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

2. Today’s 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 Women’s Department of Emergency Medicine Mariana Lesher, MS Health Research & Educational Trust (HRET)

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

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

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.

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 5th 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.

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).

8. Prepare for the ED Program
Obtain leadership support:
Administrative
Clinical
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.

9. Prepare for the ED Program
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.

10. 2009 Prevention of CAUTI HICPAC Guidelines
Alt text: Examples of Appropriate Indications for Indwelling Urethral Catheter Use. Source: Gould, et. al, Infect Control Hosp Epidemiol 2010; 31:

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

12. CDC HICPAC definition of “critically ill” is not very clear.
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.

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

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.

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.

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

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).

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.

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
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

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.

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

22. ED Improvement Intervention Timeline
Alt text: The Project timeline is broken down into the four components of the program: baseline (weeks 1 and 2), pre-implementation (week 3), implementation (weeks 4 & 5), and sustainability (quarterly). Baseline: Collect urinary catheter initial placement prevalence; number of ED admissions as well as ED admissions with newly-placed indwelling catheter (14 days). Pre-implementation: Prepare for the implementation. Create staff awareness and excitement about the program. Begin ED physician and nursing staff education. Implementation: Educate on proper (aseptic) technique and maintenance, as well as removal of UCs placed prior to transfer to inpatient units if appropriate. Collect number of ED admissions, as well as ED admissions with a newly-placed UC (14 days). Sustainability: Collect UC initial placement prevalence (total of 14 days per quarter). Data review and feedback should occur during implementation and sustainability periods.

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

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

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

26. Simplified Insertion Checklist for UC Placement
Components of Checklist
Compliant
Yes
Yes, 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?

27. What is the UC Evaluation Process?
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.

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

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.
Alt text: Example of a standard UC data collection form in Microsoft Word format. The form collects patient’s name, date, whether or not a UC was placed in the ED, if a physician order was present, and asks the user to select the reason for placement. Reasons fall into two columns, appropriate of inappropriate, based on the institution’s guidelines.

30. UC Evaluation: Metrics to Evaluate Improvements
Measurement
Calculation
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)
(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)
(Total number of UCs placed in the ED)
Mathematical equations for calculating rates.

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.

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

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

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

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

36. CAUTI Myths Perception Facts 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. 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?

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

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

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)

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

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

43. ED Nursing Education Presentation
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 Women’s Hospital American College of Emergency Physicians

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

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 provider’s alone:
ED nurse
Patient & Family
Consultant (e.g. Trauma)
Admitting service (e.g. Cardiology)

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

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

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

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

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
Give feedback to medical staff on catheter appropriateness

52. 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

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

54. 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

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

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

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
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 1 2 3

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

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

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

61. Upcoming Events & Next Steps
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:
Baseline Data Collection begins in September 17, 2013

62. Take the ED Recruitment Questionnaire
We Want to Hear from You
Take the ED Recruitment Questionnaire
( coming soon from ENA)

63. Questions?

64. Your Opinion Matters!
We rely on your opinion to shape future content calls. At the end of today’s call, please complete our survey using this link: