Presentation on theme: "Emergency Department Improvement Intervention Onboarding Webinar"— Presentation transcript:
1 Emergency Department Improvement Intervention Onboarding Webinar On the CUSP: Stop CAUTIEmergency Department Improvement Intervention Onboarding WebinarJune 12, 2013
2 Today’s PresentersMohamad 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 ProcessMohamad Fakih, MD, MPHAssociate Professor of MedicineWayne State University School of MedicineMedical Director, Infection Prevention and ControlSt. 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:PhysiciansNursesImprove 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:AdministrativeClinicalIdentify 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 obstructionAcute 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 PatientsCDC 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 monitoringUrologic surgery or other surgery on contiguous structures of the genitourinary tractThis 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-lifeCheck 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 spineMultiple 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 PlacementElderly (especially women)IncontinenceDebilityUse in non-critically ill cardiac and renal patientsMorbid obesity?ImmobilityAlt 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 AgitationAdmitted to ICURequiring 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 patientsPlacing 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 BaselineInterventionPre-implementationImplementationSustainability
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 useSustainability: 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 ChecklistCompliantYesYes, after correctionHand 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 catheterReason 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 MeasurementCalculationRequired for reporting to national project:ED UCPlacement 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 EDwithout 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, CPENNursing Education EditorEmergency Nurses Association
33 Learning ObjectivesIdentify why the ED is getting involved in CAUTI preventionReview the points of impact for the emergency nurse in CAUTI preventionDefine how the Emergency Nurses Association, and other national organizations can support ED involvement
34 Why the Emergency Department? Most urinary catheters placedEmergency environment and teamIntuitive vs. analytic decision makingThree points of impactDecision to insertInsertion techniqueMaintenanceDecision to remove
35 Decision to Insert Responsibility Communication Provision of care TeamPatient and familyProvision of careDocumentation 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 urinateIncreases risk to fall, especially in the confused patientProtects skin in the incontinent patientIncreases risk of skin breakdown from immobility, muscle loss, and catheter-related traumaSaves time for the bedside nurseExtended LOS, infection complications, and other risks, it does not
37 Other indications for urinary catheter: Urinary retention/obstruction?Use bladder scanner firstImmobilization 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 providerInsert catheter and treat signs of shock:HypotensionDecreased cardiac output/functionDecreased renal functionHypovolemiaHemorrhageRe-assess after interventionNoYesDo NOT insertExplore alternativesStill critically ill, requiring accurate output measurement?Insert or maintain catheterRemove catheter prior to admissionIs the patient critically ill and will require accurate output measurement?
38 Insertion Technique Emergency vs. sterility? Competencies Hygiene then sterilityCompetenciesReview catheter insertion techniqueTwo-person procedureBecause you can do it alone, doesn't mean you shouldChecklistsSupplies
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 collaborativeInstilling a culture of partnership between emergency departments and in-patient unitsBroadening exposure to national expertsEmergency Nurses Association (ENA)American College of Emergency Physicians (ACEP)
41 ED Improvement Intervention Goals: Best practice techniques for CAUTI PreventionTechnical change (Process):Determine catheter appropriatenessPreventing unnecessary placementPromoting compliance with institutional guidelinesPromoting proper insertion techniquesCulture change (CUSP):Teamwork and communication amongst frontline staffIdentify nurse and physician champions for leadership and buy-inCollaboration with in-patient units
42 ED Improvement Intervention National project support includes:Comprehensive ED Tool Kit with customizable resourcesEducational events:National expert presentationsCoaching support by the National Project TeamIn-person training opportunitiesData collection and analysis
43 ED Nursing Education Presentation Case Scenario: “John” An 85-year-old male with dementiaBrought 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 hoursFebrilePositive blood culturesTreated for CAUTIRequired 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 ObjectivesReview physicians’ role in urinary catheter placementIdentify strategies for improving appropriatenessReview 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 nursePatient & FamilyConsultant (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 parallelNurses often assess a patient and consider a catheter before the ordering providerPatterns of ED catheter use have developed over time and reflect local practice patternsIt 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 appropriatenessEncourage interdisciplinary conversation around catheter useEngage other services around patterns of catheter use
49 Identify Common Patterns of ED Catheter Use Measuring urine output in stable patientsCHFAssessing bladder volumeUrinary retention from spinal injuryProtocolized care for traumaIncontinence without open sacral or perineal woundsPre-operativeExisting catheter use
50 Other indications for urinary catheter: Urinary retention/obstruction?Use bladder scanner firstImmobilization 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 providerInsert catheter and treat signs of shock:HypotensionDecreased cardiac output/functionDecreased renal functionHypovolemiaHemorrhageRe-assess after interventionNoYesDo NOT insertExplore alternativesStill critically ill, requiring accurate output measurement?Insert or maintain catheterRemove catheter prior to admissionIs the patient critically ill and will require accurate output measurement?50
51 Improving Appropriateness Review appropriate indications for catheters with medical staffCDC/HICPAC GuidelinesPathwayImplement appropriateness criteria in workflowOrdering process: Computer physician order entry or Paper order setsGive feedback to medical staff on catheter appropriateness
52 Case Study: TraumaHistorically most trauma patients received a catheter as part of evaluation & resuscitationATLS 8th edition recommends urinary catheters for assessing hemodynamic statusOften placed by junior traineeIdentify current practicesReview protocol with ED and Trauma leadersSet clear criteria for catheter useDesignate appropriate staff to place catheters
53 Case Study: Congestive Heart Failure Many CHF patients get a catheter to monitor urine outputIdentify motivations for pattern of careMedical necessity? -- Not if able to regularly void & stablePatient convenience?Staff convenience?Strengthen protocols for tracking urine outputMeet with Cardiology to examine practice
54 Collaboration with Nursing Encourage communication at the time of catheter ordering/placement“Huddle” re: need for catheterAcknowledge 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 possibleCirculate descriptive summaries of any CAUTIs that are attributed to ED placementCommunicate 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 RegistrationSend the following information to Keesha MwangangiComprehensive Data System (CDS) Login ID and Password provided by HRET.Following registration, an will be sent to the Principal Data PersonAll items in RED are required for ED registrationStateHospital nameUnit namePrincipal data person’s first namePrincipal data person’s Last namePrincipal data person’sPrincipal data person’s PhoneTeam Lead First NameTeam Lead Last NameTeam LeadTeam Lead PhoneED Physician Champion First NameED Physician Champion Last NameED Physician Champion123
58 Entering Data in CDS is Simple! Log into CDS with login ID and passwordSelect the measure, then click “enter data”**Data entry dates will vary per cohort and unit
59 ED Data EntrySelect baseline (first 14 days only) or monitoring (implementation and sustainability) tabSelect 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 & denominatorSAVE or SUBMIT
61 Upcoming Events & Next Steps August ED Office Hours: Wednesday, August 14, 2013 at 11 ET/10 CT/9 MT/8 PTReview 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 YouTake the ED Recruitment Questionnaire( coming soon from ENA)