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

Webinar Transcript

On the CUSP: Stop CAUTI in ICU March Content Webinar

March 11, 2015

Stephanie: Excuse me, everyone, we now have you 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 questions. At that time, instructions will be given if you'd like to ask a question. I will now like to turn the conference over to Anna Wojcik. Ms. Wojcik, you may begin.

Anna: Thank you, Stephanie. Thank you everyone for joining today's call. Just as the first note, we are having a few technical issues with the Adobe Connect platform today, so for those of you who haven't been able to join the webinar platform, we do encourage you to keep trying. It's taking a little bit longer than normal, so if you're not able to join it on the first time you click the webinar link, please try again. If you're still not able to join, I know we have a few participants who are just on the audio today; you can go ahead and download the webinar slides from our website. That's the Cohort 9 ICU Initiative website, You can download the slides from there if you're not able to join the platform. We apologize for those technical issues today. To kick us off, so welcome to the March National Content Webinar for the On the CUSP: Stop CAUTI in ICU project. Today's topic will be on defining critically ill in the ICU, alternatives to catheters, using the CUSP Staff Safety Assessment and the Learning From Defects tool to improve safety culture.

Before we do get started, we remind you, and encourage everyone to fill out the webinar evaluation. This ICU project is new, and we are in need of your feedback to make sure that it's meeting your needs. At the end of the webinar, or whenever you need to join, if you're not able to stay with us until the end, please click the webinar link and complete the evaluation of today's webinar. We welcome any feedback and input you have on the portion, or the entire link, for the webinar that you were able to attend. We do ask that everyone who is on the line fill out the evaluation, so if you're with three other people and watching the webinar, or there's other people on the line, we ask that every person who is listening to the webinar fills out today's evaluation.

We're excited to have with us today three great presenters. Dr. Randy Garnett is a chairman of the Sentara Norfolk General Critical Care Committee, the Medical Director of the Sentara Lung Transplant Outpatient Program, and a member of the Sentara Advanced Heart Failure Group. His interests include care of organ transplants, mechanical circulatory support, pulmonary hypertension, and ethical, medical, and surgical ICU care.

We also have Sheryl Sheriff, who is the Cardiovascular Clinical Practice Specialist at Greenville Health System in Greenville, South Carolina, where she's an educator, a researcher, and a consultant to influence patient care nursing and systems.

Finally, we have Emily Passola, who is the Clinical Nurse Leader in Surgical Intensive Care Unit at St. Joseph Mercy Hospital in Ann Arbor, Michigan. As a clinical nurse leader, Emily focuses on quality improvement and unit safety. She is a unit champion for evidence-based initiatives, including CUSP, assisting and planning, and implementation and tracking outcomes.

We're glad to have everyone with us today. A few housekeeping items, as you'll see on the platform, for those who are able to join the platform. We'll have the chatbox below, so we encourage you to post questions during the presentation. We'll also have dedicated time for Q&A at the end of the webinar. On the right hand corner, there are the materials for today's webinar. They include the slides for today's webinar and an informational tool that Dr. Garnett will go over. With that, I'll turn it over to Dr. Garnett.

Randy: Thank you very much. I've been asked to define critical illness, and the need for the initiation of discontinuation of Foley catheterizations. I've found that to be a very daunting task, as critical illness is different in different places. One of the requests was to define the exact point where the risk–benefit ratio for discontinuing a Foley catheter could be measured and used. I think we're a long ways from that, but because of projects like this, hopefully we'll get a little bit closer. This is a complex issue, and one size doesn't fit all.

I think a couple premises to begin with is, if we don't need to place a Foley catheter, let's not place one. If one is in place, we need to once or twice a day, look and see if it is appropriate to discontinue the Foley catheter. Also, just like when we have failed excavations, I think we have to buy into the fact that sometimes, we'll be able to put the Foley catheter back in without a whole lot of harm to the patient.

ICU characteristics are very different amongst most of the hospitals here. I'm going to speak primarily about our institution. We have [several 00:05:13] different subspecialty ICUs, and I can tell you each one is different. They're both medical and surgical, the acuity level of the patient is different in each unit. Where the patients come from, with regards to the floor, the emergency room, the operating room, all puts them at a different risk for having Foley's placed, either for the right or the wrong reason. Who puts the Foley catheters in is different in each unit. We have to make strides towards making our care more uniform. Every ICU, here at least, has its own culture. Each ICU is its own family. I think they handle Foley catheterization differently in different ICUs. That's more of a historical thing, at least in our institution. The RN has needs, the physicians have needs, and sometimes those needs are not the same. Now with CMS regulations, the administrators have skin in the game because of the financial issues associated with hospital-acquired infections. They have become much more robust in trying to change behavior.

