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Emergency Department Improvement Intervention Onboarding Webinar June 12, 2013 1 On the CUSP: Stop CAUTI.

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Presentation on theme: "Emergency Department Improvement Intervention Onboarding Webinar June 12, 2013 1 On the CUSP: Stop CAUTI."— Presentation transcript:

1 Emergency Department Improvement Intervention Onboarding Webinar June 12, On the CUSP: Stop CAUTI

2 Todays Presenters Mohamad Fakih, MD, MPH St. John Hospital and Medical Center Marlene Bokholdt, MS, RN, CPEN Emergency Nurses Association (ENA) Jeremiah Schuur, MD, MHS, FACEP Brigham and Womens Department of Emergency Medicine Mariana Lesher, MS Health Research & Educational Trust (HRET) 2

3 Reducing Unnecessary Urinary Catheter Use in the Emergency Department: Why and How to Implement the Process Mohamad Fakih, MD, MPH Associate Professor of Medicine Wayne State University School of Medicine Medical Director, Infection Prevention and Control St. John Hospital and Medical Center, Detroit, MI 3

4 ED Improvement Intervention Objectives Improve the compliance with the appropriate indications for UC placement in the emergency department for: 1.Physicians 2.Nurses Improve the compliance with proper technique for placement. 4

5 Case Scenario: John An 85-year-old male with dementia John was transferred from the nursing home to the hospital because of a non-functioning gastrostomy (PEG) tube. In the ED, the nurse noted he was incontinent and placed a urinary catheter (UC). John was admitted and the PEG tube was changed. That night, he became more confused and pulled on his UC, leading to severe hematuria and a urologic evaluation. Within 24 hours, John spiked a fever and blood cultures were positive. John was treated for CAUTI and required a prolonged hospital stay. 5

6 Case Scenario: Jane An 82-year-old woman admitted for congestive heart failure Jane had a urinary catheter (UC) placed and was started on diuretics. She appeared frail. In the ED, the physician and nurses felt that keeping the catheter in place would make her more comfortable. On the 5 th day of admission, Jane started complaining of chills, had a fever of 102°F, and her BP dropped to 90 systolic. Blood cultures and urine cultures grew Escherichia coli. Jane was diagnosed with symptomatic CAUTI and had to be treated with intravenous antibiotics. 6

7 How to Improve Urinary Catheter (UC) Use in the ED? Establish clear guidelines for UC insertion in the ED. Engage physicians (significant role in UC use). Engage nurses (significant role in UC use). 7

8 Prepare for the ED Program 1.Obtain leadership support: –Administrative –Clinical 2.Identify the team: –ED physician champion (leader) –ED nurse champion (leader) –Project Manager: point person to facilitate implementation of the program and be accountable for data collection. 8

9 Prepare for the ED Program 3.Establishing Institutional Guidelines: –The proper indications for UC placement in the ED are based upon the CDC HICPAC guidelines. –It is acceptable to consider having alternate institutional guidelines (or additional agreed upon indications) for UC placement for the ED. 9

10 2009 Prevention of CAUTI HICPAC Guidelines 10

11 Appropriate Indications: Acute Urinary Retention or Obstruction Outflow obstruction: examples include prostatic hypertrophy with obstruction, urethral obstruction related to severe anasarca, urinary blood clots with obstruction Acute urinary retention: may be medication- induced, medical (neurogenic bladder) or related to trauma to spinal cord 11

12 Appropriate Indication: Accurate Measurement of Urinary Output in the Critically Ill Patients CDC HICPAC definition of critically ill is not very clear. In the ED, we may consider placement for patients likely to be admitted to ICU and will require fluid monitoring. Discontinue the UC if patients improve with treatment in ED, and it is no longer necessary. 12

13 Appropriate Indication: Perioperative Use in Selected Surgeries Anticipated prolonged duration of surgery, large volume infusions during surgery, or need for intraoperative urinary output monitoring Urologic surgery or other surgery on contiguous structures of the genitourinary tract This indication will be more applicable to the surgical team evaluating the patient 13

