ICU Clinical Decision-Making; Processes to Improve Catheter Insertion and Removal Choices; Science of Safety Concepts to Improve ICU Culture

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ICU Clinical Decision-Making; Processes To Improve Catheter Insertion And Removal Choices; Science Of Safety Concepts To Improve ICU Culture

David Pegues, MD
Medical Director, Hospital Epidemiology
Infection Prevention and Control
University of Pennsylvania Medical Center

Julia Retelski MSN, RN, SCRN, CCRN, CCNS
Clinical Nurse Specialist, Neurosurgical Intensive Care
Carolinas HealthCare System

Pat Posa, RN, BSN, MSA, FAAN
System Performance Improvement LeaderSt. Joseph Mercy Hospital

Images: Photos of the three authors.

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Learning Objectives

  • Identify appropriate and inappropriate indication for indwelling urinary catheter use
  • Describe catheter insertion, maintenance, and removal procedures
  • Define the first step of CUSP: Educate staff on the Science of Safety

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CAUTI Indications

David Pegues, MD
Medical Director, Hospital Epidemiology, Infection Prevention and Control
University of Pennsylvania Medical Center
Philadelphia, PA

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On the CUSP: Stop CAUTI:  ICUs are Lagging

Image: Line graph showing the NHSN CAUTI Rate trend over time, where the rate in ICU's is higher than that in non-ICUs. the rate in ICUs is 2.36 CAUTIs/1,000 catheter days, compared to non-ICU's where it is 1.91 CAUTIs/1,000 catheter days.

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Use of Urinary Catheters in Adult ICU Patients

Image: Line graph showing rates of urinary catheter utilization by ICU type for the perior 1990-2007.

Source: Burton DC, et al. Infect Control Hosp Epidemiol 2011;32:748-56.

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Appropriate Indications for Indwelling Urinary Catheter Use

Appropriate Indications

Patient has acute urinary retention or obstruction.

Need for accurate measurements of urinary output in critically ill patients.

Perioperative use for selected procedures:

  • Urologic surgery or other surgery on contiguous structures of genitourinary tract,
  • Anticipated prolonged surgery duration (removed in post-anesthesia unit),
  • Anticipated to receive large-volume infusions or diuretics in surgery,
  • Operative patients with urinary incontinence,
  • Need to intraoperative monitoring of urinary output.

To assist in healing of open sacral or perineal wounds in incontinent patients.

Requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine).

To improve comfort for end of life care if needed.

Gould C, et al. Infect Control  Hosp Epidemiol 2010;31:319-26.

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Inappropriate Indications for Indwelling Urinary Catheter Use

Inappropriate Indications

As a substitute for nursing care of the patient or resident with incontinence.

As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void.

For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anaesthesia, etc.).

Routinely for patients receiving epidural anesthesia/analgesia.

Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26.

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Inappropriate Catheter Placement

  • Initial indication for catheter placement1:
    • Inappropriate in 21%-54% of catheterizations
    • Varies by location of placement and site of care
Indication2 MICU (N=135) Med Unit (N=67)
Justified % Unjustified % Justified % Unjustified %
Monitoring urine output 93 7 90 (17/19) 10 (2/19)
Urinary incontinence 0 0 20 80
Urinary retention 0 0 92 8
Periop/periprocedural 97 3 100 0
Unclear reason 0 100 0 100

1 Hooton TM, et al. Clin Infect Dis 2010;50:625-63.
2 Jain P, et al. Arch Intern Med 1995;155:1425-9.

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Prolonged Urinary Catheter Device Utilization by Location

Indication MICU (N=597 days) Med Unit (N=315 days)
Justified No. % Unjustified No. % Justified No. % Unjustified No. %
Monitoring urine output 254/413 (61) 159/413 (36) 49/95 (52) 46/96 (48)
Urinary incontinence --- --- 24 /127 (19) 103/127 (81)
Urinary retention --- --- 38/39 (97) 1/39 (3)
Periop/periprocedural --- --- 5/11 (45) 6/11 (55)
Unclear reason 0/66 (0) 66/66 (100) 0/22 (0) 22/22 (100)
Other 45/51 (88) 0 16/21 (76) 5/21 (24)
Total 349/597 (59) 248/597 (41) 132/315 (42) 183/315 (58)

Jain P, et al. Arch Intern Med 1995;155:1425-9.