As an aside, right before I go into going through these slides, I was on call this past week and I had four cases where Foley catheterization came into question, about whether or not it was needed anymore. That's because we've been very active in educating the nurses and trying to move things forward, and we've got a forty-eight hour discontinuation protocol. The first patient was a patient who was a status post to surgery, who was up eating breakfast, had the Foley in, and then the nurse said, when the patient gets to the floor, we'll take the Foley out. Possibly could've been taken out sooner.

The next one, the nurse at the time of rounding out an ICU patient who had just been excavated and who was fairly alert. We had a collegial conversation. The nurse thought that she could care for this patient without having a Foley in, and the Foley was discontinued.

The next patient was a patient who was incubated with a PCO2 of a hundred and ten. We were having significant difficulties keeping him sedated, and after the forty-eight hours the Foley catheter was removed at about three in the morning without any physician input. As expected, the patient needed to have the Foley catheter put back in, but I learned at that time that putting a catheter back in, and giving the chance for a patient who is in and out of consciousness, to use a condom-catheter. It is an option that I need to adjust.

Finally, the one I found the most interesting was the head of our hospital was harassing on the ICU nurses to call the doctor immediately, because it was five minutes after the forty-eight hours. The Foley catheter either had to be reordered, or, taken out.

It's a new paradigm, I think it's good that we're talking about this, and I'm going to run through some basic thoughts about critical illness and how we can do this a little bit differently. Change the historical habits that we've had in the past. This mainly is our experience here, and is not representative of everyone's experiences. Please take this discussion in that light.

The first is a very difficult slide to see, but it has indications for urinary bladder catheterizations. One of these is urine output in a critically ill patient. There's other reasons to have catheters in the ICU. The bottom talks about the end of life care, people with wounds that need to be kept clean, people with GU or neurological problems. I'll put that up there for people to look at and learn from. There are other good examples on the CUSP website that give you more information about this for the future.

Let's start talking about patients who are in step-down unit or heading to the ICU, who don't have Foley catheters in. What I call this is the potentially critically ill patient, and the clinical observations that you see. This is someone who's ill, who's agitated, or confused, who responds but not normally. Who has multiple signs and symptoms of SARS, heart rate elevated, blood pressure down and low urine output. This patient, in my opinion, five years ago would've gotten a Foley as one of the first things that we do, because we have to do things. I think this patient may eventually need a Foley, but at the same time, we need to treat the patient and see where they are in fifteen or twenty minutes.

That moves on to the critically ill patient who has progressed- sorry we have a printer going off in the office here- has progressed to looking very, very ill and hemodynamically unstable. I think most people in this particular scenario would move towards a Foley catheter fairly quickly. Even in our own institution, I think we have different thresholds as to when a Foley catheter is placed. Multiple system organ failure usually requires Foley catheterization.

Now we're going to talk about surgical and medical patients in terms of patients that we would normally have Foley catheters in. Surgical patient categories, who will almost always have an indwelling urinary catheter as a postoperative patient with continued mechanical ventilation and sedation. This is early on, it doesn't mean that a patient on mechanical ventilator who is not heavily sedated, who can help you move around in bed and needs a catheter in the long term. Patients who have had major cardiothoracic surgery, cardiac bypasses, valve surgeries, transplants, dissections, will almost, without exception, come out with Foley catheters in. A major abdominal GI surgery, whether it's fluid shifts, major vascular surgery. Most GU surgeries, because of potential for bleeding and needing to keep the GU tract clean, will have Foley catheters. Hemodynamic unstable, postoperative where urine output helps guide therapy. Immobilized patients who have got pelvic fractures and trauma, and brain injury. Also patients with multiple comorbid processes, where [inaudible 00:12:11] urine output is important to monitor, such as people with acute and chronic renal failure, people with cardiomyopathy and congestive heart failure, and other low cardiac output states.

On the rare occasion, someone with a high urine output syndrome, such as diabetes and [syphilis 00:12:27]. Other patients who have postoperative delirium, agitation and cephalopathy. I think we oftentimes feel that this can simplify their care, although sometimes a Foley catheter is one of the [inaudible 00:12:41] for their discomfort.

Medical patient categories who will almost always need urinary catheters include respiratory failure, mechanical ventilation. Hemodynamic instability with septic shock, hemorrhagic shock, GI bleeds, trauma, post procedures, cardiogenic shock. Unstable CHF patients undergoing massive diuresis probably need Foley catheters in the ICU, although I don't believe that all patients do. It depends on their level of illness. Patients with severe neurologic impairment with altered mentation after a large strokes, intracranial hemorrhages, [inaudible 00:13:25] hemorrhages, traumatic brain injury, etc. most times will start off with Foley catheters in the ICU, and acute and chronic renal failure with obstruction, retention.

I've also seen the rare patient who is not terribly, critically ill, but because of BPH or something like that, especially in males, trying to pass their urine puts them into distress. Maybe another reason to use Foley catheters in the critically ill.

