Emergency Department and Catheter Insertion

Paul Tedrick
AHA – Chicago
September 10, 2013
11:00 AM CT

Operator: This is a recording of the Paul Tedrick conference with the American Hospital Association on September 10^th, 2013, at 11:00AM Central Time. Ladies and gentlemen, thank you for your patience in holding. We now have your presenters in conference. Please be aware that each of your lines is in a listen-only mode. At the conclusion of the presentation, we will open the floor for your questions. At that time, instructions will be given as to the procedure to follow if you would like to ask a question. It is now my pleasure to introduce today’s first presenter, Mr. Paul Tedrick.

Paul Tedrick:  Good afternoon, everyone. Welcome to the National CAUTI Content Call for September. Today’s topic is Emergency Department and Catheter Insertion. Real briefly, I just wanted to introduce all three of our speakers. Our first speaker is going to be Dr. Mohamad Fakih, and he is – you know what? I’m sorry, I lost my place here. I will come back to Dr. Fakih; I apologize, everyone. So our second speaker is going to be Dr. Lisa Wolf. She is the Director of Research and she is with the Emergency Nurses Association; and another presenter for us today is going to be Dr. Schuur, and I apologize for the delay here. I’m trying to get my – been having some computer issues this morning. Okay, here we go.

So going back to the beginning, our first presenter today is going to be Dr. Mohamad Fakih. He is the Medical Director of Infection Prevention and Control and St. John Hospital and Medical Center in Detroit. He is also a Professor of Medicine at Wayne State University. And presenting after him, we have Lisa Wolf, Dr. Lisa Wolf, and she is with the Emergency Nurses Association. And following Lisa, we have the Chief of the Division of Health Policy at Brigham and Women’s Department of Emergency Medicine; that’s Dr. Jeremiah Schuur. So without further ado, I will go ahead and turn the call over to Dr. Fakih. You may begin.

Dr. Mohamad Fakih:  Thank you very much, Paul. Good morning, everyone. Our session objectives are to understand how to improve the compliance with the appropriate indications for urinary cath replacement in the ED for both the nurses and the physicians, and also, I will talk about the improving compliance proper technique for placement and review the points of impact for the emergency nurse in CAUTI prevention, and finally, we’ll review the ED physicians’ role in urinary catheter replacement.

And I’m going to start with a case and it’s the story of Mr. Smith, and Mr. Smith is an 82-year-old gentleman who was admitted to the hospital because of mild congestive heart failure. When he reached the emergency department, he had an urinary catheter placed. Mr. Smith, at that point, was able to use the urinal but they were worried that he may have some trouble walking to the restroom, and they put the catheter in. He was transferred to the floor but he couldn’t sleep, so they gave him sleeping pills. He became more restless, got out of bed and tripped with the catheter and fell, and then he was found to have – at that point, after the fall, he was found to have a left hip fracture and he goes for surgery. Post-operatively, they noted that his leg was swollen and he was diagnosed to have DVT and was started on blood thinners.

So because of his immobility, he developed a pressure ulcer on his sacrum and the physician decided to remove the catheter because there was no apparent indication for the use, but because of his pain medication, he developed urinary retention. The urinary catheter is placed again and because of the blood thinners, high risk of hematuria – he developed hematuria, the catheter was hard to place and he results in hematuria on blood thinners. A few days later, he developed fever and his blood pressure dropped and blood cultures are done and the urine cultures also; they grew the same organism, Ecoli, and he is diagnosed to have CAUTI and septicemia, and after six weeks in the hospital and many complications, Mr. Smith is no longer the same person who came into the hospital.

Now, you know, some people may see this as exaggeration but for those that have practiced for a long time in a hospital, a similar scenario can be seen, and what I tried to do is I tried to connect the different harms that we may have in the hospital and how they can play together. So one event can lead to multiple other events, and I’m now on the slide – that is slide 6, I think – which shows, you know, the patient’s urinary catheter harm in the center and then you have the infectious issues such as CAUTI, but other issues related to the catheter such as pressure ulcers, immobility. With immobility comes venous thrombo-embolism and falls. Adverse drug events can lead to urinary retention, so the use of the catheter. Patient discomfort is another thing that we rarely discuss. Having a catheter may really bother the patient and they may not feel that, you know, this is something that they should have inside of them. Another item that can be linked to this is length of stay, increased length of stay in the hospital in these patients.

