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!

QUESTIONS?

emizerek@rwjuhh.edu eam1944@aol.com

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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