Types of treatment require close urine output monitoring. We all know those things when we're using boluses of fluid for resuscitation, when patients are on vasopressors and inotropes, when we're using high-dose diuretics, when hourly urine studies to measure life threatening laboratory abnormalities, are important. These are all patients that a Foley is utilized in multiple situations. The important thing is, look at the patients. We're trying to get away from, because you're in the ICU you need a Foley. Look at the patient. You can always put a Foley in later if they progress and get worse. You can always take the Foley out as they get better. To have a conversation every day, or twice a day, about getting Foleys out, I think has the most utility, at least in our unit, to decreasing the time that Foley catheter's in and the risk of CAUTI.

Now what we're going to do is go through four cases real quickly. There are no right or wrong answers. I think Anna has asked for people to vote yes or no with each one of these. There are no right or wrong answers because I think, in our hospital, I've seen all of these cases almost have a Foley in or not have a Foley in a two-week period.

The first patient, twenty-four years old, they present with acute shortness of breath [inaudible 00:15:31], they have a history of asthma and they're acutely ill and moved to the ICU. The blood pressure's a little high, the heart rate's high, the respiratory rate's high. The patient is oriented. 2+ accessory muscle use, and they're diffuse wheezing bilaterally with a very prolonged expiratory phase. They can move from the stretchers to the bed without significant change in their status. Their arterial blood gas shows a mild respiratory acidosis. I guess the question here is, does this patient need a Foley catheter? We'll give you ten or fifteen seconds to vote yes or no. This is not graded, and there are no right or wrong answers.

Anna: The poll is on the bottom of the screen, you should all be able to see it. Just click yes, no, or not applicable if you're part of HRET or the National Project Team. Randy, are you able to see the votes as well?

Randy: I just voted. I voted with the majority, it looks like, so that's good. Let's go to page two, it looks like we've got a consensus. The next case is a seventy-two year old male, forty-eight hours post cardiac bypass times three and MVR. He's still on mechanical ventilation with moderate levels of sedation, and we use a RASS here and it's -2 which means that the patient will arouse and stay with us for fifteen to sixty seconds before he drifts back off to sleep. He's on moderate doses of norepinephrine and epinephrine. Let's just say we use mics per minute here. Let's say he's on eight of norepinephrine and three of epinephrine, which is being adjusted for mean arterial pressure of sixty-five to seventy. He's on fifty-five percent and eight of PEEP. He opens his eyes, follows simple commands before drifting off. Lung and cardiac exam are normal. Abdomen is benign as extremities are well profused. His lab and chest x-rays are not concerning. Once again, let's ... Whether this person still needs a Foley or not. Votes are still coming in, I can see. We are almost up to two hundred.

Anna: That's about where we should be, Randy.

Randy: I'm impressed that about twenty percent of people said no, this patient may not need a Foley. I think in a year ago, before I got involved in this, I would've said yes, a hundred percent of the time. I think we need to start thinking about this patient, because he will open his eyes and follow some commands. He may be somebody that the Foley can come out before he is completely cured. The thing that concerns me is, he's on norepinephrine. No right or wrong answers here.

We'll go to number three. An eighty-three year old male with BPH who is post op, a ruptured triple A, returns to the ICU for his postoperative care. Remarkably, he's excavated two hours post-arrival in the ICU and has only moderate abdominal pain. His drips are low dose norepinephrine. His vital signs are relatively stable. His physical exam is relatively stable and he's making fifty to a hundred ccs an hour since going through the operating room. Can this indwelling catheter come out? The votes are coming in a little more slowly this time. People are thinking a little bit harder, it seems. I guess it was a good question, because it's closer to fifty-fifty. I think this is the type of thing, at least, that our institution, two or three years ago, it would have probably been ninety percent leave the Foley in, and ten percent take the Foley out. I think everyone's thinking along the same lines.

For our final question, sixty-five year old with moderate to severe COPD with acute and chronic respiratory failure in the ICU from the ED. Placed on non-invasive ventilation. He does not have a Foley and he has no cardiac history. His vital signs are relatively benign, with a heart rate of only a hundred and ten. Respiration's twenty-one and only 1+ accessory muscle use. His breath sounds [resistance 00:20:34] of rare wheezing and a prolonged expiratory phase. His cardiac exam is pertinent only for tachycardia. His abdomen is benign and he's oriented times three, moving around the bed. He's been supported three times short-term, with non-invasive ventilation in the past year, without needing incubation. AVG on forty percent shows that he has a moderate respiratory acidosis with adequate oxygenation. The votes are coming in a lot faster than I can read the question, and I think most people would agree that this patient probably doesn't need a Foley catheter, but this patient is the one that every time he had to urinate, went into respiratory distress at our institution and actually did get a Foley catheter.

I think this shows the diversity of the patient population. It shows the fact that we need to look at critical illness as a journey with a beginning, middle and end, and that Foley catheters have that same journey. If they're needed, we put them in. When they're not needed, we get them out. I do not know of a way to stratify for all institutions that particular moment when the risk-benefit ratio changes. I think that's something we'll get better at with time, because of this project. I thank you all for your attention.

