1. 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

2. 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

3. 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

4. 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.

5. 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.

6. 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!

7. 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

8. 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).

9. 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

10. 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)

11. 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

12. 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

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

14. 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.

15. 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)

16. 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).

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

18. 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

19. 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.

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

21. 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

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

23. 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 

24. 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.

25. 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?

26. 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?

27. 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

28. Urinary Catheter Utilization
About % 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.

29. 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.

30. 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.

31. 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

32. “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.

33. 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.

34. 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.

35. 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

36. 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

37. 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

38. 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.

39. 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

40. 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

41. 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

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

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

44. 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)

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. Questions

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