 70
Anuric or oliguric

9. Critically Ill
Surgical Patient Categories who will almost always need indwelling urinary catheters:
Post op patients with continued mechanical ventilation and sedation
CSICU- CVG, Valve surgery, transplant , aortic dissections
Major abdominal GI surgery- SBO, ischemic bowel, bowel perforations, liver transplant, abdominal compartment syndrome
Major Vascular surgery- Ruptured AAA, retroperitoneal bleeds
Most GU surgeries
Hemodynamically unstable post op patients where UO guides therapy
Immobilized patients- trauma , fractures, TBI
Post operative co-morbid processes where accurate urine output is important to monitor - acute and chronic renal failure, CHF/CMO or low Cardiac output states, DI
Post operative delirium, agitation, encephalopathy where incontinence has a detrimental effect on optimal care – wounds , staff safety

10. Critically Ill
Medical Patient Categories who will almost always needs indwelling urinary catheters:
Respiratory failure on mechanical ventilation and significant sedation
Hemodynamic instability
Sepsis and septic shock
Hemorrhagic Shock – GI bleed, trauma, post procedural
Cardiogenic Shock
Unstable CHF patients undergoing aggressive diuresis
Severe neurologic impairment with altered mentation- CVA,ICH,SAH, SDH,TBI
Acute or chronic renal failure with obstruction/retention
Critical illness where voiding exacerbates the primary process – COPD or CHF on NIV

11. Types Of Treatments Requiring Close UO Monitoring
Bolus fluid resuscitation
Vasopressors
Inotropes
High dose diuretics
Hourly urine studies to measure life threatening laboratory abnormalities

12. Case #1 Indwelling urinary catheter – Yes or No?
24 yo presents with acute SOB with history of asthma. Acutely ill.
BP 155/95
HR 124
RR 30
EXAM:
Oriented x 3
2 + accessory muscle use
Diffuse wheezing bilaterally, prolonged expiratory phase
Can move from stretcher to bed without significant change in status
ABG on 2 LNC PaO2 – 87; PCO2 - 46; pH 7.36

13. Case #2 Indwelling urinary catheter – Yes or No?
72 yo male 48 hrs post CVG x 3 and MVR. Still on mechanical ventilator with moderate levels of sedation and RASS of -2
Is on moderate doses of norepinephrine and epinephrine that are being adjusted for MAP of 65-70
Remains on 55% FiO2 and 8 PEEP
EXAM:
Opens eyes and follows simple commands before drifting off
Lung and cardiac exam are normal
Abd is benign and extremities feel perfused
Labs and CXR s are not concerning

14. Case #3 Indwelling urinary catheter – Yes or No?
83 yo male with BPH who is post op ruptured AAA returns to ICU for post op care.
Is extubated 2 hrs post arrival in the ICU and has moderate abd pain.
Drips: low dose Neosynephrine
VS: HR 90, BP 140/85 , RR 17. Temp 95.4
EXAM:
Lungs clear
Heart – RRR without murmer
Abd – moderately tender
Extremities perfused
Urine out put cc /hr since going to the OR
When can the indwelling urinary catheter come out?

15. Case #4 Indwelling urinary catheter – Yes or No?
65 yo with moderate to severe COPD presents with acute on chronic respiratory failure to the ICU from the ED and is placed on NIV . No cardiac history.
VS: HR 110, RR 21 with 1 + accessory muscle use, BP 125/66 , afebrile
EXAM:
Distant breath sounds with rare wheezing and prolonged expiratory phase
Cardiac exam pertinent only for tachycardia
Abdomen is benign and extremities are adequately perfused
He is oriented x 3 , moves around in bed
He has been supported 3 times with short term NIV in the past year without needing intubation
ABG in 40 % and NIV : PaO2 – 72 ; PCO ; pH – 7.35

16. Indwelling Urinary Catheter Removal Protocol
Sheryl Sheriff, RN Greenville Hospital System Greenville, South Carolina

17. Indwelling Urinary Catheter Removal Protocol: Review, Remove, Reduce
Patient no longer meets approved foley indications.
Remove
Nurses are empowered to remove the foley per protocol.
Reduce
Catheter days are reduced by timely removal of foley catheters when no longer indicated
CAUTI rates are reduced.