Anna: Thank you very much, Dr. Garnett. With that, I'll pass it over to Sheryl.

Sheryl: Hello. I'll be sharing with you our unit's experience with a nurse-driven, indwelling urinary catheter removal protocol. We initially started our CAUTI journey I'm sure like everyone else, focusing on our insertion issues, what are our maintenance issues, development of bundles and then of course our surveillance of those. We identified many opportunities in both of those categories, and made improvements, but when we begin to analyze our data, we continue to see more opportunities for improvement. Our practice council, in looking at research and evidence, took this on as a project. One of the things that we kept finding was information on this nurse-driven removal protocol. We wanted to embark and see what an implementation of this, how this might impact our CAUTI rates. Of course, our first step was engaging the leadership. It takes various levels of engagement. For example, the nurses, physicians and administrators. In our situation, I attribute a large degree of our success was that this idea came from the bedside staff. They were engaged in this, they initiated this project. Working together, we moved it up through physician leadership and administrative leadership, to get approval to do this as a pilot on our unit. We started small, we started on one area. I think that was a key success in our program as well.

When we first approached the leadership about this, we found out that it had been discussed in some other committees that were looking at CAUTI reduction. Of course, one of the biggest barriers and concerns there was from the physician, but there was also a lot of push-back and concern from nurses as well. Nurses were concerned. There were some nurses who said, "I don't want to be empowered to remove the Foley, because what if something happens?" There were a lot of things like that that we had to identify as our barriers, and how do we approach and deal with those barriers.

We worked with our medical director, mapped out what we wanted to do. Our medical director supported us in the initiative. Medical director went to bat with the other physicians that admit entire unit, and explained to them what our pilot would be, what we were looking for, and then we began to educate our staff, and educate, of course, the physicians who would admit into the unit. We presented some of the evidence that we had found in research where this had been utilized at other facilities, and the impact it had had on their CAUTI rates and their patient outcomes. Fortunately we were able to start the pilot in our unit.

With the education, we tried to simplify it. I will say that yes, education was needed, but I think the biggest thing that was already pointed out, is that this is a huge culture change in critical care. We got a lot of deer-in-headlights kind of looks. When I say that our bedside nurses started this, our practice council only consisted of a few members of our nursing staff. We were not fortunate enough to have all of our staff nurses engaged at the very beginning. We had to work with them in getting them engaged with what we wanted to do with the pilot.

We put together some information, and we started with the Rs. We wanted to review. We already had existing criteria for indications for Foley that had been reviewed and supported by physicians. This was coming from the SCIP measures, but we translated that over into the care of all our patients and began, initially, with those same indications. We began to look and say, every shift, when we do our GU assessment, each nurses is responsible for reviewing as to whether or not the patient meets those indications for having the indwelling catheter in. If not, then during this pilot, the nurses in our unit were empowered to remove the Foley per protocol. They simply wrote the order, made it per protocol, and then went ahead and removed the indwelling catheter. It took some time, but we did begin to see a reduction in our catheter days with this timely removal. We began to see a reduction in our CAUTI rates.

This slide depicts for you the indications that we used. This is not what we initially started with. I think what Dr. Garnett was saying earlier about the approved indications for catheter, it's very unique to each unit. You have to tweak those, and ours have evolved over time. The one we focused on was, we had a very blanket statement about accurate measurement of intake and output in critically ill patient. We quickly found that when we would review each patient, discuss with the nurse, so what's the indication for the Foley? I'm forking the indication that it's a critically ill patient.

We worked with our medical director, and we put some qualifiers on that. When we put the qualifiers in, that's when I feel we began to see the tide turn, and when we began to take some strides in getting the indwelling catheters out, and reducing some of our CAUTI rates and our device utilization.

By no means are these qualifiers perfect. One of the ones that we did tweak was the oxygenation with exertion or position changes, because as we reviewed patients, and we looked at the criteria that they were meeting, we originally did not have this one on here. Sometimes we would find that patient who was on a non-invasive ventilator, or non-invasive ventilation, and the work and stress of moving him to bed, trying to use a urinal or for females, trying to get off and on the bedpan, they would quickly [inaudible 00:29:31]. It could be that patient who had had a very rocky course with incubation, very lengthy time of incubation. We finally got them excavated, but it would cause very severe drops in their [inaudible 00:29:51] with the stress of using urinal, getting on and off the bedpan. We went back and added that qualifier in as well, and that was based on staff discussion, going back to our medical director and presenting some of the things we were finding with our daily review.

The other way that we implemented this, is we do care-rounds each day, so this became one of our main focus during the care-round was focusing on our patients who had Foleys. With each nurse, either individually or with the group of nurses all around, we would review the criteria and apply that to that specific patient situation. We would discuss together, does this patient meet the criteria for us to go ahead and implement our removal protocol? I think this was very beneficial, because it helped to ensure that the protocol was followed. It also sent the message that this is an expectation of all nurses.

