Post on 17-Dec-2015
On the CUSP: Stop CAUTI ED Intervention
National ED Office Hours
Co-hosted by:
Emergency Nurses Association Health Research and Educational Trust
December 10, 2014 at 10 CT/ 11 ET
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ED Office Hours Agenda
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• Welcome and Agenda Overview– Shannon Davila, NJHA
• Polling Questions– Shannon Davila, NJHA
• No More CAUTI: Preventing Catheter Associated Urinary Tract Infections– Elizabeth Mizerek, Robert Wood Johnson University Hospital Hamilton
• Open Discussion and Q&A – National Project Team
Polling Question 1
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What has been the major focus of your team’s effort throughout the project?
1. Integrating the appropriate indications into your MD orders and RN documentation systems
2. Designing staff competencies to test staff knowledge around need for catheter, insertion, and maintenance
3. Improving teamwork and communication efforts among clinicians that care for patients with catheters
4. Implementing alternative strategies to indwelling catheters (example- use of condom catheters, straight cathing for sample collection)
Polling Question 2
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If your team has a urinary catheter competency in place for staff, please choose the main components of that program:
1. Online self- directed education learning module2. Hands on simulation program for insertion and maintenance
procedures3. Group discussion following lectured presentation of urinary
catheter best practices4. A hybrid model using both active in-person and online training5. We do not currently have a urinary catheter competency
program for staff
NO MORE CAUTI – PREVENTING CATHETER ASSOCIATED URINARY TRACT INFECTIONS
Elizabeth Mizerek, MSN, RN, CEN, CPEN, FN-CSAED Nurse Educator, Robert Wood Johnson University Hospital Hamilton
CAUTI PREVENTION EDUCATION
Impact of CAUTI
Insertion indications – decision making scenarios
Review of policies and procedures
Demonstrated insertion competency
WHAT IS CAUTI?
Catheter associated urinary tract infection
Publicly reported
Most common cause of healthcare acquired infections
Up to ¼ of hospital patients may have an indwelling urinary catheter
COMPLICATIONS OF CAUTI
Increased length of stay – 3.8 days!
Increased healthcare costs - $500 million annually
Non-reimbursement of CAUTI related expenses
URINARY CATHETERS
Increased risk for patient mortality
2nd leading cause of sepsis
13,000 deaths annually associated with CAUTI
INSERTION INDICATIONS
APPROPRIATE CATHETER INDICATIONS Urinary retention or urinary flow
obstructions
APPROPRIATE CATHETER INDICATION
Monitoring fluids in critically ill patients
APPROPRIATE CATHETER INDICATIONS Healing of significant sacral or perineal
wounds
APPROPRIATE CATHETER INDICATIONS Improving comfort at end of life
APPROPRIATE CATHETER INDICATIONS Selected perioperative use
APPROPRIATE CATHETER INDICATION
Immobilization due to trauma
ALTERNATIVE TO INDWELLING CATHETER Bladder scanner to assess volume of
urine in bladder
Straight catheter
Condom catheter for men
INAPPROPRIATE CATHETER INDICATIONS
INAPPROPRIATE CATHETER INDICATIONS Incontinence
Catheters do not protect skin
INAPPROPRIATE CATHETER INDICATIONS Morbid obesity
INAPPROPRIATE CATHETER INDICATIONS
Limited mobility or debility
Catheters do not prevent falls
INAPPROPRIATE CATHETER INDICATIONS Dementia or confusion
Catheters do not prevent falls
INAPPROPRIATE CATHETER INDICATIONS Monitoring of fluids in non-critically ill
patients
You can monitor output many ways
INAPPROPRIATE CATHETER INDICATIONS Urine specimen collection
Straight cath!
INAPPROPRIATE CATHETER INDICATIONS Patient or family request
Educate patient and family on catheter risks
INAPPROPRIATE CATHETER INDICATIONS Staff convenience
Catheters don’t save us time
DECISION MAKING SCENARIOS
FOLEY OR NO FOLEY?