So why are we focusing on the emergency department? When we look at those admitted to the hospital, more than half of those admitted to the hospital get through the emergency department so it’s a great place for us to intervene, to appropriately use the urinary catheter. So the usual decision for placing the catheter often happens in the ED and if we can intervene in the ED and reduce unnecessary placement, we have an impact, not only on the non-intensive care unit but also the intensive care unit. So it’s a global impact on the hospital if we work with the ED.

I’m going to give you some examples from our facility. This is a study we’ve done at my facility, St. John Hospital and Medical Center in Detroit, Michigan, where we looked at 12 weeks of data of those admitted from the emergency department and we looked at those that had a urinary catheter placed, and we checked on the reason why they had the urinary catheter placed. This was after we had an intervention to have institutional guidelines and, you know, clear guidelines for appropriate use for the catheter. What did we find? We found about 12 percent of patients having an urinary catheter placed and about 70 percent of them were indicated, so 30 percent were not fitting the institutional guidelines.

When we looked at those that had the catheter, you know, what was the risks of having a catheter without an appropriate indication? So we found out if the patient was a woman that’s above the age of 80, of those that had a catheter, half of them did not have an appropriate indication, so that group seems to be very vulnerable to inappropriate urinary catheter insertion. Now we know the elderly are very vulnerable to infection and other injury in the hospital. So women were twice as more likely to have a catheter placed inappropriately than men, and the very elderly, whether they’re a woman or a man, were three times more likely than those that are 50 years or younger to have a catheter placed inappropriately.

So what are the common conditions, the conditions where the catheter is placed inappropriately? Elderly, again, are very susceptible to have the catheter placed without an appropriate indication, those that are immobile. Morbid obesity; when you talk to nurses and physicians, sometimes when you ask them, they will place a catheter on someone who’s morbidly obese and it may be a combination of immobility that’s present in that group. Debility of being frail is another one and incontinence is also a factor. Other reasons would be it’s used in non-critically ill cardiac and renal patients, and if you see this, this is pretty much a culture; whether it’s a physician or a nurse practice, it’s usually a local culture in the hospital that’s involved.

So how did we address this at the St. John Hospital and Medical Center? And what we did is we initially worked with the physicians, the emergency physicians, emergency department physicians, and we had consensus from them on institutional guidelines. This was a gravitas effort between myself and an emergency physician, Dr. Pena (ph), who championed the work and was an advocate for appropriate urinary catheter placement (indiscernible 9:39), who did an intervention with minimum – with minimal nursing indication intervention but mostly physician. We had a pre and post-intervention, three months of baseline and then nine months of intervention sustainability. What we found out is that utilization dropped significantly, and when we looked at where did it drop the most, it was dropped in those who had a physician order. So the physician order group improved from having quite a bit of inappropriate indications to less inappropriate indications, and also, the percentage of patients who had a physician order for the catheter had dropped.

What was very interesting is about half of those that had a catheter in the ED at that point did not have a physician order, and when we looked at that proportion of patients post-intervention, they did not have much of a change in their inappropriate use, those that did not have a physician order. So we knew that, at that point, that is not a component that’s extremely important, which is the ED nurse is as important or even more important than the physicians.

I’m on slide 12 right now. I’m going to tell you a little bit about the pilot work. So there are two places where great pilot work has been done. Michigan Hospital Association has led work in about 18, 20 Michigan hospitals, hospital EDs, and Ascension Health had a very small number. In total, more than 30 EDs were involved. What we have done, we engaged both emergency department physicians and nurses, we encouraged establishing institutional guidelines and we looked at change in placement rate and appropriateness. This was done last year, and what we did is we based our appropriate indications on the CDC/HICPAC guidelines to these hospitals, and we allowed them to have additional indications that they thought would be appropriate for the ED.

Now on slide 14. So what was the pilot work? I’m going to show you the pilot work from Ascension Health, 18 EDs in Ascension Health. What we found was, with the intervention, less catheters were placed and in some instances, up to 50 percent drop, average about a third if you look at all the 18 together, and we had them increase the appropriateness of use. The physician order documentation for placement also improved and we had a more noticeable improvement in hospitals who started with a higher baseline. So if the hospital started with a higher baseline of utilization – so let’s they started with 12 percent being placed – they had an improvement, more significant improvement than someone who started with a 6 percent or 5 percent baseline placement. So this is – you know, in the graph bars, as you see the baseline, we had about 9 percent average utilization in all 18 EDs and during the intervention, which was two weeks – the baseline was one week and the intervention two weeks and sustainability was about six months – you’ve seen the drop in utilization from 9 percent, 6 percent and then the sustainability period was less than 6 percent, about 5 percent or something close to that. So great achievement and this would not have been – and as you see also, the appropriate reasons for placement have improved.