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Critically Ill Patients

  • Q1: How can we identify “critically ill” patients who are appropriate candidates for urinary catheterization?
  • Q2: What processes can we use to identify patients who are no longer critically ill and who are appropriate candidates for urinary catheter removal?

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Critically Ill Patients: Reframe the Question

  • Who needs hourly monitoring of I’s and O’s?
    • Physiology–MSOD, AKI
    • Pharmacology/hemodynamics–pressors
    • Volume status—CHF exacerbation, GI bleeding
  • Other considerations:
    • Level of consciousness—sedation, CNS event
    • Mobility—paralytics, orthopedic trauma

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Reducing CAUTIs in the ICU

Goal Tool
Optimize catheter maintenance
  • Periodic audit
  • Direct observation
Limit duration of catheter use
  • Device rounds
  • Daily assessment of indication
  • Reminders/stop orders
  • Nurse-driven removal protocol
Limit inappropriate culturing practices
  • Perform clinical assessment for S/Sx of SUTI
  • Require RUA
  • Avoid “pan culturing”

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Catheter Insertion and Maintenance

Julia Retelski MSN, RN, SCRN, CCRN, CCNS
Clinical Nurse Specialist, Neurosurgical Intensive Care
Carolinas HealthCare System

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Team Members

  • Nursing
  • Providers
    • Acute Care
    • Rehab
  • Administration
  • Infection Preventionist
  • Care Tech
  • Family

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Insertion Criteria

  • On going evaluation
  • Small variations in patient populations
    • Neuro
    • Surgical
    • Medical

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Alternatives

  • Increase use of alternatives
    • Condom catheters
      • Evaluate multiple products
    • Moisture wicking incontinence pads
      • Urinary Retention Protocol
        • Ease of use
        • Available bladder scanners

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Insertion

  • Minimize urethral trauma by using generous amounts of sterile lubricant
  • Perform Hand Hygiene
  • Patient positioning
  • Timing and location

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Maintenance

  • Scheduled urinary catheter care 0800-1000
  • Scheduled bath times 1500-2300:
    • Bath Team received Hands On training
  • No dependent loops
  • Stat lock
  • Transport

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Maintenance

  • Do not perform bladder or catheter irrigation unless medically necessary
  • Maintain sterile, closed system
  • Turn, Turn, Turn
  • Bowel Regimen
    • Either not enough or way to much

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Urine Specimen

  • Do not send routine cultures
  • Consider changing the urinary catheter prior to drawing urine culture
  • Evaluate technique
  • Send urinalysis prior to sending urine culture

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Prompt Removal

  • Set times to evaluate
  • Ongoing follow up 24/7
  • Follow up after removal
    • Urinary Catheter Protocol
      • Scheduled intermittent catheterization
      • Bladder scan

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Adult Urinary Retention Algorithim

Image: Flowchart showing procedures for discontinuing the urinary catheter.

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Rounding

  • Clinical Nurse Specialist rounds with intensivist team daily
  • Nightshift charge RN rounds every morning at 0600 to evaluate necessity
    • Daily report via EMR
  • Virtual Critical Care (VCC)

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Event Tool

Image: Screen shot of a CAUTI Event Tool form.

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CUSP - The Science of Safety

Pat Posa RN, BSN, MSA, FAAN
System Performance Improvement Leader
St. Joseph Mercy Hospital
Ann Arbor, MI

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CUSP

Adaptive /Cultural

CUSP

  1. Educate on the Science of Safety
  2. Identify Defects (Staff Safety Assessment)
  3. Senior Executive Partnership
  4. Learn from Defects
  5. Implement Teamwork & Communication Tools

Technical

Clinical

  1. CAUTI Prevention
    1. Insertion
    2. Maintenance

www.ahrq.gov/cusp

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Key Concepts: Technical and Adaptive Work

Image: Venn diagram showing the "sweet spot" where Technical Work: Evidence-based interventions intersects with Adaptive Work: Local culture.