This is now our culture in critical care. I think one of the most important things is, I think it helps engage some of the nurses who are more skeptical about this. We could really validate patients who were being identified as yes, you're correct, this is a patient where it's appropriate for you to go ahead and remove the Foley per protocol, no, I agree, this is a situation where we need to hold off. We need to have a physician discussion about this patient. One of their biggest fears was being empowered to do this, and then removing the Foley and having to reinsert it for some catastrophic reason.

One of the other challenges that we found is that going back to the surgical patients, there were some surgical patients. We found like even though our criteria was there, and the indications for which patients the indwelling catheter needed to remain, there were still some concern from certain surgeons, particularly urologists. One of the things that we have implemented is, if it is a Foley that's inserted [insurgent 00:32:18], that is inserted in the OR, and the surgeon does not want us to use the nurse-driven protocol, or the protocol for removal, they can tag it in the OR with the yellow band. That is a visual to us that that patient falls out of our protocol. There are some workarounds with this, and we found there was a workaround in our cardiovascular ICU and our POCT bypass patients, that the cardiac surgeons were tagging all their Foleys with that. We went back and had a discussion with them, and so now they have changed that practice and they are on board with what we're doing.

We started, as I said, in one critical care unit in our CCU and based on the data that we were able to present, we have now rolled the protocol out to all of our other intensive care units. They're beginning to see some of the same reductions in device utilization. Some of the other particular patients that we found question about was when we did what we call a fact or fiction with the nursing staff. One of the questions was that any patient on Lasix needs to require accurate intake and output. The only way you can get that is with an indwelling urinary catheter. We reiterated with them that that is a case-by-case basis, and not every patient who's receiving Lasix IV has to have the indwelling urinary catheter in. Even some of our cardiologists were very supportive in that in saying, that they were more concerned with the weights on that patient, more than the intake and output. One of the other fact or fictions is all patients in critical care require an indwelling urinary catheter for accurate measurement of intake and output. I think, as we've all mentioned and have experienced, this is probably one of the biggest things because it's a culture change. We begin to encourage them, the qualifiers that we put in place, and as I mentioned earlier, we continue to revisit these and tweak these as we go along in our process.

The other thing is that critical care patients who are admitted from OR and TACU, they don't automatically need to keep the urinary catheter in. It goes back to that daily review of what is the need on this particular patient? Some of the lessons learned, I've already mentioned the culture change that it requires a daily focus to initiate and sustain this kind of initiative.

One of the other lessons learned is collect your data. Review the number that are removed per this protocol, and then look at the number of those that require reinsertion. This is how we were able to take the data from our pilot, roll it out to other units. This helped us overcome some of the physician concerns with this being protocolized, then also document what the reason for reinsertion is, because if it's just that they failed the urinary retention protocol, that's different than another issue for it being reinserted.

To close up, to end my session, this came from the bedside caregivers. They were very engaged in doing this. It has helped impact our device utilization and as a result, has helped us reduce our CAUTI rate. I thank you for your attention, and welcome any questions at the end of the presentation.

Anna: Thank you so much, Sheryl. Emily?

Emily: Yes.

Anna: We'll let you get started, thank you.

Emily: Today, I'll be discussing how to identify defects and using the Learn From a Defect Tool. I'll review an example of how we've used it here at St. Joe's in Ann Arbor. A defect is anything that you don't want to happen again. In many cases, the defect may be something that has caused patient harm or has a potential to cause harm. Specifically, the events listed here on the slide are things that can be considered defects, or they are defects in our facilities. For events like CLABSI, CAUTI, or VAE, each month we review charts of these patients to try to find themes to help the Learn From a Defect process along. Other defects can include environmental factors, so things like staff safety concerns, or issues related to staffing or patient acuity.

There's several strategies that we have here that we've used to help identify defects. Talking to the frontline staff has probably been one of the most beneficial. The best [inaudible 00:37:44] staff are the eyes and ears of the unit. For example, every day we do shift huddles during every shift. We talk about a lot of outcome metrics and educational topics, but each shift we also try to discuss the climate of the unit. We ask staff if they have any safety concerns or anything that's bothering them. If there, if there's something that we need to talk about, we talk about it then. This is the time during the huddle to quickly talk about how things are going.

Other strategies are learning about defects in staff meetings. Leader rounds are another way. Directly asking staff, do you have everything you need to do your job? What are your safety concerns? There's also times that's been identified right in the moment, or right after they happened. When people perform a medication error, or a new hospital acquired pressure ulcer is found. We also have an anonymous, electronic reporting system that allows our staff to enter information about events that occur. They can be anything related to communication breakdown, or ethical concerns, all the way to patient falls and pressure ulcers.

Lastly, monthly data reports also help us to identify things or trends. For example, if we're not meeting our goals of resuscitation with our septic shock patients. Like timely antibiotic administration. That we could consider a defect. It's something that we can investigate.