14 Appropriate Indication: Assist Healing of Perineal and Sacral Wounds in Incontinent Patients This is an indication when there is concern that urinary incontinence is leading to worsening skin integrity in areas where there is skin breakdown. 14

15 Appropriate Indication: Hospice/Comfort Care/Palliative Care Patient comfort at the end-of-life Check with the patient before placing UC. What provides most comfort to the patient. 15

16 Appropriate Indication: Required Immobilization for Trauma or Surgery Including: 1.Unstable thoracic or lumbar spine 2.Multiple traumatic injuries, such as pelvic fractures 16

17 Questionable Indications: Chronic Indwelling Urinary Catheter upon Admission Chronic indwelling UC is defined as present for >30 days. Difficult to find the reason for initial placement when assessed. We suggest that these patients represent a special category and may need a further assessment for the appropriateness of catheterization. Considered to have an acceptable indication for UC use until more information is available (primary care physician evaluation). 17

18 How Do We Achieve Agreement on Acceptable Indications? Each institution may have additional reasons (beyond CDC HICPAC appropriate indications) for UC placement in the ED. Indications should be clearly identified during program preparation. We suggest limiting the additional acceptable indications to a minimum. 18

19 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 Physician and Nurse Practice 19

20 Examples of Common Conditions where the Catheter May Be Placed Inappropriately Who is Critically Ill?Unconsciousness versus Agitation Admitted to ICU Requiring high amounts of Oxygen (e.g., >4 liters, >6 liters, or on 100% O2 non- rebreather)? Agitated patients may have a higher risk of trauma related to UC, if placed. Evaluate whether you have any standing orders for UC placement as a part of the treatment of acute stroke. Emergent Pelvic Ultrasound for Pregnancy?Frail and Immobile patients Placing UC would increase the risk for introducing bacteria to the bladder. Patients can drink fluids and will have a full bladder without risk. It is usually an issue with workflow in the ED. The UC reduces mobility, and makes patients at a higher risk for pressure ulcers. Frail patients may become more deconditioned with a UC and infectious complications (CAUTI) may result in poor outcomes. 20

21 The Measurement Phases of the ED Improvement Intervention Baseline Intervention –Pre-implementation –Implementation Sustainability 21

22 ED Improvement Intervention Timeline 22 Intervention

23 Defining the ED Measurement Phases Baseline: assess the proportion of those UCs placed (evaluate the magnitude of the problem of inappropriate use) Intervention: assess whether the placement of UCs has dropped, and inappropriate use Sustainability: continued reduction in placement rate will reflect whether the program effect persists 23

24 How to Spread the Message Pocket cards, posters, lectures, and algorithms describing the appropriate indications. Make sure the information is shared with nurses and nursing assistants, staff physicians, physicians- in-training, and mid- level providers 24

25 For Patients Requiring a UC 1.Ensure your policies for placing the UCs are up to date. 2.Ensure the staff placing UCs are evaluated for competency (i.e., know proper insertion technique). 3.Consider using a catheter insertion kit that includes all the elements required for insertion. 4.May use simplified insertion checklist for periodic audits. 25

26 Simplified Insertion Checklist for UC Placement Components of Checklist Compliant YesYes, after correction Hand hygiene before and after procedure? Sterile gloves, drapes, sponges, aseptic sterile solution for cleaning, and single use packet lubricant used? Aseptic insertion technique (no contamination during placement)? Proper securement of urinary catheter post- procedure? Closed drainage system and bag is below patient post-procedure? 26

27 What is the UC Evaluation Process? Physician and nurse evaluate patient. Decision to place a UC based on appropriate indication. Patients ED nurse reevaluates need for UC and reason for use before transfer to unit. 27