So what do we think was key in this case for the improvement? I’m on slide 16. So the first thing is, you know, having clear guidelines on when to use a catheter. I think that’s very important because if we want to talk to a physician or a nurse, we have to have some clarity about when it’s appropriate, when it’s not appropriate to place a full (ph) catheter. The second thing is engaging both stakeholders, the nurses and the physicians, and both have very significant roles in the urinary catheter use; and I think the next two presentations will address each one of them. Lisa?

Dr. Lisa Wolf:  Thanks very much. So my name is Lisa Wolf and I am the Director of the Institute for Emergency Nursing Research with the Emergency Nurses Association, and my part of this presentation is to talk to you about some very specific nursing considerations in the emergency department.

So I am going to start on slide number 18, and so the problem essentially is that the emergency department is a very unique setting and so the emergency nurse, at both the initial patient encounter, so when the patient comes in, either through triage or by ambulance, really guides, sets and guides the trajectory of care for these patients, by making clinical decisions that are going to affect patient safety and efficacy and efficiency and also the cost effectiveness of care. And so the role of the emergency nurse is to initially get some sense of what the problem is, how sick the patient is, what kind of resources the patients are going to need and then, finally, to advocate for appropriate care for all these patients who are essentially unknown and potentially really ill. So the role of the emergency nurse is very rooted in an ethical perspective that asks us to do the greatest good for our patients while minimizing harm to them.

I think it’s important to have a sense in the context here is that clinical decision takes place in a social context. We can educate nurses and physicians about when the catheter should go in and when it should come out, but it is the culture of these departments that is going to dictate whether or not the outcome of this clinical decision-making is good for patients or not as good for patients. The attitudes and biases of each participant – nurse, physician, patient, family member – all of these can affect how we express the final expression of this clinical decision-making, and so what’s going to be important is to do a cultural assessment of your department to look at some (audio interference) barriers for implementing culture change. You want to think about who is driving patient care in your department. Is it the nurses? Is it a nurse-driven environment? Is it your physicians? Is it the hospitalists who are admitting your patients into the hospital? Is it the guys in the intensive care unit, your intensivists, intensivist physicians? Or is it the patients and their families themselves who are asking you to put in catheters or to take – or to not put them in? So either one can affect the actual outcome of that decision.

Moving on to the next slide, so we’re on 21 right now, specifically, what is different about emergency department nursing? And I think this is part of the reason that we have partnered with this group in really talking about some important differences in the way that emergency nurses practice than in other areas of the hospital environment. One is that there are very rapidly shifting priorities. We have very sick patients coming in, we have patients who we don’t think are sick coming in who certainly can suddenly become sick. There’s a quick turnover between patients being discharged to home or transferred out to other areas of the hospital. It’s a very chaotic environment. There’s a potential for rapid deterioration. We see people of all ages, you know, babies to the very old, and the most important thing is that we don’t really know what’s wrong with them when they come in necessarily. We have a sense of how they’re responding to whatever’s wrong with them, but we don’t really know. It would be so nice if people came in with little, you know, “hi, I have congestive heart failure,” sort of sign, but they don’t so there is some effort that has to go into the initial diagnosis of what’s going on with a patient.

Because of that, in the emergency department, there is a higher level of autonomous nursing practice than you – than that that may be found in other parts of the hospital. Whereas physicians are the ones who attend to the patient and write orders and make disposition decisions, they are essentially brought to the bedside by the nurse, so the nurse is integral in deciding – you know, assigning acuity, recognizing who is ill, who needs the attention of the physician sooner; and so in this sense, nurses have a really important role in this environment that can’t be discounted in terms of clinical decision-making, especially in the decision to place or not place a catheter. We use a lot of protocols and care guidelines in the emergency department and there is a higher level of collaborative practice, because there has to be because we’re all working together with patients that we’re not really sure what’s wrong with them, again.

So I want to talk a bit about a framework that I use, a practice model that I think is really useful when you’re looking at how to implement CAUTI reduction techniques in your department and how to involve each of the members of the care team and to look overall at how each nurse or each physician is embedded in the culture of your department. So on slide number 23, talk about the framework as an integrated, ethically-driven environmental model. So there are three pieces to this. There are core elements, which are the things that are particular to any given nurse – knowledge base, how much does a nurse know; critical application, how can they apply it to each unique patient situation; and moral agency, which is an ability and a drive to advocate for the patient above all else.