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CUSP Implementation So Far

  • Assemble a CUSP for CAUTI team
  • Partner with a Senior Executive

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Steps of CUSP

  1. Educate staff on the science of safety
  2. Identify defects
  3. Partner with a senior executive
  4. Learn from defects
  5. Improve teamwork and communication

Adaptive Components

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The Science of Safety

  • Understand system determines performance
  • Use strategies to improve system performance
    • Standardize
    • Create Independent checks for key process
    • Learn from Mistakes
  • Apply strategies to both technical work and team work.
  • Recognize that teams make wise decisions with diverse and independent input

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Medical errors most often result from a complex interplay of multiple factors.  Only rarely are they due to the carelessness or misconduct of single individuals.

Lucien L. Leape, MD
Harvard School of Public Health

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Why Mistakes Happen?

Process Factors

  • Variable input (diff pts)
  • Inconsistency/variation
  • Complexity
  • Too many/complicated steps
  • Human intervention
  • Tight time constraints
  • Hierarchical culture

People Factors

  • Fatigue
  • Inattention/distraction
  • Unfamiliar situations/new problem
  • Using past solutions
  • Equipment design flaws
  • Communications errors
  • Mislabeling/inadequate instructions

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IOM (Institute of Medicine) Basic Concepts in Patient Safety

  1. User-Centered Design
    • Understanding how to reduce errors depends on framing likely sources of error and pairing them with effective ways to reduce them
      • Make things visible
      • Incorporate affordances and force function
        • Affordance: characteristics of equipment or workspace that communicate how it is to be used
          • Push bar on an outward opening door that says PUSH
          • Marking the correct site before surgery or procedure

AHRQ: Patient Safety and Quality: An Evidence-based Handbook for Nurses 2008 pp41-44

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IOM (Institute of Medicine) Basic Concepts in Patient Safety

  1. Avoid Reliance on Memory
    • Standardize and simplify the structure of task to minimize the demand on working memory, planning or problem solving
      • Simplify key processes- limit the choice of drugs or dose strengths available in order sets/pharmacy
      • Central line carts
  2. Attend to Work Safety
    • Evaluate conditions of work including work hours, staffing ratios and sources of distraction
      • Example: “Red Zones” to prevent medication errors

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IOM (Institute of Medicine) Basic Concepts in Patient Safety

  1. Avoid Reliance on Vigilance
    • Provide checklists, employ equipment that automates some functions, use flags or alarms as reminders
  2. Train Concepts for Teams
    • When ever possible training programs and hospitals should establish interdisciplinary team training
  3. Involve patients in their care
    • Invite patients and families to become a part of the care process.
    • Safety improves when patients and families know their condition, treatments and technologies used in their care
    • Patients need clear information regarding next steps after discharge.

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IOM (Institute of Medicine) Basic Concepts in Patient Safety

  1. Anticipate the Unexpected
    • Likelihood of errors increases with reorganization, mergers, and other organizational changes—IE: CPOE Healthcare professionals should expect any new technology to introduce new sources of error and should adopt the custom of automating cautiously
  2. Design for Recovery
    • Assume that errors will occur and design and plan for recovery by duplicating critical functions and making it easy to reverse operations Use simulation training  to practice recovery strategies
  3. Improve Access to Accurate, Timely Information
    • Information for patient care decisions should be available at the point of patient care

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How Can These Errors Happen?

Image: A sign indicating a wet floor is removed while the floor is still wet. As a result, a patient slips on the floor.

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Key Messages

  • Safety is everyone’s responsibility
  • Mistakes are usually the result of system and process issues—improving those will improve safety
  • Improving culture will positively impact safety
  • Remember the human factor—we all make mistakes---our job is to identify risks and put in place processes to mitigate that risk

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Resources

Go to CUSP Toolkit: http://www.ahrq.gov/cusptoolkit

Duke patient safety: www.dukepatientsafety.org safety as a system video

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Thank you!

Questions?

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Funding

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

Return to CAUTI Toolkit Information for Specialty Audiences Page

Page last reviewed December 2017
Page originally created December 2015
Internet Citation: ICU Clinical Decision-Making; Processes to Improve Catheter Insertion and Removal Choices; Science of Safety Concepts to Improve ICU Culture. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/icu-clinical-decision-making-slides.html