Defining Critically Ill in the ICU; Alternatives to Catheters; Using CUSP Staff Safety Assessment and the Learning From Defects Tool to Improve Safety Culture

Slide 1

Defining “Critically Ill” in the ICU; Alternatives to Catheters; Using the CUSP Staff Safety Assessment and the Learning from Defects Tools to Improve Safety Culture

Randy Garnett Jr., MD
PCCM Physician, Sentara Medical Group
Chairman, Sentara Norfolk General Critical Care Committee
Medical Director, Sentara Lung Transplant Out Patient Program
Norfolk, Virginia

Sheryl Sheriff, RN, MS
Cardiovascular Clinical Practice Specialist
Greenville Hospital System
Greenville, South Carolina

Emily Pasola MSN, RN, CNL
Clinical Nurse Leader
Surgical Intensive Care Unit
Saint Joseph Mercy Hospital
Ann Arbor, Michigan

Slide 2

Learning Objectives

• Define when “critically ill” is an appropriate indication for an indwelling urinary catheter in the ICU
• Describe how to implement an indwelling urinary catheter removal protocol
• Identify defects in the ICU by using the CUSP tool, Learn from Defects

Slide 3

Indwelling Urinary Catheter Use in the ICU: Critically Ill Patients

Randy Garnett Jr., MD
PCCM Physician, Sentara Medical Group
Chairman, Sentara Norfolk General Critical Care Committee
Medical Director, Sentara Lung Transplant Out Patient Program
Norfolk, Virginia

Slide 4

ICU Characteristics
(Complex Interactions, May Effect Indwelling Urinary Catheter Utilization)

• Medical vs.Surgical
• Acuity level of patients
• Arena from which patient comes from to the ICU- OR, ED, floor SNF
• Who put the indwelling urinary catheter in?
• ICU culture
  • RN
  • MD
  • Leadership/admin support
  • Other

Slide 5

Indications for Urinary Bladder Catheters

Image: Screen shot of table showing indications for indwelling urinary, intermittent urinary, suprapubic and condom catheters.

Slide 6

Potentially Critical Illness Clinical Observations

• Sweaty, anxious, pale
• Agitated or confused
• Responds to moderate stimulation only – loud voice, physical prodding
• Accessory muscle use and RR 20-30 or RR < 8
• HR > 100
• SBP < 90
• UO < 0.5 ml/kg/hr

Slide 7

The Critically Ill Patient Clinical Observations

• Looks ill – poorly perfused
• Unresponsive or poorly responsive neurologically
• Resp Rates < 8 or > 30
• HR < 50 or > 150
• SBP < 60 to 70
• Anuric or oliguric

Slide 8

Critically Ill

Surgical Patient Categories who will almost always need indwelling urinary catheters:

• Post op patients with continued mechanical ventilation and sedation
• CSICU- CVG, Valve surgery, transplant, aortic dissections
• Major abdominal GI surgery- SBO, ischemic bowel, bowel perforations, liver transplant, abdominal compartment syndrome
• Major Vascular surgery- Ruptured AAA, retroperitoneal bleeds
• Most GU surgeries
• Hemodynamically unstable post op patients where UO guides therapy
• Immobilized patients- trauma, fractures,TBI
• Post operative co-morbid processes where accurate urine output is important to monitor - acute and chronic renal failure, CHF/CMO or low Cardiac output states, DI
• Post operative delirium, agitation, encephalopathy where incontinence has a detrimental effect on optimal care – wounds, staff safety

Slide 9

Medical Patient Categories who will almost always needs indwelling urinary catheters:

• Respiratory failure on mechanical ventilation and significant sedation
• Hemodynamic instability
  • Sepsis and septic shock
  • Hemorrhagic Shock
  • GI bleed, trauma, post procedural
  • Cardiogenic Shock
• Unstable CHF patients undergoing aggressive diuresis
• Severe neurologic impairment with altered mentation- CVA, ICH, SAH, SDH, TBI
• Acute or chronic renal failure with obstruction/retention
• Critical illness where voiding exacerbates the primary process – COPD or CHF on NIV

Slide 10

Types Of Treatments Requiring Close UO Monitoring

• Bolus fluid resuscitation
• Vasopressors
• Inotropes
• High dose diuretics
• Hourly urine studies to measure life threatening laboratory abnormalities

Slide 11

Case #1:  Indwelling Urinary Catheter – Yes or No?