There are immediate elements, which are comprised of unit leadership and nurse provider relationship. So how your nurses and physicians relate to each other, how they communicate, how they view the contribution of each other is really important in how these clinical decisions are carried out. The leadership of the unit in both nursing and medicine need to be very collaborative in order to exact really good practice change. And then you have your influential elements, which is the third ring of this model, and what that is about is basically the overall environment of your hospital. What is it – what is the general environment of care? What is the culture? What is your nursing culture? What is your physician culture? How does that affect how these decisions are made?

On the next slide is a little visual, if you’re a visual person. Again, we’re looking at an open model where – so whatever is going on with each individual nurse is going to have an effect on everything else, and similarly, the practice environment in which the nurse functions will also affect the expression of clinical decision-making.

So we look at, on slide 25, the elements of the individual, so what does your provider know, what does your nurse know? Moral reasoning; what derives questioning and assessment? What makes somebody say, “All right, I know that a part of this protocol is to put a catheter in. Does the patient really need it? Is it going to be good for them? Who – if I decide that a catheter is warranted, is it good for me, is it good for the patient? And is there a drive to act? Is there an ability to know what the right thing is to do and to actually be able to do it?” Okay?

Then we look at the elements in the environment, on slide 26, where we’re looking at standards, so the environmental structure of your department. What’s expected of each level of provider? Are nurses expected to make decisions that are in the best interest of the patient, or are they expected to wait for the physician to write an order? Are they expected to go seek out a physician to get an order if it’s appropriate? So there’s a lot of different levels and sort of variations on what that looks like. How does – how do nurses and physicians transmit concern back and forth? Is there a good flow, open flow of information, or is it a very rigid hierarchy? And that, again, is going to affect what happens to patients. Is everybody working with the same agenda and goals? Is everybody working toward what’s best for the patient, or is this an environment in which there are turf wars going on? Is this an environment in which it is so short-staffed that nurses can’t even bear the thought of walking a patient to the bathroom and so catheters get put in?

You also want to look at autonomy of practice, so who is able to make these decisions about acuity? Who is able to determine resources needed and under what circumstances? So are you able to use protocols? Are you able to say, you know, this patient is critically ill, they – you know, they’re hypotensive, it looks like they’re in some kind of shock state, they’re going to go to the ICU, this is clearly a situation in which we want to monitor output, I’m going to put the catheter in? Who is able to make that decision? Is the nurse able to do that ahead of time, or do they need the physician to come and be present at the bedside and examine the patient and make that decision? Because whatever that looks like is really going to affect how quickly a decision is made, how completely it’s carried out and sort of what the ramifications are for the patient.

So when we talk about fostering excellence in clinical decision-making, especially in this area, we need to look at all pieces of this model, so we need to look at individual nurses, we need to look at the environmental situation; what is the context, what is the social context? What is the practice context in which these decisions are made and in which these decisions are acted upon? So getting a good sense of what’s really going on in your department is going to reduce your frustration level a lot, especially when, you know, you’re trying to implement a practice change and it’s not working. So, you know, is it the nurses? Is it the physicians? Is it a combination? Is it just the overall practice environment, and what changes can you make to facilitate a better practice for your patients?

So bringing this very specifically to urinary catheter utilization, we know that about 15 to 25 percent of patients will have a catheter placed during their hospitalization, and this is based on research that is done by Dr. Fakih. Many are placed in either the ICU, the ED or the OR. I know as a practicing emergency room nurse, we put tons of catheters in and so they go up to the floors with these catheters, so a large proportion of these patients are going up with catheters that were placed in the ED. So the easiest way to reduce catheter-associated infections is just not to put the catheter in. You want to avoid it if there’s no indication and we want to get it out as soon as it’s no longer needed.

Okay, so we’re on slide 30 now, and you want to think about why putting a catheter in is a good idea, right? So these are sort of the traditional reasons why emergency nurses put in catheters. We think they’re a good idea but they’re actually not. We think that it facilitates intake (ph) and output measurement; sometimes it does. Sometimes you can do that with a hat or a – you know, some kind of commode. You know, there’s a lot of other ways to do that. It keeps patients from having to get up to urinate, protecting them from injury, but we know that they get up anyway because they always feel like they have to go. It protects skin in the incontinent patient and it saves time for the bedside nurse, so these are all reasons why we think, “hey, great idea, let’s put that catheter in. It’ll be better for us, better for the patient.”