Finally, the staff safety assessment can allow staff to think about and dive into concerns that they have. This is an example of the staff safety assessment. You can format it to your unit's needs, or even add questions to it. Last year our ICUE, we asked an additional question that was specific to patients receiving mechanical ventilation. We asked for feedback about that specific population as well.

The staff safety assessment is focused on the staff answering two questions. First, please describe how you think the next patient in your unit or clinical area will be harmed. The second, please describe how you think that what can be done to prevent or minimize this harm. The reason why this is important is because we want to engage staff in our work around safety, and being transparent about how their ideas and their feedback influences our action plans, and the solutions around those defects.

We have taken our staff safety assessments in the past, and we collate all of these results. We share the results with staff. We share with them what the major themes were. We ask them in different venues to help us develop action plans related to that. They should know what we're doing to help fix the defects.

When we're talking about defects, we use the Learn From a Defect Tool. It helps us support our culture of safety. It's a very easy tool to use. It's efficient. It's very structured. It also provides venues to talk about defects in a non-punitive way. We want to focus more on system and process issues, versus personal performance. When we do learn from a defect, it can happen in a variety of settings. It helps to build collaboration among the team and it can also be multidisciplinary. One thing that I've liked about it is that sometimes it brings frontline staff together with other members of the team that they may not get to work with on a day-to-day basis.

As I said, the Learn From a Defect strategy can be brief. This slide shows an example of a badge card that we have here available. Using the shift huddle as an example, most recently we used the Learn From a Defect process to discuss an equipment issue. We had a patient situation where staff were unaware where some emergency equipment was kept. It's because the sterile equipment was wrapped in a different color of wrapping than it had been before. It wasn't able to be identified during the emergency situation. We ran this problem through the Learn From a Defect process. The outcome of that situation was okay, because we had additional equipment on the unit, but we decided through this process, that we needed to standardize where our equipment was set, so that we could clear up the confusion. We didn't focus on, at all, personal performance. It was all about the fact that there was a problem with the system. We didn't have things standardized. By consistently using this process with the staff, we want them to begin to use this on their own, when they're talking about defects on their own.

Lastly, this is an example of the Learn From a Defect worksheet that we have here at St. Joe's. As I said earlier, we use it on a variety of things, including CAUTI. Every month we will get a report if we had any CAUTIs in our unit, and so there's a thorough chart review done, and then we try to find major themes among those patients. Learning about why did it happen, seeing if we can figure that out. What we could do to prevent it, what happened to cause the defect, and then we develop action plans. The nice thing about having this kept in one place and having it organized in this fashion is that, it's one central location for people to go back and look at to see when updates are needed, what are our targeted dates for completion are for different action plan items. It, overall, helps support accountability, and keeps things consistent, keeps us on track to meeting our goal.

Overall, [inaudible 00:43:55] the defect very easy. It's an organized approach to resolving defects that we've identified. It encourages engagement from frontline staff. It helps them to base their thoughts and ideas that can be shared with a multidisciplinary team. Having a clear action plan that identifies responsible parties, and target themes for accomplishing tasks, it all establishes accountability among team members. It helps them track outcomes that will help make meeting goals more meaningful. That's it.

Anna: Thank you very much, Emily. As I move on to our ... to our Q&A portion here, I do want to remind everyone to, once again, to please make sure you fill out the evaluation link. It's on the screen right now, so if you're not able to stay for the entire Q&A portion, or you just wanted to fill out the evaluation now. We do appreciate that feedback.

With that, Stephanie, could you open up the Q&A portion?

Stephanie: I sure can. At this time, we will open the floor for questions. If you'd like to ask a question, please press the star key, followed by the one key on your touch-tone phone now. Again, if you'd like to ask a question, please press star one now.

Our first question come from Susan [Candy 00:45:21] North Carolina.

Susan: Thank you. Hi Sheryl, this question is for you. How long after vasopressors are stopped do you guys allow for them to keep a Foley in for potentially needing to restart it?

Stephanie: Is Sheryl still on the line?

Sheryl: I'm sorry, yes. We don't have a definitive timeframe. I think this is where some of the case-by-case analysis comes in. It's looking at the patient, how long have they been on the vasopressors, have they had a rocky course, and that it has been they stopped and restarted. We might allow them a longer time to stabilize. If it's someone who has had a relatively stable course, short-term vasopressors, blood pressure's looking good, probably earliest is a couple of hours.

Susan: Okay, that helps, thank you.

Stephanie: Our next question comes from Donna Boatwright, in Florida.

Donna: Hi, this question is for Dr. Randy Garnett. Dr. Garnett, are you still on the line?

Randy: I still am.

Donna: I would love to know about your forty-eight hour protocol to do [C 00:46:54] Foley.