• 24 yo presents with acute SOB with history of asthma. Acutely ill.
• BP 155/95
• HR 124
• RR 30
• Exam:
  • Oriented x 3
  • 2 + accessory muscle use
  • Diffuse wheezing bilaterally, prolonged expiratory phase
  • Can move from stretcher to bed without significant change in status
• ABG on 2 LNC — PaO2 – 87; PCO₂ - 46; pH 7.36

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Case #2: Indwelling Urinary Catheter – Yes or No?

• 72 yo male 48 hrs post CVG x 3 and MVR. Still on mechanical ventilator with moderate levels of sedation and RASS of -2
• Is on moderate doses of norepinephrine and epinephrine that are being adjusted for MAP of 65-70
• Remains on 55% FiO2 and 8 PEEP
• Exam:
  • Opens eyes and follows simple commands before drifting off
  • Lung and cardiac exam are normal
  • Abd is benign and extremities feel perfused
• Labs and CXR s are not concerning

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Case #3: Indwelling Urinary Catheter – Yes or No?

• 83 yo male with BPH who is post op ruptured AAA returns to ICU for post op care.
• Is extubated 2 hrs post arrival in the ICU and has moderate abd pain.
• Drips: low dose Neosynephrine
• VS: HR 90, BP 140/85, RR 17. Temp 95.4
• Exam:
  • Lungs clear
  • Heart – RRR without murmur
  • Abd – moderately tender
  • Extremities perfused
  • Urine out put 50 -100 cc/hr since going to the OR
• When can the indwelling urinary catheter come out?

Slide 14

Case #4: Indwelling Urinary Catheter – Yes or No?

• 65 yo with moderate to severe COPD presents with acute on chronic respiratory failure to the ICU from the ED and is placed on NIV. No cardiac history.
• VS: HR 110, RR 21 with 1 + accessory muscle use, BP 125/66, afebrile
• Exam:
  • Distant breath sounds with rare wheezing and prolonged expiratory phase
  • Cardiac exam pertinent only for tachycardia
  • Abdomen is benign and extremities are adequately perfused
  • He is oriented x 3, moves around in bed
• He has been supported 3 times with short term NIV in the past year without needing intubation
• ABG in 40 % and NIV: PaO2 – 72; PCO2 - 52; pH – 7.35

Slide 15

Indwelling Urinary Catheter Removal Protocol

Sheryl Sheriff, RN, MS
Cardiovascular Clinical Practice Specialist
Greenville Hospital System
Greenville, South Carolina

Slide 16

Indwelling Urinary Catheter Removal Protocol: Review, Remove, Reduce

Review

Patient no longer meets approved indwelling urinary catheter indications.

↓

Remove

Nurses are empowered to remove the indwelling urinary catheter per protocol

↓

Reduce

Catheter days are reduced by timely removal of indwelling urinary catheters when no longer indicated

↓

CAUTI rates are reduced.

Slide 17

Approved Indwelling Urinary Catheter Indications

• Ordered or placed peri-operatively for selected surgical procedures (i.e. Unstable Pelvic, Hip/Spine fracture, Renal/Urologic surgery, Gynecological Surgery, Perineal procedure)
• Accurate measurements of intake and urinary output in critically ill patients:
  • Hemodynamic instability (requiring Pressors, shock), &/or
  • Neuromuscular blockade (ventilated), &/or
  • Deoxygenation with exertion or position changes (i.e. acute respiratory compromise, acute decompensated CHF)
• Epidural catheter in place for pain management and patient is unable to ambulate
• Traumatic bladder and/or ureter
• Acute urinary retention with failure of  Urinary Retention Protocol
• Bladder outlet obstruction
• Gross hematuria/irrigation
• Assistance in pressure ulcer healing for incontinent patients with stage 3 or 4 sacral ulcer or perineal wound(s)
• Comfort care (category 4)/hospice at patient/family request
• Pre-existing catheter upon admit and unable to verify indwelling urinary catheter indication
• Pre-existing catheter upon admit with chronic Urological issues
• Catheter tagged with “yellow band”  (Note: Yellow tag located around Foley tubing or at juncture of tubing and bag. If Foley is tagged, do not remove without a physician’s order.)