In fact, the indications for catheterization are very minimal. We use the HICPAC guidelines and the – so the indications there are that the patient’s critically ill and will require accurate output measurement. The definition of critically ill is something that needs to really be, I think, nailed down in your department. People with urinary retention and obstruction, you want to do a bladder scanner or a bedside ultrasound first. Possibly, the patient needs immobilization for trauma or surgery, patient is incontinent with open wounds in the perineal area, end of life or hospice care is always a possibility, and if the patient comes in with an existing catheter or uses catheters chronically, that’s when you want to have that discussion with the provider and figure out, you know, whether it’s actually needed.

What are not, absolutely clearly not indications for catheterization are a substitute for frequent toileting, so your patient who has frequency or urgency or who is very elderly. If a patient can void freely, don’t put a catheter in them to get a specimen. Patient preference is not an indication for catheterization. Dementia or obesity, again, not indications. We put our patients at risk unnecessarily. So patients who are at very high risk for inappropriate catheterization – a lot of times just keeping this in your head, like, okay, I want to put a catheter in this person but why? Is it because they need it or because this is sort of the category, the bucket into which they go that I’ve always put a catheter in these sorts of patients? So elderly women, and as Dr. Fakih said, very high risk for inappropriate catheterization. The incontinent patient, the obese patient, the immobile patient and non-critically ill cardiac and renal patients, right? So just because a patient’s on a monitor doesn’t mean they need a catheter, and those are two things that I think we need to start really separating out in our practice.

When – and when we think about doing good for our patients, when we reduce the inappropriate placement, we also reduce infection rates, so we are not causing harm, we are not giving them what I like to call the bonus problem, giving them something that they didn’t come in with. It reduces cost, it reduces the use of antibiotics, and we want to do that, just across the board. It reduces their length of stay, morbidity and patient discomfort. So there’s a lot of reasons to not put a catheter in, the least of which is not – reducing infection.

So we want to look at the attributes of each individual nurse when we’re looking at this problem. What are – in terms of knowledge base, what are their assessment skills? Do they understand the appropriate indications for placement? Do they – can they apply that to each individual patient? Do they have the autonomy of practice, either the confidence or the explicit ability to make these decisions and apply what they know? Can they advocate for safe patient care? So can an nurse, in the space of a provider who say, “Yeah, I want you to put that catheter in,” can that nurse say, “You know what? There – this is not indicated. It’s not indicated and I’m not putting it in.”? Can you – do you have an environment in which that is possible? In some environments, it is not. In most, it is, but you need to give nurses the backup and the permission, the freedom to advocate for their patients in a way that perhaps they may not be used to. The goal here is to promote beneficence, so doing good for the patient while reducing maleficence or harm, so we want to promote non-maleficence, not doing harm to our patients.

It’s important to put systems in place that allow nurses to do this, so want to, again, look at the environmental situation. What is a unit leadership? Is the both nursing and medical leadership collaborative? Are they on the same page? Are they working together for what is best for the patient? So everybody needs to set standards of practice, both nursing and medicine. You have to maintain the sunnum bonum or the highest good for every patient to the extent that is, you know, possible, and we need to promote collective and collaborative clinical decision-making in care because this is the sort of environment where you must have communication between physicians and providers in order to maintain good patient care.

So we’re on slide 37 now. Central to this is nurse-provider relationships and communication. I can’t stress this enough. If people aren’t talking professionally about what’s good for patients, you can’t even begin to implement practice change. So you need to take a look at your department. Is there mutual respect and autonomy of practice to the extent that practice acts allow? At the institutional level, is there an ethos of teamwork? Is there autonomy? Is there control over practice, that which is in the purview of each discipline? So ethical standards have to drive practice. Are we doing this for the best – are we doing the best thing for the patient at any given decision point? Disciplinary training and governance and practice committees that all work to enact practice change that, again, is in the best interest of the patient. We want to have really clear understanding of indications for catheter placement and removal. We want a commitment to non-maleficence, and we need to have patient-focused care across the board throughout the hospital, across disciplines.

So the implications here – we’re looking on slide number 39. The implications here are that in an environment where you’re having trouble enacting practice change, or the attributes of the environment and not just the individuals within the environment is really important in terms of identifying barriers to practice change and facilitating a smooth transition to a different way of doing things. So you want to look at administrative support, you need to look at nurse-physician relationships, you need to look at your practice culture to identify potential barriers.

