On the CUSP: Stop CAUTI Cohort 8 Onboarding Webinar Series

1. On the CUSP: Stop CAUTICohort 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: http://www.onthecuspstophai.org/on-the-cuspstop-cauti/educational-sessions/on-boarding-calls/

2. On the CUSP: Stop CAUTICohort 8 Onboarding Webinar #6 Emergency Department Improvement Intervention Mohamad Fakih, MD, MPH St. John Hospital and Medical Center Marlene Bokholdt, MS, RN, CPENEmergency Nurses Association (ENA) Jeremiah Schuur, MD, MHS, FACEP Brigham and Women’s Department of Emergency Medicine Neel Pathak, MHAHealth 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 Professor of Medicine Wayne State University School of Medicine Medical Director, Infection Prevention and Control St. John Hospital and Medical Center

4. Case Scenario: An 85-year-old male with dementia . . . • 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.

5. How to Improve Urinary Catheter 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).

6. Goals • 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.

7. Prepare for the Program • Obtain leadership support: • Administrative • Clinical • Identify: • 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. 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 institutional guidelines (or additional agreed upon indications) for UC placement for the ED.

9. 2009 Prevention of CAUTI HICPAC Guidelines

10. 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. 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

12. 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.

13. 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?

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

15. 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. • Discontinue the UC if patients improve with treatment in ED, and it is no longer necessary.

16. 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. Issues to Clarify • 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.

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 UC is Placed Inappropriately Physician and Nurse Practice

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

21. Example of ED Appropriate Indications at St. John Hospital & Medical Center • 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).

22. Example of ED Appropriate Indications at St. John Hospital & Medical Center • 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.

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

24. Project Timeline

25. How Each Period Helps • 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.

26. 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

27. 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.

28. Simplified Insertion Checklist for UC Placement

29. What is the 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.

30. 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

31. UC 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.

32. Metrics to Evaluate Improvements

33. 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). • Use provided resources (ED Urinary Catheter Toolkit).

34. Example of Success: AH Pilot- 18 EDs(Fakih et al, Ann Emerg Med 2014;63:761-768) • Reduction in catheter use by a third! • The results were sustained for more than 6 months • Catheter avoidance translates into preventing exposure to the catheter for thousands of patients

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

36. 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

37. 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

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

39. CAUTI Myths • 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

40. Is the patient critically ill and will require accurate output measurement? No Yes • 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? Yes 40 No Insert or maintain catheter Remove catheter prior to admission

41. 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

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

43. 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)

44. 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

45. 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

46. 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

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

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

49. 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)

50. 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