28 UC Evaluation: Data Collection in the Emergency Department A form is completed by the ED nurse transferring the patient to the hospital unit: 1.Patient with or without catheter 2.Reason for use of catheter (for internal evaluation) 3.If no appropriate reason, nurse to evaluate removal 28

29 UC Evaluation: Data Collection Form Example of the form that may be used for those collecting data in the emergency department (ED) Used during intervention and sustainability periods. 29

30 UC Evaluation: Metrics to Evaluate Improvements MeasurementCalculation Required for reporting to national project: ED UC Placement Rate = (Number of ED admissions with a newly-placed indwelling UC, including observation patients) X 100 (Number of ED admits from the ED, including observation patients) Optional recommended to internal evaluation: Inappropriately Placed UC Rate = (Number of UCs placed in the ED without appropriate indication) X 100 (Total number UCs placed in the ED) Documented Physician Order to Place UC Rate = (Number of UCs placed in the ED without a documented physicians order) X 100 (Total number of UCs placed in the ED) 30

31 ED Intervention Checklist for Success Select physician and nurse champions. Establish agreed upon ED institutional guidelines. Create a mechanism to ensure data collection (and feed the data back to different stakeholders). More ED resources available here on our project website.here 31

32 The CAUTI Emergency Department Improvement Intervention Marlene Bokholdt, MS, RN, CPEN Nursing Education Editor Emergency Nurses Association 32

33 Learning Objectives Identify why the ED is getting involved in CAUTI prevention Review the points of impact for the emergency nurse in CAUTI prevention Define how the Emergency Nurses Association, and other national organizations can support ED involvement 33

34 Why the Emergency Department? Most urinary catheters placed Emergency environment and team Intuitive vs. analytic decision making Three points of impact –Decision to insert –Insertion technique –Maintenance –Decision to remove 34

35 Decision to Insert Responsibility Communication –Team –Patient and family Provision of care Documentation prompts 35

36 CAUTI Myths 36 PerceptionFacts Facilitates I/O measurement Alternatives are available with less risk (e.g., urinals, daily weights) Prevents falls from getting up to urinate Increases risk to fall, especially in the confused patient Protects skin in the incontinent patient Increases risk of skin breakdown from immobility, muscle loss, and catheter- related trauma Saves time for the bedside nurse Extended LOS, infection complications, and other risks, it does not

37 37 Other indications for urinary catheter: Urinary retention/obstruction? o 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? o 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 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?

38 Insertion Technique Emergency vs. sterility? –Hygiene then sterility Competencies –Review catheter insertion technique Two-person procedure –Because you can do it alone, doesn't mean you should Checklists Supplies 38

39 Decision to Remove Re-evaluation prior to admission Not an ED issue…Maybe, maybe not 39

40 The CAUTI Emergency Department Improvement Intervention What is the On the CUSP: STOP CAUTI ED Improvement Intervention? Expanding the reach of the On the CUSP: STOP CAUTI national collaborative Instilling a culture of partnership between emergency departments and in-patient units Broadening exposure to national experts Emergency Nurses Association (ENA) American College of Emergency Physicians (ACEP) 40

41 ED Improvement Intervention Goals: Best practice techniques for CAUTI Prevention Technical change (Process): Determine catheter appropriateness Preventing unnecessary placement Promoting compliance with institutional guidelines Promoting proper insertion techniques Culture change (CUSP): Teamwork and communication amongst frontline staff Identify nurse and physician champions for leadership and buy-in Collaboration with in-patient units 41

42 ED Improvement Intervention National project support includes: Comprehensive ED Tool Kit with customizable resources Educational events: National expert presentations Coaching support by the National Project Team In-person training opportunities Data collection and analysis 42

43 ED Nursing Education Presentation 43 Case Scenario: John An 85-year-old male with dementia Brought to the ED with a nonfunctioning PEG tube. Noted to be incontinent and a urinary catheter is placed. Admitted for a PEG change. Overnight he became more confused; pulling on his catheter. Developed severe hematuria; urology evaluation. Within 36 hours –Febrile –Positive blood cultures –Treated for CAUTI –Required a prolonged hospital stay

44 ED Physician Champions for CAUTI Jeremiah D. Schuur MD, MHS, FACEP Brigham and Womens Hospital American College of Emergency Physicians 44

45 Learning Objectives Review physicians role in urinary catheter placement Identify strategies for improving appropriateness Review role of physician champion in CAUTI project 45

46 Physician Role in Urinary Catheter Placement All urinary catheters require an order… Yet, the decision to place a catheter is not the ED ordering providers alone: –ED nurse –Patient & Family –Consultant (e.g. Trauma) –Admitting service (e.g. Cardiology) 46

47 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 avoid CAUTI 47

48 Role of ED Physician Champion to Reduce CAUTI Promote reduction of catheter use by championing appropriateness Encourage interdisciplinary conversation around catheter use Engage other services around patterns of catheter use 48

49 Identify Common Patterns of ED Catheter Use Measuring urine output in stable patients –CHF Assessing bladder volume –Urinary retention from spinal injury Protocolized care for trauma Incontinence without open sacral or perineal wounds Pre-operative Existing catheter use 49

50 Other indications for urinary catheter: Urinary retention/obstruction? o 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? o 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 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

51 Improving Appropriateness Review appropriate indications for catheters with medical staff –CDC/HICPAC Guidelines –Pathway Implement appropriateness criteria in workflow –Ordering process: Computer physician order entry or Paper order sets –Pathway Give feedback to medical staff on catheter appropriateness 51

52 Case Study: Trauma Historically most trauma patients received a catheter as part of evaluation & resuscitation –ATLS 8 th 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 52

53 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 53

54 Collaboration with Nursing Encourage communication at the time of catheter ordering/placement –Huddle re: need for catheter –Acknowledge nursings deeper knowledge of patient and ability to care for self 54

55 Champion Roles Share data on catheter use with medical staff –Break out by physician if possible Circulate descriptive summaries of any CAUTIs that are attributed to ED placement Communicate with other medical services about specific patterns of care 55

56 Emergency Department Data Mariana Lesher, MS Senior Data Analyst Health Research & Educational Trust 56

57 CDS Registration Send the following information to Keesha Mwangangi Comprehensive Data System (CDS) Login ID and Password provided by HRET. –Following registration, an will be sent to the Principal Data Person 57 All items in RED are required for ED registration State Hospital name Unit name Principal data persons first name Principal data persons Last name Principal data persons Principal data persons Phone Team Lead First Name Team Lead Last Name Team Lead Team Lead Phone ED Physician Champion First Name ED Physician Champion Last Name ED Physician Champion

58 Entering Data in CDS is Simple! Log into CDS with login ID and password https://www.hretcds.org Select the measure, then click enter data* *Data entry dates will vary per cohort and unit 58

59 ED Data Entry Select baseline (first 14 days only) or monitoring (implementation and sustainability) tab Select date*, then click Go *Data entry dates will vary per cohort and unit 59

60 Enter These Three Simple Items 1.Was data collected (yes or no)? 2.If YES, enter numerator & denominator 3.SAVE or SUBMIT 60

61 Upcoming Events & Next Steps 61 August ED Office Hours: Wednesday, August 14, 2013 at 11 ET/10 CT/9 MT/8 PT Review all Resources located on the project webpage: cuspstop-cauti/toolkits-and-resources/emergency-department- improvement-intervention/ cuspstop-cauti/toolkits-and-resources/emergency-department- improvement-intervention/ Baseline Data Collection begins in September 17, 2013

62 We Want to Hear from You Take the ED Recruitment Questionnaire https://www.surveymonkey.com/s/5VGX6FX 62

63 Questions? 63

64 Your Opinion Matters! 64 We rely on your opinion to shape future content calls. At the end of todays call, please complete our survey using this link: https://www.surveymonkey.com/s/CAUTI_Onboarding


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