1. VCU DEATH AND COMPLICATIONS CONFERENCE

2. Introduction of Case  Complication  Urinary Tract Infection  Procedure  Ex. Lap, Lysis of Adhesions, Wedge Resection of Small Bowel Mass  Primary Diagnosis  Bleeding small bowel mass

3. Clinical History  76 y/o male with 2 month h/o of melana and anemia that was worked up with an EGD was found to have leiomyoma in proximal duodenum.  PMH: HTN, DMII, CKD ( Cr-Baseline 3.3), Colon Cancer, BPH  PSURG: Total colectomy with ileorectal anastomosis, Proctectomy with Ileostomy  ALL-PCN  FH-CAD, DM  Social- smoking, social alcohol  MEDS:ASA, Allopurinol, Alprostadil, Vit D3, Finasteride, Glipizide, Levothyroxine, Lisinopril, Omeprazole, Sodium Bicarbonate

4. Clinical History  PE- 99.1 HR-70 BP-140/80 100% on RA  GEN-AAA, in no acute distress  RESP-CTA B  CV-RRR  ABD-s/nt/nd, BS, well healed midline incision, no hernia, ilestomy in RLQ  LABS: HBG- 10 WBC 7.0, Bun/Cr (35 /3.23)  EGD: the ampulla was found to be in the normal position in the second part of the duodenum and appeared normal. There was a submucosal lesion approximately 1.5 cm in diameter distal to the ampulla. Two india ink tattoos were placed on the wall opposite the lesion  Path: FNA- leiomyoma

5. OR  Ex. Lap, Lysis of Adhesions, Wedge Resection of Small Bowel Mass  Enterotomy that was repaired primary  EBL-100  Foley D/C on POD 3  POD 5 spike fever 101.9, Pt clinically stable, no abd pain, no wound infection, and ilestomy +output, WBC -5.7, chest-xray - some atelectasis, blood cultures negative  U/A- + WBC, Nitrates, bacteria  Urine culture- Ecoli >100,00 CFU  Pt D/C on POD 8

6. Analysis of Complication Was the complication potentially avoidable? -Yes/potentially Would avoiding the complication change the outcome for the patient? – Yes, increase risk of morbidity/ mortality (low) What factors contributed the complication? – Insertion?/ duration of foley

7. Catheter-Associated Urinary Tract Infection (CAUTI) Event Guideline for Prevention of Catheter-associated Urinary Tract Infections CDC -2012  The urinary tract is the most common site of healthcare-associated infection, accounting for more than 30% of infections  Virtually all healthcare-associated urinary tract infections (UTIs) are caused by instrumentation of the urinary tract  Duration of catheter is an independent risk factor for UTI  85 percent of patients undergoing surgery have urinary catheters  50 percent of these catheters remain in place for more than two days  These patients were twice as likely to develop CAUTI prior to hospital discharge  Surgical Care Improvement Project.

8. Urinary Catheter Documentation Issues Related to SCIP (Surgical Care Improvement Project):  RECOMMENDATION:  The necessity of the foley remaining in place must be reviewed on POD 1 or POD 2.  There must be a MD/NP documented order written on POD 1 or POD 2 to remove the foley OR MD/NP documentation of a justified reason for leaving it in place such as: “leave foley in place until epidural is d/c”, “strict I&O, maintain foley”, “continue foley while pt is ventilated/sedated”, etc.  Per the guidelines, if there is “a medical staff-approved facility protocol” to address removal of or continued necessity of a foley catheter, there must be:  A MD/NP written order on POD 0, 1 or 2 to follow the protocol, AND  the protocol states a reason for leaving it in place AND  there is MD/NP or nursing documentation on POD 1 or 2 of a reason listed in the protocol for leaving the foley in place, then we will be in compliance..