On the CUSP: Stop CAUTI Cohort 8 Onboarding Webinar Series Welcome to Cohort 8! Today’s Topic: Emergency Department Improvement Intervention Access slides, audio recording, and transcript of today’s webinar on the national project website: cauti/educational-sessions/on-boarding-calls/ 1

On the CUSP: Stop CAUTI Cohort 8 Onboarding Webinar #6 Emergency Department Improvement Intervention 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 Women’s Department of Emergency Medicine Neel Pathak, MHA Health Research & Educational Trust (HRET) 2

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

Case Scenario: An 85-year-old male with dementia... 4 Was transferred from the nursing home to the hospital because of a non-functioning gastrostomy (PEG) tube. In the ED, the nurse noted the patient was incontinent and placed a urinary catheter (UC). The patient was admitted and the PEG tube was changed. That night, the patient became more confused and pulled on his UC, leading to severe hematuria and a urologic evaluation. Within 24 hours, he spiked a fever and blood cultures were positive. He was treated for CAUTI and required a prolonged hospital stay.

How to Improve Urinary Catheter Use in the ED? 5 Establish clear guidelines for UC insertion in the ED. Engage physicians (significant role in UC use). Engage nurses (significant role in UC use).

Goals 6 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.

Prepare for the Program Obtain leadership support: 1.Administrative 2.Clinical Identify: 1.ED physician champion (leader) 2.ED nurse champion (leader) 3.Project Manager: point person to facilitate implementation of the program and be accountable for data collection. 7

Establishing Institutional Guidelines 8 The proper indications for UC placement in the ED are based upon the CDC HICPAC guidelines. It is acceptable to consider having institutional guidelines (or additional agreed upon indications) for UC placement for the ED.

2009 Prevention of CAUTI HICPAC Guidelines 9

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 10

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 11

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. 12

Hospice/Comfort Care/Palliative Care Patient comfort at the end-of-life Check with the patient before placing UC. What does the patient feel is comfortable? 13

Required Immobilization for Trauma or Surgery 14 Including: 1.Unstable thoracic or lumbar spine 2.Multiple traumatic injuries, such as pelvic fractures

Accurate Measurement of Urinary Output in the Critically Ill Patients 15 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. Discontinue the UC if patients improve with treatment in ED, and it is no longer necessary.

Chronic Indwelling Urinary Catheter upon Admission 16 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).

Issues to Clarify 17 A chronic indwelling UC present on admission to the ED would not be counted as placed in the ED (even if the catheter is changed there). Some patients have a UC upon admission, prior to presentation to the ED (for example, obstructive uropathy). Again, these may represent appropriate indications for utilization, but would not be counted as originally placed in the ED.

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

Common Conditions where the UC is Placed Inappropriately 19 Inappropriate Catheter Placement Elderly (especially women) IncontinenceDebility Use in non- critically ill cardiac and renal patients Morbid obesity? Immobility Physician and Nurse Practice

Examples of Common Conditions where Catheter May Be Placed Inappropriately 20 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.

Example of ED Appropriate Indications at St. John Hospital & Medical Center 21 Urinary flow obstruction or retention: covers prostatic hypertrophy, hematuria with clots, urethral stricture, trauma to area involved; neurogenic bladder (including paraplegia/ quadriplegia or other conditions that lead to non-obstructive retention including medications). Perioperative use in selected surgeries: includes urologic surgery or surgery on contiguous structures of genitourinary tract, and perioperative surgical where prolonged duration of surgery is anticipated, need for large volume infusion, and intraoperative monitoring of fluid. This may include some emergent surgeries. Need for prolonged immobilization: either related to trauma or surgery (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures, may consider hip fracture if risk of displacement).

Example of ED Appropriate Indications at St. John Hospital & Medical Center 22 Monitoring fluids in critically ill patients: defined as those that may end up being admitted to intensive care. This group may initially be critically ill and improve with treatment in the ED (e.g., pulmonary edema). If UC is initially placed and patient improves, then removal of UC prior to ED exit is recommended. To this group, we may add those that require high amounts of oxygen (≥6 liters per minute nasal cannula or ≥40% face mask FIO2). This may also include all patients intubated, except those on hemodialysis (or chronic anuria). Assist healing of sacral and perineal wounds in those with incontinence: need to have an ulcer or wound and risk of worsening with incontinence. Incontinence alone is not an acceptable indication. To improve comfort for end of life care: this is related to patient comfort. Some patients may not want a UC.