Slide 18

Yellow Banded Indwelling Urinary Catheters

Catheter tagged with “yellow band”  (Note: Yellow tag located around catheter tubing or at juncture of tubing and bag. If indwelling urinary catheter is tagged, do not remove without a physician’s order.)

Image: Photo a yellow banded indwelling urinary catheter.

Slide 19

Fact or Fiction and Indwelling Urinary Catheters

Fiction: Any patient on Lasix or requiring accurate intake & output measurement require indwelling urinary catheters – not true.

Fact:  Lasix and I/O measurement are not approved indications for indwelling urinary catheters.

• Follow the hospital approved indwelling urinary catheter indications.
• Use alternatives to indwelling urinary catheter for measurement of output.

Slide 20

Fact or Fiction and Indwelling Urinary Catheters in Critical Care

Fiction: All patients in critical care require a indwelling urinary catheters for accurate measurement of intake and output – not true.

Fact: Patients do not need indwelling urinary catheters just because they are in a critical care bed.

Approved indications defines “Accurate measurements of intake and urinary output in critically ill patients” as:

• Hemodynamic instability (requiring pressors, shock)
• Neuromuscular blockade (ventilated)
• Deoxygenation with exertion or position change
  (i.e. acute respiratory compromise and/or acute decompensated CHF)

Critical care patients admitted from the OR/PACU do not automatically need a urinary catheter.

Slide 21

Identifying Defects and Using the Learn From a Defect Tool

Emily Pasola MSN, RN, CNL
Clinical Nurse Leader
Surgical Intensive Care Unit
Saint Joseph Mercy Hospital
Ann Arbor, Michigan

Slide 22

Objectives

• Discuss strategies to identify defects
• Review steps of Learn From a Defect Tool (LFD)
• Discuss example using LFD

Slide 23

What is a defect?

HAPU
Self Extubation
Infection Control
CLABSI/CAUTI/VAE
Medication Error
RN Shift Handoff
Missed Documentation
Knowledge Gap
Environmental Safety

Image: Circular badge with Every Patient Every Time in the center, and Quality Safety Satisfaction on outer ring of badge.

Slide 24

Finding the Defects

• Staff feedback:
  • Shift huddles, staff meetings
• Event reporting:
  • Root Cause Analysis, hospital reporting system
• Quality and safety measures:
  • Monthly data reports
  • Recurring gaps
• Staff Safety Assessment survey

Slide 25

Staff Safety Assessment - CUSP

Image: Screen shot of a Staff Safety Assessment form.

Slide 26

Staff Safety Assessment

• What is it?
  Two questions for bedside staff:
  • Please describe how you think the next patient in your unit/clinical area will be harmed.
  • Please describe what you think can be done to prevent or minimize this harm.
• Why is it important?
  • Staff engagement-driving change
  • Staff understanding their role in patient safety
• What should you do with the information?
  • Be transparent
  • Identify theme
  • Learn From It

Slide 27

Learn From a Defect

Supporting a culture of safety

• Easy to use:
  • Efficient
• Structured Method
• Continuity
• Non-punitive
• Ownership:
  • Collaborative, multidisciplinary
• Improve Quality

Slide 28

Images: Screen shots of 2 Learning from Defects tools used by the Saint Joseph Mercy Health System.

Slide 29

Learn from Defects Tool Worksheet

Image: Screen shot of a sample filled out Learn from Defects Tool Worksheet.

Slide 30

Conclusion

• Easy, efficient & organized
• Supports staff engagement:
  • Multidisciplinary approach to quality care
• Provides transparency:
  • Staff want to know what we do.
  • Staff want to know that we listen.
• Provides structure & accountability.
• Tracks progress.

Slide 31

Summary/Next Steps

• Understand the HICPAC indications for urinary catheter use, especially in the critically ill population
• Understand when catheters may be discontinued in critically ill patients
• Know what alternatives to indwelling urinary catheters are available in your organization
• Implement the Learning From Defects tool and staff safety assessment with your ICU team

Slide 32

Thank you!

Questions?

Slide 33

Funding

Prepared by the Health Research & Educational Trust of the American Hospital Association with contract funding provided by the Agency for Healthcare Research and Quality through the contract, “National Implementation of Comprehensive Unit-based Safety Program (CUSP) to Reduce Catheter-Associated Urinary Tract Infection (CAUTI), project number HHSA290201000025I/HHSA29032001T, Task Order #1.”

Return to CAUTI Toolkit Information for Specialty Audiences