Acute stroke patient with left sided weakness who is going to receive IV t-PA
ACUTE STROKE PATIENT WITH LEFT SIDED WEAKNESS WHO IS GOING TO RECEIVE IV T-PA Foley No Foley
FOLEY OR NO FOLEY
Family requests foley for patient….and provider orders it.
FAMILY REQUESTS FOLEY FOR PATIENT….AND PROVIDER ORDERS IT
Foley No Foley
FOLEY OR NO FOLEY
Hip fracture going to OR…..eventually
HIP FRACTURE GOING TO OR…..EVENTUALLY
Foley No Foley
FOLEY OR NO FOLEY
Elderly, confused non-ambulatory patient
ELDERLY, CONFUSED NON-AMBULATORY PATIENT
Foley No Foley
FOLEY OR NO FOLEY
Critically ill ICU patient
CRITICALLY ILL ICU PATIENT
Foley No Foley
FOLEY OR NO FOLEY?
Patient unable to provide clean catch urine
PATIENT UNABLE TO PROVIDE CLEAN CATCH URINE
Foley No Foley
FOLEY OR NO FOLEY?
Acute CHF receiving lasix on bi-pap
ACUTE CHF RECEIVING LASIX ON BI-PAP
Foley No Foley
POLICY AND PROCEDURES REVIEW
STRATEGIES FOR DECREASING CAUTI Consider supplies
What is included in kit Closed system for all catheter sizes and
types Where supplies are located
Availability of staff to assist
Overbed tables
Patient arrives to the ED with an indwelling foley
catheter. Assess appearance of catheter
and drainage bagfor gross contamination.
If grossly contaminated, removefoley. Do not obtain
specimen from contaminated foley.
If not grossly contaminated, determine if
there is an appropriate indication for foley.
Reassess patient. Is there an
appropriate indicationto place indwelling foley?
If appropriate indicationfor indwelling foley,
obtain provider order and insert foley.
Obtain specimen from new foley.
If no appropriate indication for indwelling foley, do not insert foley.
Obtain urine specimen through clean catch
or intermittent straight catherization.
If no appropriate indication for indwelling foley,
remove foley and do not reinsert. Obtain urine specimen
through clean catch or intermittent straight
catherization.
If appropriate indicationis present, foley
may remain in place. Obtain urine specimen
from catheter.
Appropriate indication for foley insertion:• Urinary flow obstruction or retention• Hematuria with clots• Monitoring output in critically ill patients• Required immobilization for trauma or surgery• Perioperative use • Healing of sacral and perineal wounds in
incontinent patients• End of life comfort
INDWELLING CATHETERS
Do not routinely replace indwelling catheters based on duration
Assess each catheter placement individually
Reinforce appropriate urine specimen collection techniques
DEMONSTRATED COMPETENCY
EDUCATION
When, where and how to nurses learn to place indwelling urinary catheters?
Does the learning environment match the practice environment?
COMPETENCY
Good perineal care prior to opening kit
Alcohol based hand hygiene
Appropriate draping
Appropriate swabbing
Contamination of catheter – bring two kits
SOME ADDITIONAL THOUGHTS…
TEAMWORK
Shared mental model – trained nurses and techs together
Teamwork to facilitate placement
Empowered all staff to speak up when breach of sterile technique noted – patient safety!
ONGOING EFFORTS
Provide feedback to staff
Post CAUTI rates and link to insertion
One on one education and remediation
Don’t forget providers education!
CONCLUSION
A indwelling urinary catheter is not a life-saving procedure
Think, slow down, appropriate technique
Safe practice, safe care!
ED Office Hours
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General Questions/Concerns?
Quarterly ED Office Hours
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• Access slides, audio recording, and transcript of today’s webinar on the national project website:– http://
www.onthecuspstophai.org/on-the-cuspstop-cauti/educational-sessions/ed-improvement-intervention-educational-sessions/
• Upcoming Office Hours:– Wednesday, March 11, 2015 at 11 ET/10 CT– Wednesday, June 10, 2015 at 11 ET/10 CT
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