On the CUSP: Stop CAUTI

1. On the CUSP: Stop CAUTI The Emergency Department & Catheter Insertions September 10, 2013 11:00 AM CT / 12:00 PM ET

2. Today’s Presenters Mohamad Fakih, MD, MPH St. John Hospital and Medical Center Lisa Wolf, PhD, RN, CEN, FAEN Emergency Nurses Association (ENA) Jeremiah Schuur, MD, MHS, FACEP Brigham and Women’s Department of Emergency Medicine

3. Session Objectives • Understand how to improve the compliance with the appropriate indications for UC placement in the emergency department for nurses and physicians • Improve the compliance with proper technique for placement • Review the points of impact for the emergency nurse in CAUTI prevention • Review ED physicians’ role in urinary catheter placement

4. Could this happen at your hospital? The Story of Mr. Smith (1) • Mr. Smith is 82 year old and gets admitted because of mild congestive heart failure. In the Emergency Department, a urinary catheter is placed (although he can use the urinal), and he is transferred to the floor but could not sleep. He is prescribed a sleeping pill. He gets more restless, gets out of bed, trips on the catheter and falls. He is found to have a left hip fracture, and undergoes surgery. Post-operatively, the staff notes that his left leg is swollen and he is diagnosed with deep venous thrombosis. He is started on blood thinners.

5. Could this happen at your hospital? The Story of Mr. Smith (2) • Because of his immobility, he develops a pressure ulcer on his sacrum. His physician removes the catheter, but now he is having urinary retention related to pain medications. The urinary catheter is placed again. The procedure results in hematuria with the difficulty in insertion and being on blood thinners. Few days later, he develops fever and his blood pressure drops. Blood cultures and urine cultures grow Escherichia coli and he is diagnosed with CAUTI and septicemia. After 6 weeks in the hospital and many complications, Mr. Smith is no longer the same.

6. Partnership for patients Different harms are connected! Venous thrombo-embolism Falls Adverse drug events

7. Why the Emergency department (ED)? • More than half of the hospitalized patients are admitted from the ED • Decision to place urinary catheter often made in the ED • Avoiding unnecessary placement would prevent exposure (complications) during hospitalization, especially for the most vulnerable patients

8. Elderly Women: High Risk for Unnecessary Use(Fakih et al, Am J Infect Control 2010;38:683-8) • Evaluated urinary catheter (UC) placement for all admissions from ED for 12 weeks. • 532/4521 (11.8%) patients had a UC placed, 69.7% indicated. • Women ≥80 years: half had a UC placed without indication. • UC without appropriate indication: • Women: twice more likely than men • Very elderly (≥80 years): 3 times more likely than those 50 or younger

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

10. Effect of Establishing Institutional Guidelines in ED(Fakih et al, Acad Emerg Med 2010; 17:337–340) • Established institutional guidelines for UC placement in ED • Compared the rate of placement before and after guidelines • ED physician champion involved • Minimal nursing education/ intervention • Pre- and post-intervention: 3 months baseline, and 9 months intervention/ sustainability (sampled 5 days per quarter)

11. Physician Intervention ED (Fakih et al, Acad Emerg Med, 2010; 17:337–340) • UC utilization dropped significantly after starting the physician intervention from 14.9% pre-intervention to 10.6% post-intervention (p=0.002) • Physicians ordered fewer UCs post-intervention 4.3% compared to pre-intervention 7.5% (p=0.002) • Only 47.0% UCs initially placed in the ED had a physician order documented • Post-intervention: more compliance with indications for catheters placed with physician order, no change for those without

12. Pilot Work: Ascension and Michigan Hospital Association • More than 30 EDs involved • Engaged both ED physicians and nurses • Encouraged establishing institutional guidelines • Looked at change in placement rate and appropriateness

13. Indications Based on CDC HICPAC Guidelines (Gould, et. al, Infect Control Hosp Epidemiol 2010; 31: 319-326)

14. Pilot work: 18 EDs in Ascension Health • Results: less catheters placed, in some instances up to 50% drop, average about a third, and increased appropriateness of use • Physician order documentation for placement increased • More noticeable improvement in hospitals who started with a higher baseline use

15. Ascension Pilot of 18 EDs • 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

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

17. Nursing Considerations in the Emergency Department Lisa Wolf, PhD, RN, CEN, FAEN Emergency Nurses Association

18. Problem The emergency nurse at both the initial patient encounter and throughout the trajectory of care makes clinical decisions that affect patient safety, efficacy, efficiency and cost-effectiveness of care involving Problem identification Acuity assignation Need for resources Patient advocacy

19. Problem • Clinical decision-making takes place in a social context. • The attitudes and biases of each participant can affect the decision-making process. • The overall culture of an emergency department can challenge or enhance good clinical decision-making.