Randy: Honestly, I just found out about it last week. It was developed by some of the nurses in our burn trauma and neuro ICU. I just got a copy of it the other day. I think some of the comments that Sheryl just made are very important, in that if every patient is different and you have to use clinical judgement. I think each system needs to come up with a nurse-driven protocol that makes sense for that particular unit. At the same time, it pushed me, as a physician who's old and who's done the same thing maybe the wrong way for twenty-five years to at least think it through again. I think we need to push the physician side of this, because we tend to want to control everything. I don't have an answer about the exact protocol, but I can try to get it for you, if you would send me an email.

Donna: Could you put your email address on the chat?

Randy: I can try.

Donna: Thank you.

Randy: Thanks.

Stephanie: Our next question comes with Anna Vance in Florida.

Anna: This is actually Marguerite Selena [inaudible 00:48:10], and Anna Vance and Richard Cox, the three of us. The question I was going to ask was, I see there's a considerable amount of paper, tools, to have feedback. What is your success rate on getting those back to assess them, and then maybe collect data to see where that trend is going with your staff huddles and that paper to be filled in?

Stephanie: I think you're asking that question of Emily, about the staff safety assessment?

Anna: That's correct.

Stephanie: Emily, are you on the line?

Emily: I am, but things were kind of cutting out. Can you repeat the question, please?

Anna: Certainly. I see from the tool that you anticipate feedback. What is your success rate on your tool? The success rate for the completion and return for appropriate data collection and how you're able to trend for the safety when it is on paper, as we hopefully move away from paper?

Emily: I don't have an exact number of how many nurses or staff members responded last time. We do try to make it a situation where the surveys are available and a staff need ten minutes away from their assignments to fill it out. One of the leadership members on the team, or on the unit that day, will provide at that time and watch their assignment for them.

Anna: You're getting your paper back, your tools back? Surveys?

Emily: Yep.

Anna: Something to think about. Thank you.

Tina: This is Tina. Just to put this out there, these tools are used by many, many hospitals now across the country. They use them for many, many different quote-unquote defects. They might use them for falls, if that's their focus for the month, or med errors, or CAUTIs, or whatever is the issue. Many staff will use them as an ice-breaker for a staff meeting, and they pass them up, pass them out and they collect them up. They give a minute synopsis at the staff meeting about what were the major group of problems identified. The team has the opportunity, then, to respond to those identified needs. Some people don't have the development of their team to do all the problems identified, but can, in fact, prioritize their problems that are identified, and look at acuity and frequency of those issues and address the most important ones first, as far as patient safety are concerned. Many other nurse leaders are starting every meeting with those two questions.

Anna: Thank you.

Stephanie: Our next question comes from John, in South Carolina.

John: This question is for Sheryl, in Greenville. Sheryl, I have a question about your care rounds. I'm curious as to how often do you do this? How long? Who are the inter-professionals that were involved in your care rounds? How many patients do you see? We seem to struggle with this quite a bit. Also, I'd like to know more about your process to engage your physicians. I think what you did with nurse engagement was very clever and was very smart. I'd like to know more of the physician side, how you engage them in this process.

Sheryl: The way that we do our rounds, is we have a version of interdisciplinary care round. However, with our unit, we're a twenty-eight bed unit. We have multiple physicians, as I'm sure everyone does, seeing the same patient. There was no way we could get the physicians to participate in those rounds. What we have in our conference room s we have a board. We update the board every shift. We have every patient's name. We have a category for each of our quality measures. We have a category, for example, for progressive mobility, for daily sedation, [vacation 00:52:46] and awakenings. We have an area for progressive mobility. Each day, we start rounds, for example, on day shift we start at about nine forty-five. We do about the same time on night shift. Each nurse comes in, discusses with our supervisor, nurse manager, or myself, about their patient. We go over the quality measures. We stress that this is not another shift report or an update on our patient. We're looking at what are the needs of this patient, and transferring them from critical care, what are our barriers to doing that? What are some avenues, what are some things we can be doing?

That's where we started with the Foley. We added that category to the board, and when the nurses came in to discuss their patient, we would say, "Does your patient have a Foley?" We had the list of our approved indications there. We would review them with each nurse, and then we would make a decision yes, this patient meets the protocol for the nurse to remove the Foley, or no they don't. If we weren't quite sure, that is one of the things we would write down. That helped us refine our indications, because we would follow up with those and discuss with our medical director. That's how we approach our rounds. The people who participate are supervisors, the charge nurse, they're the ones who lead the round. The nurse manager usually attends the day shift round. I drop in to the round as often as I can. I, as we were rolling this initiative out, I took the lead for the rounds being the clinical person, because this was a new clinical initiative. I wanted to be there to discuss it with each nurse and get their feedback. Gradually, I transitioned that back to the supervisor, charge nurse, and the nurse manager as leader of the those rounds. They have continued to be able to sustain that.