Clinical decision-making is not a matter of information in and decision out, so you need to look, again, not just at, you know, the nurses are doing this or the physicians are doing this, but what is the social context in which they are functioning that allows or does not allow them to implement the practice change that you’re talking about. So the commitment – the take home here is that you need commitment at the institutional and unit levels. You need physicians and nurses that model ethically-driven patient focus, a collaborative care. You really need to make this a joint effort and the environment of care has to change to afford behavioral change. You can’t say, “We’re going to change everything that we’re doing” in the same environment with the same structures (ph). You need to really look at this as an organic changing environmental model that, when you change one thing, a whole bunch of other things can change as well. So getting a good understanding of what nursing practice looks like in your hospital is really going to facilitate making this practice change, which is going to (ph) ultimately be better for the patient.

And now I will turn this over to Dr. Schuur.

Dr. Jeremiah Schuur: Thank you very much and it’s a pleasure to speak today. I would just echo everything that Dr. Wolf said around the collaborative nature of practice. I’m going to focus on emergency department physician champions, what roles you should try to engage your physicians in in the projects around reducing catheter-associated UTI. So on my objectives, we’ll review ED physicians’ role in urinary catheter placement, we’ll identify strategies for improving appropriateness and we’ll review the role of a physician champion in a CAUTI project.

On the next slide, the physician role in urinary catheter placement is not as straightforward as just placing the order. As has been described, the practice environment in the emergency department is such that, although all urinary catheters require an order from a physician or other independent licensed practitioner, the decision to place a catheter is not the ED ordering doctors alone and so the ED nurse, the patient and his family, consultants and admitting services play important roles in that.

On the next slide, I would emphasize that the ED workflow and culture and urinary catheter placement are different than other places in the hospital, and in particular, physicians and nurses work in parallel and nurses often assess a patient and consider a catheter before the ordering provider does and, over time, each ED’s catheter use patterns have developed and so it will take teamwork from physicians, nurses and others to reduce the use of urinary catheters.

On the next slide, I’m going to emphasize three roles that you can – should aim to try to get an emergency department physician involved as a champion in a CAUTI project. The first is to promote reduction of catheter use by championing the idea of appropriateness. Second is to encourage interdisciplinary conversation around catheter use, and the third is the engagement with other services around patterns of catheter use.

On the next slide, I’ll start talking about improving appropriateness. Roles for physicians are to review appropriate indications for catheters with the medical staff. These can start with the CDC/HICPAC guidelines or the ENA-developed pathway, and they can be modified for your local environment. We would recommend implementing an appropriateness criteria into the workflow and the physician can help with the team doing this. It should be part of the ordering process, either computer physician order entry, if you have it, or a paper order set, and having it as part of a pathway is helpful also. Physicians can also be involved in giving feedback to medical staff on appropriateness. If you are able to collect those data, they can play that leadership role.

So physician task one is championing appropriateness. It’s important to engage an emergency department physician to champion the work with nursing to develop and review the ED policy addressing appropriate indications for urinary catheter placement. A good place to start is the CDC/HICPAC guidelines. These define both indications and contraindications and it’s important that your policy do that. It’s reasonable to consider any ED-specific modifications; the HICPAC guidelines were not thought of specifically with the ED in mind. And then have it reviewed by the hospital’s infection control committee and implement it.

On the next slide, the other parts of that task are to have the ED physician champion the work with nursing to implement the policy, so it’s important to require an order for placement of a catheter; that’s one way of ensuring that whatever pathway or policy gets placed happens. It also will help communication with nursing and physicians, and if – it’s important to require documentation of the indication with the order. Depending on what technology you have, you can include prompts if you have an electronic health record, or you can include a pathway on paper if you’re using paper for your orders. Have the ED physician speak to the ED physician group about CAUTI and about the policy.

The next slide shows an algorithm that was developed by the Emergency Nursing Association as part of this project. It is available as part of the materials on the website, and this is just one example of a pathway that can be used. And so this is one example you could take this and use it as is or potentially modify it if there’s a strong reason to.

The second physician task is to address specifically clinical patterns. On the next slide, I start addressing that. It’s important to have the ED physician champion work with nursing and other services to address local patterns of care. Have them identify specific clinical conditions where catheters are used but can be avoided. Have them serve as a liaison with physician leaders from other services around these patterns of care and then develop context-specific  improvement plans.

So the next slide lists several common patterns of ED catheter use that might be addressed. Measuring urine output in stable patients, for example, patients with congestive heart failure; assessing bladder volume, for example, urinary retention from possible spinal cord injury; protocolized care for trauma; incontinence without open sacral or perineal wounds; pre-operative placement outside of other indications or other specific indications that may occur at your hospital, for example, small bowel obstruction.

On the next slide, we’ll – one case study is trauma. Historically, most trauma patients receive the catheter as part of the evaluation and resuscitation. The eighth edition of ATLS does recommend urinary catheters for assessing hemodynamic status but it doesn’t say exactly when these required. Historically, the catheters in trauma were often placed by the most junior trainee who has the least infection prevention training and technique, so one place to start is with trauma. Identify your current practices, review the protocol with the ED and trauma leaders, set clear criteria for catheter use and designate an appropriate staff member to place catheters, someone who has excellent technique and training, generally a nurse, not a junior resident.

The next slide is another case study and that would be congestive heart failure. This is another specific condition where it would be helpful to have a physician leader involved, including – so we know that many CHF patients get a catheter to monitor urine output, so the physician leader from the emergency department could liaison with the cardiology service to determine the motivations for these patterns of care. Is it a medical necessity? Generally not if the patient is able to regularly void and they’re clinically stable. Is it done for patient convenience? Is it done for staff convenience? So things to do or to strengthen the protocols for tracking urine output, because that is important in patients with congestive heart failure, and meet with cardiology to examine the practice and determine ways to track data and give feedback.

The third physician task, which is on the next slide, is collaboration with nursing. So you can encourage communication – an important role for physicians is to encourage communication at the time of catheter ordering and placement, and there is an irony about electronic health records, that although they improve documentation of orders and legibility, many clinicians find that they decrease communication because each specialty is siloed at their own work station, either entering an order or taking off an order and the typical communication that happens doesn’t necessarily happen as often. So having a huddle around the need for a catheter that can be initiated by either the physician or the nurse and that is the standard practice is one way of making sure that everyone’s on the same page and encouraging communication. It’s also important for a physician champion to speak out to other physicians and acknowledge nursing’s deeper knowledge of the patient and ability to care for themselves, and that’s important in these huddles because the nurse will often have more knowledge about the patient and their family that they can bring to that decision.

So finally, the ongoing physician champion roles, once you’ve got your quality improvement program up and running, would include sharing data on catheter use with the medical staff. If you can break this out by a physician, if you have a large enough sample size, if you have the ability to collect that data, that is very motivating for physicians. Second, circulating descriptive summaries of any CAUTI cases that are attributed to ED placement, so if you can work with your hospital infection prevention department so that they can notify you if there are cases and create brief narratives, that’s a very impactful way to remind people about the importance of this condition. Finally, communicating with other medical services about specific patterns of care; having the physician champion speak with physician liaisons from other departments.

That’s all I have today and I think we’ll be able to take questions in a moment. I’m going to turn it back over to Paul.

Paul Tedrick: Operator, can you go ahead and open up the lines for questions and give everybody the instructions, please?

Operator: Absolutely. Ladies and gentlemen, at this time, the floor is now open for your questions. If you would like to ask a question, you may do so by pressing “star one” on your Touchtone phones now. We’ll take questions in the order they are received. If at any time you would like to remove yourself from the questioning queue, press “star two”. Again, to ask a question, please press “star one” now. Our first question comes from Linda Egbert with Health Insight.

Linda Egbert: Hi. Thank you for the presentation. It was excellent. My question’s for Lisa. You had talked about doing the cultural assessment in your emergency department. Do you have a specific tool you used for that?

Dr. Lisa Wolf: I do not. That’s a good question. I – again, I used – there’s a number of different ways of looking at this. One particularly good tool to look at workplace environment, of environment practice is the Revised Professional Practice Environment tool, the RPPE, and that actually you can obtain from the Munn Center at Massachusetts General Hospital. It’s probably also out there, you know, on the internet, but it’s a very good tool in terms of a lot of the things that I talked about in terms of autonomy of practice and nurse-physician relationships and teamwork. There’s a bunch of really good aspects to that tool that may give you a very good sense of what’s going on.

Linda Egbert: Thank you.

Dr. Lisa Wolf: You’re welcome.

Operator:  Our next question comes from Tara Rhone with SMQAI.

Tara Rhone: Hi, good afternoon. This question is for Lisa. I was just wondering, does your facility work with other units, maybe your ICU or even other departments that may be participating in, say for example, ATA (ph) reduction projects to see what they are doing, because sometimes – well, I’m just curious to know if the ED physicians and nurses work with other infection control programs in other units.

