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Emergency Nursing Education 1. An 85 year old male with dementia… Brought to the ED from his skilled nursing facility with a complaint of nonfunctioning.

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Presentation on theme: "Emergency Nursing Education 1. An 85 year old male with dementia… Brought to the ED from his skilled nursing facility with a complaint of nonfunctioning."— Presentation transcript:

1 Emergency Nursing Education 1

2 An 85 year old male with dementia… Brought to the ED from his skilled nursing facility with a complaint of nonfunctioning PEG tube. In the initial assessment, the nurse notes the patient was incontinent and placed a urinary catheter The patient is admitted for a PEG change. Overnight the patient becomes more confused and pulls on his catheter leading to severe hematuria and requiring a urology evaluation. Within 36 hours was febrile, with positive blood cultures, treated for CAUTI and requires a prolonged hospital stay. 2

3 Objectives Describe urinary catheter use with focus on the emergency department (ED) Identify current evidence on prevention of CAUTIs Outline nursing assessment of the ED patient who may require urinary catheterization List criteria for catheter placement Review communication necessary between nurses and providers to facilitate appropriate clinical decision-making 3

4 Urinary Catheter Utilization About % of patients will have a urinary catheter placed during their hospitalization. Many are placed in ED ICU OR 4

5 Reducing CAUTI Determine appropriate indication Avoid use if no indication Seek alternatives when possible Use sterile technique for placement Remove as soon as possible 5

6 Why we think putting in a catheter is a good idea – but its not 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 6

7 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 7

8 Not indications for catheterization Substitute for frequent toileting To obtain a specimen if the patient can void freely Patient preference Dementia Obesity 8

9 Patients at high risk for inappropriate catheterization Elderly Women Independent factors: women were twice more likely than men, and very elderly (80 years) were 3 times more likely than those 50 or younger, to have urinary catheter placed without indication. Fakih et al, Am J Infect Control 2010;38:683-8 Incontinent Obese Immobile Non-critically ill cardiac and renal patients Monitor does not necessitate catheter 9

10 Reducing inappropriate placements reduces Infection rates Cost Antibiotics use Length of stay Morbidity Patient discomfort 10

11 Communication with providers Clear understanding of indications Commitment to nonmaleficence (doing no harm) Patient focused care 11

12 So, how does this affect the care of this patient? Brought to the ED from his SNF with a complaint of nonfunctioning PEG tube. In the initial assessment, the nurse noted the patient being incontinent and placed a urinary catheter Incontinence is not an indication by itself for catheter placement 12

13 So, how does this affect the care of this patient? The patient was admitted for a PEG change. Overnight the patient became more confused and pulled on his catheter leading to severe hematuria and requiring a urology evaluation. The agitated patient (possibly due to dementia) is not a good candidate for catheter placement 13

14 So, how does this affect the care of this patient? Within 36 hours was febrile, with positive blood cultures, treated for CAUTI and required a prolonged hospital stay. This patient had no indications to place a catheter; the suggestion is that placement of the catheter in the ED was a potential cause of infection. Patient stay is prolonged, patient develops a clinical problem he did not present with initially. This infection is potentially preventable. 14

15 Another example… A 76-year-old woman admitted for congestive heart failure… Urinary catheter placed and started on diuretics Condition improved; ready for discharge on 3 rd day No urinary output for 5 hours after catheter removal Bladder scan showed 500 mL of urine Straight catheterization Observed overnight for symptom resolution CAUTI ED slides, Fakih,

16 So, how does this affect the care of this patient? Urinary catheter placed and started on diuretics Accurate I & O measurement can be a valid indication for catheter placement for critically ill patients Evaluate for need before placement 16

17 So, how does this affect the care of this patient? Condition improved; ready for discharge on 3 rd day No urinary output for 5 hours after catheter removal Bladder scan showed 500 mL of urine Not all patients with congestive heart failure require catheterization Early removal may have prompted evaluation of urinary retention Additional day of hospitalization Risk for urosepsis Explore alternatives for measuring I & O Removal after initial diuresis to shorten exposure Frequent toileting Communicate with inpatient staff indication for placement to assure timely removal 17

18 Another example… A frail 82-year-old woman was admitted for congestive heart failure… Urinary catheter placed and started on diuretics Team felt the catheter would make her more comfortable On day 5 Chills; fever of 102°F SBP dropped to 90 mmHg Blood cultures and urine cultures grew Escherichia coli. Diagnosed with symptomatic CAUTI and treated with intravenous antibiotics. CAUTI ED slides, Fakih,

19 So, how does this affect the care of this patient? Team felt the catheter would make her more comfortable Comfort is a myth It may be convenient for the staff and the patient, but does not promote comfort, nor is it a safe indication Some patients may request a catheter to avoid the need to get up. It is still an inappropriate reason Consequences Prolonged, unexpected hospitalization from hospital- acquired CAUTI Risk for urosepsis 19

20 The take home Review indications for urinary catheter placement Discuss placement with provider Communicate indications for placement with inpatient staff for timely removal Do no harm 20

21 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? 21


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