20. Who is driving patient care in emergency settings? Nurses? Physicians? Hospitalists? Intensivists? Patients?

21. What’s different about ED nursing? • Rapidly shifting priorities • Quick turnover of patients • Chaotic environment • Potential for rapid deterioration of patients • Range of ages/developmental stages • Unclear diagnosis/etiology of symptoms

22. EDs as a unique setting • Higher levels of autonomous practice • Nurse-driven environment • Use of protocols/care guidelines • Collaborative practice

23. The Framework An integrated, ethically-driven environmental model of clinical decision-making The model is an open environmental model with each element influencing the others. Core elements knowledge base critical application moral agency Immediate elements unit leadership nurse-provider relationship • Influential elements • institutional leadership • environment of care

24. Core elements An integrated, ethically-driven environmental model of clinical decision-making (Wolf, 2011) Immediate elements Influential elements Core elements exert influence on accuracy in problem identification and decision-making. Immediate elements of the practice environment can be influenced by the core elements of leaders Influential elements will also reflect the core attributes of leaders, managers and administrators in the health care environment.

25. Elements of the individual Knowledge base – what does the provider know? Moral reasoning –what drives questioning and assessment? Drive to act – able to operationalize moral agency?

26. What are the elements in the environment? Environmental structure Standards – what is expected of each level of provider? Communication – how does information and concern get transmitted between providers? Teamwork – are all providers working with the same agenda and goals? Autonomy of practice – who is able to make decisions about acuity and resources and under what circumstances?

27. Fostering excellence in clinical decision-making Needs to address all aspects of the model Individual Knowledge and critical application Moral agency Drive to act Environmental Context in which decision making occurs and is acted upon Unit level Institutional level

28. Urinary Catheter Utilization • About 15 - 25% of patients will have a urinary catheter placed during their hospitalization. • Many are placed in: • ICU • ED • OR

29. Reducing CAUTI • Avoid use if no indication • Remove as soon as possible

30. Why we think putting in a catheter is a good idea – but it’s not • Facilitates I/O measurement • Keeps patients from having to get up to urinate, protecting them from injury • Protects skin in the incontinent patient. • Saves time for the bedside nurse.

31. 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 • HCPAC Guidelines

32. “Not” indications for catheterization • Substitute for frequent toileting • To obtain a specimen if the patient can void freely • Patient preference • Dementia • Obesity

33. Patients at high risk for inappropriate catheterization • Elderly Women • Incontinent • Obese • Immobile • Non-critically ill cardiac and renal patients • Monitor does not necessitate catheter

34. Reducing inappropriate placements reduces • Infection rates • Cost • Antibiotics use • Length of stay • Morbidity • Patient discomfort

35. Attributes of the Individual Emergency Nurse • Knowledge base: • Assessment skills • Indications for placement/non-placement of catheter • Critical application • Under what circumstances catheter is placed • Autonomy of practice • Moral agency • Ability to advocate for safe patient care • Promotes beneficence and non-maleficence

36. Putting systems in place Environmental: Context in which decision making occurs and is acted upon Unit Leadership Must set standards of practice Must maintain ‘sunnum bonum’ for patients Must promote collaborative clinical decision-making and care

37. Nurse-Provider relationships and communication • Central to decision-making and action • Assess for mutual respect and autonomy of practice • Institutional level – foster teamwork, autonomy and control over practice. • Ethical standards drive practice • Interdisciplinary training, governance, practice committees

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

39. Implications • Environment: • In settings with problematic decision-making or change process implementation, the attributes of the practice environment should be examined and managed as well as the skill level of individual nurses who practice in that environment. • Administrative support • Nurse-physician relationships • Practice culture

40. The take home Clinical decision-making is not a matter of information in, decision out Elements that encompass both characteristics of the individual as well as the context in which the individual functions are crucial to fostering excellence in decision-making

41. The take home Commitment at the unit and institutional levels is required to support and facilitate excellence. Both physicians and nurses need to model ethically-driven, patient focused, collaborative care The environment of care must change to afford behavioral change

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

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

44. 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)

45. 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 reduce catheter use

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

47. Improving Appropriateness 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

48. Physician Task 1: Champion Appropriateness • Have ED physician champion work with nursing to develop / review ED policy addressing appropriate indications for urinary catheter placement • Start with CDC/HICPAC guideline • Define both indication and contraindications • Consider any ED specific modifications • Have reviewed by infection control  Implement

49. Physician Task 1: Champion Appropriateness • Have ED physician champion work with nursing to implement ED policy • Require order for placement of catheter • Require documentation of indication with order • Include prompts of indications/contraindication • Possible in EHR or on paper form • Have ED physician speak ED to physician group about CAUTI and policy

50. 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 50 No Insert or maintain catheter Remove catheter prior to admission