Dr. Lisa Wolf: That’s – yeah, that’s a very good question. I think that’s going to be facility dependent. I think, in a lot of institutions, anecdotally in the hospitals that I’ve worked at, the ED is kind of seen as this, you know, outlier, almost an outpatient setting, and so a lot of times, the structure of communication is not as good as it could be; and that’s something to really look at when you are looking to do handoffs, you know, as your patients are admitted to the floors or to the ICU, to talk about, you know, there is or is not a catheter at this time and why, or there’s a catheter in but you need to evaluate this in 24 hours, make sure you get an order to take it out. So I think looking, not only at the culture of your emergency department, but again, looking at the larger culture of the hospital and what the relationship is between the emergency department, again, both with physicians and nurses and their counterparts on other units is going to be really helpful for you to look at that.

Tara Rhone: Thank...

Dr. Mohamad Fakih: (Overlap) if I may just chime in. This is Mohamad Fakih. I think it’s the best solution is to have a multi-disciplinary, multi-departmental approach. If we can reach that in the hospital, I think it’ll be great. So if you – you know, as what was asked in the question, you know, how do we engage infection prevention with the ED, how do you engage ICU and the ED, so if the ED does not place the catheter, the ICU team would not be (indiscernible 49:03). Same thing with OR to ICU or to floor. So the more we engage the different stakeholders, I think the better our results would be.

Operator: At this time, we have no other questioners in the queue. I’m sorry, we have a question now from Shawn Horton with Kearny County Hospital.

Shawn Horton:  Hello. I have one question from Dr. Schuur.

Dr. Jeremiah Schuur: Go ahead.

Shawn Horton: Okay, I just have a quick question. I’m new to this process, a rural hospital here in Kansas, and I’m just learning all this. Are these CDC/HICPAC guidelines on the CDC website, or…

Dr. Jeremiah Schuur: They are on the website. If you typed in CDC CAUTI HICPAC into any search engine, they would come up. It’s a long document that was several hundred pages that was developed in – I think published in 2009, and – but the – there’s a table in there at the front in the executive summary that has them. Additionally, there’s lots of material that’s available from HRET at the website, and I’m going to turn it over to Dr. Fakih to talk a little bit more about that.

Dr. Mohamad Fakih:  Thank you, Dr. Schuur. Yeah, there’s plenty of information on the (indiscernible 50:35) CAUTI website that would be very helpful. In fact, we have multiple lectures also that address each of the indications and explain it a little bit more, you know, in detail, and these are all downloadable from the website, so they may be probably the best place to start.

Shawn Horton:  Okay. Thank you.

Operator: At this time, we have no other questions in the queue. Again, if you’d like to ask a question, press “star one” now. We have a question from Carol Miranowski with Essentia Health.

Carol Miranowski:  Yeah, I was wondering, does anybody have a Texas catheter or male catheter that works well for them?

Dr. Mohamad Fakih: The – I mean, this is Dr. Fakih. I can answer that. I think this has been a tough issue. The – you know, there’s some – I mean, that’s one of the drawbacks of not using more of the common catheters in the hospital setting. It really depends on the patient. That said, you know, the only way to know is to try, if it works on the patient, and this is usually in patients with incontinence, male patients with incontinence that you don’t want to have damage to the skin in the perineum. Otherwise – and also, if you don’t use the Foley catheter, you know, this is less trauma to the urethra, but this is – I mean, like you said, it’s a tough issue. There is no clear solution.

Operator: At this time, we have no other questions.

Paul Tedrick: Hi, everyone. This is Paul with HRET. If there are no further questions, I guess we can go ahead and wrap up a couple of minutes early today. Operator, are you showing any further questions?

Operator: We have none at this time, sir.

Paul Tedrick: Okay. I wanted to, first and foremost, thank all of our presenters today, Dr. Fakih, Dr. Schuur and Dr. Wolf, for taking the time to share this outstanding information with us and a wonderful presentation. I wanted to remind everybody as far as the presentation goes, if you do not have a copy of the presentation, you can get it by going to our website at www.onthecusp – C-U-S-P – stopahi.org/contentcalls, and that’s with an S. You can also send me an email if you like. You can reach me at P as in Paul, Tedrick – T-E-D-R-I-C-K – @aha.org.

One last reminder before you sign off. Your feedback is extremely important to us. Based on prior feedback, we’re actually developing new content for future content call presentations based on the information that we are getting from you. So your feedback is extremely important. We definitely want to hear from you. Take a moment to fill out the evaluation form. The best place to find it is there is a link at the back of the slide presentation that will link to Survey Monkey, and that’s where you can access it. Once again, thank you, everybody, for your participation in today’s call and we wish everybody a happy and productive day.

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