18. Approved Indwelling Urinary Catheter Indications
Ordered or placed peri-operatively for selected surgical procedures (i.e. Unstable Pelvic, Hip/Spine fracture, Renal/Urologic surgery, Gynecological Surgery, Perineal procedure)
Accurate measurements of intake and urinary output in critically ill patients:
Hemodynamic instability (requiring Pressors, shock), &/or
Neuromuscular blockade (ventilated), &/or
Deoxygenation with exertion or position changes (i.e. acute respiratory compromise, acute decompensated CHF)
Epidural catheter in place for pain management and patient is unable to ambulate
Traumatic bladder and/or ureter
Acute urinary retention with failure of Urinary Retention Protocol
Bladder outlet obstruction
Gross hematuria/irrigation
Assistance in pressure ulcer healing for incontinent patients with stage 3 or 4 sacral ulcer or perineal wound(s)
Comfort care (category 4)/hospice at patient/family request
Pre-existing Foley catheter upon admit and unable to verify Foley indication
Pre-existing Foley catheter upon admit with chronic Urological issues
Foley tagged with “yellow band” (NOTE: Yellow tag located around Foley tubing or at juncture of tubing and bag. If Foley is tagged, do not remove without a physician’s order.)

19. Yellow Banded Indwelling Urinary Catheters
Foley tagged with “yellow band” (NOTE: Yellow tag located around Foley tubing or at juncture of tubing and bag. If Foley is tagged, do not remove without a physician’s order.)

20. Fact or Fiction and Indwelling Urinary Catheters
Fiction: Any patient on Lasix or requiring accurate intake & output measurement require foley catheters – not true.
Fact: Lasix and I/O measurement are not approved indications for foleys.
Follow the hospital approved foley indications.
Use alternatives to Foley for measurement of output.

21. Fact or Fiction and Indwelling Urinary Catheters in Critical Care
Fiction: All patients in critical care require a foley for accurate measurement of intake and output – not true.
Fact: Patients do not need foleys just because they are in a critical care bed.
Approved foley indications defines “Accurate measurements of intake and urinary output in critically ill patients” as:
Hemodynamic instability (requiring pressors, shock)
Neuromuscular blockade (ventilated)
Deoxygenation with exertion or position changes
(i.e. acute respiratory compromise and/or acute
decompensated CHF)
Critical care patients admitted from the OR/PACU
do not automatically need a urinary catheter.

22. Identifying Defects and Using the Learn From a Defect Tool
Emily Pasola MSN, RN, CNL Clinical Nurse Leader Surgical Intensive Care Unit Saint Joseph Mercy Hospital Ann Arbor, Michigan

23. Objectives Discuss strategies to identify defects
Review steps of Learn From a Defect Tool (LFD)
Discuss example using LFD

24. What is a defect?
HAPU Self Extubation Infection Control CLABSI/CAUTI/VAE Medication Error RN Shift Handoff Missed Documentation Knowledge Gap Environmental Safety

25. Finding the Defects Staff feedback Event reporting
Shift huddles, staff meetings
Event reporting
Root Cause Analysis, hospital reporting system
Quality and safety measures
Monthly data reports
Recurring gaps
Staff Safety Assessment survey

26. 13

27. Staff Safety Assessment
What is it?
Two questions for bedside staff:
Please describe how you think the next patient in your unit/clinical area will be harmed.
Please describe what you think can be done to prevent or minimize this harm.
Why is it important?
Staff engagement-driving change
Staff understanding their role in patient safety
What should you do with the information?
Be transparent
Identify theme
LEARN FROM IT

28. Supporting a culture of safety
Learn From a Defect
Supporting a culture of safety
Easy to use
efficient
Structured Method
Continuity
Non-punitive
Ownership
collaborative, multidisciplinary
Improve Quality

31. Conclusion Easy, efficient & organized Supports staff engagement
Multidisciplinary approach to quality care
Provides transparency
Staff want to know what we do.
Staff want to know that we listen.
Provides structure & accountability
Tracks progress

32. Summary/Next Steps
Understand the HICPAC indications for urinary catheter use, especially in the critically ill population
Understand when catheters may be discontinued in critically ill patients
Know what alternatives to indwelling urinary catheters are available in your organization
Implement the Learning From Defects tool and staff safety assessment with your ICU team

33. Questions?
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