The Different Components of the Effort 23 Baseline Pre-implementation Implementation Sustainability

Project Timeline 24

How Each Period Helps 25 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.

How to Spread the Message 26 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

For Patients Requiring a UC 27 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.

Simplified Insertion Checklist for UC Placement 28 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?

What is the Process? 29 Physician and nurse evaluate patient. Decision to place a UC based on appropriate indication. Patient’s ED nurse reevaluates need for UC and reason for use before transfer to unit.

Data Collection in the Emergency Department 30 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

UC Data Collection Form 31 Example of the form that may be used for those collecting data in the emergency department (ED) Used during intervention and sustainability periods.

Metrics to Evaluate Improvements 32 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 physician’s order) X 100 (Total number of UCs placed in the ED)

Checklist for Success 33 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). Use provided resources (ED Urinary Catheter Toolkit).

Example of Success: AH Pilot- 18 EDs (Fakih et al, Ann Emerg Med 2014;63: ) Catheter avoidance translates into preventing exposure to the catheter for thousands of patients Reduction in catheter use by a third! The results were sustained for more than 6 months 34

The CAUTI Emergency Department Improvement Intervention Marlene Bokholdt, MS, RN, CPEN Nursing Education Editor Emergency Nurses Association 35

Objectives 36 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

Why the Emergency Department? 37 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

Decision to Insert 38 Responsibility Communication – Team – Patient and family Provision of care Documentation prompts

CAUTI Myths 39 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

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? 40

Insertion Technique 41 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

Decision to Remove 42 Re-evaluation prior to admission Not an ED issue…Maybe, maybe not

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) 43

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 44

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 45

ED Nursing Education Presentation Case-based learning-example 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 46

ED Physician Champions for CAUTI Jeremiah D. Schuur MD, MHS, FACEP Brigham and Women’s Hospital American College of Emergency Physicians 47

Objectives 48 Review physicians’ role in urinary catheter placement Identify strategies for improving appropriateness Review role of physician champion in CAUTI project

Physician Role in Urinary Catheter Placement 49 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)

ED Workflow and Culture & Urinary Catheter Placement 50 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

Role of ED Physician Champion to Reduce CAUTI 51 Promote reduction of catheter use by championing appropriateness Encourage interdisciplinary conversation around catheter use Engage other services around patterns of catheter use

Identify Common Patterns of ED Catheter Use 52 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

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? 53

Improving Appropriateness 54 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 – Pathway Give feedback to medical staff on catheter appropriateness

Case Study: Trauma 55 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

Case Study: Congestive Heart Failure 56 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

Collaboration with Nursing 57 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

Champion Roles 58 Share data on catheter use with medical staff – Break out by physician if possible Circulate descriptive summaries of any Caulis that are attributed to ED placement Communicate with other medical services about specific patterns of care

Emergency Department Data Neel Pathak, MHA Research Specialist Health Research & Educational Trust 59

Registration 60 Send the following information to Neel Pathak at CDS Login ID and Password provided by HRET. – Following registration, an will be sent to the Principal Data Person All items in RED are required for ED registration State Hospital name Unit name Principal data person’s first name Principal data person’s Last name Principal data person’s Principal data person’s 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

Entering Data in CDS is Simple! 61 Log into CDS with login ID and password Select the measure, then click “enter data”* *Data entry dates will vary per cohort and unit

Data Entry Select baseline (first 14 days only) or monitoring (implementation and sustainability) tab Select date*, then click “Go” 62 *Data entry dates will vary per cohort and unit

Enter These Three Simple Items Was data collected (yes or no)? If YES, enter numerator & denominator SAVE or SUBMIT 63

Questions? 64

Upcoming National Content Webinars 65 DateTime/DurationTopic 7/8/ ET/11 CT/10 MT/9 PT (60 minutes) July National Content Webinar Preventing CAUTI in Specialized Patient Populations: Procedural-Related Catheter Use

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