Physician engagement, I have to give credit to our infections preventionist, and also to our medical director. As we begin to look at the data that we were seeing from our pilot, and knowing the only thing we were doing different was implementation of the indwelling catheter removal protocol, we began to see some steady reductions in our device utilization. Probably the downside to that is that as you decrease your device utilization rate, sometimes your CAUTI rate will look a little worse. That was a bitter thing for our staff to have to look at. They're like, wait a minute, we had the same number of CAUTI instances as the other critical care unit did, but just because our days are lower, because we're getting the devices out earlier, we get dinged on our overall rate and our overall rate looks worse. That began to come together and now we're consistent.

That is something to keep in mind, that you will see in your data. I believe, with the presentation from our infections preventionist, and sharing it in the committee groups and the system groups that they were in, we were asked to come and share our experiences. The medical directors of the other critical care units wanted it rolled out to their areas as well. I think it's the data. One of the first questions we got asked when we rolled it out was, how many have you had to reinsert, and how many have the nurses removed per utilization of the protocol? That's why I included that as a lesson learned, because we did not formalize that hindsight twenty-twenty. I don't know how we overlooked that, but we did. We went back and had some patient information that we could pull from, to get that information. It's a very small percentage of patients that had to have it reinserted. The ones that did require the reinsertion, the most common cause was because they failed the urinary retention protocol. Not for any adverse reason.

Tina: This is Tina, and I would just let you know, folks, that there are studies on this question out there. The studies have demonstrated that reinsertion has been lower than all usual expected numbers. Depending on how you structure your acute urinary retention protocol, some hospitals are using different bladder scanner volumes to reinsert the catheter. Others are doing straight caths, and then waiting again four to six hours and seeing if the patient can void spontaneously. Some hospitals are going to two or three straight catheterizations before the catheter is reinserted, if it's just because of retention. If the patient worsens or needed increased support, whether it be ventilation or inotrope then yes, they could get a new Foley for that reason. If it's based on the acute retention protocol, just so you know, they are moving away from just reinsertion. Those data are very helpful to demonstrate as you spread to other services, or other physician groups, or other units, that this was not a problem.

The other thing that your yellow tag, your Foley tag with the yellow thing in, that's a great idea. I really love that. I just want you to know that some other hospitals have also had an opt out portion of the nurse-driven protocol order, so that the physicians can opt out in an order, written order. I don't know if you considered that.

Sheryl: That is something that ... that gives me something to consider.

Emily: Thanks everyone. I have three o'clock now. Sheryl and Emily and Randy, I know that it's at the hour, but if you're able to stay for a few more questions ...

Randy: Happy to.

Sheryl: Yes, I can.

Emily: Thank you both. [crosstalk 01:00:00] Stephanie, do we have any ...

Stephanie: Our next question comes from Hillary Archer, in Colorado.

Hillary: Hi, we were wondering if anybody has found an increases in their CMA hours needed with the removal of the catheter?

Sheryl: We not have any unlicensed assistive personnel in our unit. We are an all RN team. We've not really measured that from the nursing care perspective. We do have probably more frequent linen change. I know that there's a lot of institutions that have found some better incontinence pads. That was one of the barriers. One of the things when we presented it is that we're not going to be doing anything all day but changing linens, because of incontinence. We continue to stress that the alternative to that is leaving an indwelling catheter in, putting your patient at risk for an infection. We've emphasized the alternative to the indwelling catheter. When those were presented as barriers, we reiterated options for alternatives.

Hillary: Did you look at increasing any pressure ulcer problems or [inaudible 01:01:45] problems?

Sheryl: We have been monitoring our pressure ulcer rate in conjunction with that. We have not seen increase.

Hillary: Thank you.

Sheryl: Thank you.

Anna: Great stuff [inaudible 01:02:02] there. Any other questions at this time?

Stephanie: There are no more questions at this time.

Anna: Thank you everyone, for joining us today. As a summary of today's webinar, the next steps of everything that we reviewed. After today's webinar, you should be able to understand the HICPAC indications for urinary catheter use, especially in the critically ill population. You should be able to understand when catheters may be discontinued in critically ill patients, know what alternatives to indwelling urinary catheters are available in your organization, and how to implement the Learning From Defects Tool and staff safety assessment within your ICU team. The Learning From Defects Tool and the staff safety assessment are part of the CUSP tool kit. All those resources are available on the website, so please be sure to check there for more information on that. We will post them as well, with the slides and the recording of today's webinar.

One final plug for our evaluation. Please be sure to complete that, we do value your feedback. Thank you to all of our presenters and for everyone joining us today. We look forward to talking to you again next month. Thank you.

Sheryl: Thank you.

Stephanie: Thank you, ladies and gentlemen, this concludes today's conference. You may now disconnect.

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Page last reviewed December 2017
Page originally created November 2015
Internet Citation: Defining Critically Ill in the ICU; Alternatives to Catheters; Using CUSP Staff Safety Assessment and the Learning From Defects Tool to Improve Safety Culture. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD.