On the CUSP: Stop CAUTI

1. On the CUSP: Stop CAUTI Welcome to ED Quarterly Office Hour! Access slides, video recording, and transcript of today’s webinar on the national project website: http://www.onthecuspstophai.org/on-the-cuspstop-cauti/emergency-department-improvement-intervention/

2. ED Quarterly Office Hour Brooke Zacheis, BSN, RNClinical Coordinator RWJUH Hamilton Chris Dietz , RNTeam Lead RWJUH Somerset

3. CAUTI State of Mind

4. Our Journey: Creating a CAUTI State of Mind • RWJ Hamilton Emergency Department • CAUTI Team: Brooke Zacheis, BSN, RN; Elizabeth Mizerek, MSN, RN, CEN, CPEN, FN-CSA; Lauren Stabinsky, MSN, RN, CEN; Anne Dikon, BSN, CIC, RN; Gwen Pownall, BSN, RN; Wendy Solymosi, RN • Todays Presentation by: Brooke Zacheis, BSN, RN

5. Emergency Department Information • Community Hospital • 26 bed ED • 55,000 ED visits annually

6. Why Did We Join On the CUSP: STOP CAUTIEmergency Department Intervention? The CAUTI Intervention Offered: • Opportunity to improve catheter use in ED • Best practice techniques for CAUTI prevention • Collaboration with other intervention participants

7. Our CAUTI Team CAUTI TEAM

8. First Steps Hospital wide “Culture of Safety” reviewed Concurrent integration with TeamSTEPPS patient safety program Highlighted need for interdisciplinary approach

9. AIM Statement Align the ED use of urinary catheters with current best practice to prevent catheter acquired urinary tract infections (CAUTI).

10. Goals Align patient care with evidence based practice Decrease the number of inappropriate indwelling catheters placed Improve on aseptic insertion technique

11. Leadership Involvement • ED Leadership part of CAUTI Team • ED reports to senior hospital leadership on CAUTI Intervention • 2014 Organizational Goal CAUTI

12. Policy Update Inpatient nurse initiated catheter removal policy New ED specific catheter placement and removal policy Specific considerations for patients who arrive with a catheter

14. Staff Engagement Identify CAUTI champions Positive feedback Information sharing

15. Learning From Defects • Just Culture • Data Analysis • Speak Now!

16. Sustainability Challenges • Momentum • Inpatient and Long Term Care Facilities Engagement • Tracking Trends • Identifying Need for Additional Resources

17. Thank You, CAUTI State of Mind Team

18. Emergency Department Christopher Dietz, RN

19. Emergency department background • Robert Wood Johnson University Hospital Somerset, previously known as Somerset Medical Center, is located in central New Jersey. (RWJ Merger finalized June 1st, 2014) • Layout/capacity • 47 designated private patient rooms • 2 designated supply rooms • 355 inpatient bed capacity on site • Approximately 53,500 visits per year • Physician staffing provided by Emergency Medical Associates(EMA)

20. RWJUHS ED Collaborative Team • Christopher Dietz, RN Team Leader • Christopher Crean, MD Physician Champion • Sharon Parrillo, RN Education/Data Collection • Robert Wood Johnson University Hospital Somerset joined the ED CAUTI Collaborative in August 2013.

21. On the Cusp: ED improvement intervention • RWJUHS began evaluating ED Foley usage in 2008, however, no prior data available. • Staff Education focused on: • Evidence-based guidelines to reduce CAUTI • Appropriate Indications • Urine output measurement of the critically ill patient

22. output measurement of critically ill patient

23. ED Implementation Challenges • Admitting physician resistance • “strict I&O” commonly misunderstood/over-utilized. • Telephone admission orders create the need for RN to act in line with the collaborative mission. • Urimeter vs Non-Urimeter Collection Devices • Use only urimeter bag in effort to maintain closed system. SUCCESS: Administration support regardless of cost • Disconnection between MD orders and nursing actions • Accountability of placement – pre/post arrival in ED • Modification of EHR to establish Foley present on admission. • Nurse reminder to obtain baseline urinalysis if indicated.

24. Implementation Successes • Supportive ED physician staff • ED nurse/physician relationship encourages open communication and collaboration. • ED physician acts as strong patient advocate – willing to intervene in admitting plan when Foley not indicated. • Designated Infection Prevention team member • CAUTI Education Program • Many staff already familiar with goals due to prior education programs. Education served as a good reminder. • Engaged staff nurses • Strong support for CAUTI collaborative noted from all staff, new graduates all the way up to staff in ED for 20+years.

25. Maximize Electronic Health Record • The ED CAUTI Collaborative provided an opportunity to work with the IT department in order to create reports: 1. Admission/Observation Patients through the ED 2. Patients who are catheterized • Unable to discern between straight cath and Foley, however, proved to be much more accurate than self reporting. Data is reviewed and collated by the Infection Prevention team member in order to decrease staff burden

26. The appropriateness of Foley catheter insertion continues to increase. Data Results

27. Future in the ED • Continued focus on appropriate placement • GOAL = 100% • Increased emphasis on catheter removal • Culture change in process regarding discontinuing treatments in the ED after patient admission. • Changed circumstances/improved patient condition. • Send urinalysis, if clinically indicated, when Foley inserted to identify any pre-existing UTI on admission. • Bladder scanner • Underutilized resource that can drastically reduce both indwelling and intermittent catheterizations.

28. Case study • Elderly female- admitted to a medical surgical unit with telemetry- diagnosis hyponatremia/syncope- Patient alert and oriented x3- ambulatory- vital signs stable- accurate output obtainable • Admitting MD order for Foley placement- indication documented as strict I&O in critical care patients • physician specified q shift in secondary order • Order questioned by RN- MD insisting placement with no justification for strict I&O • Consulted CAUTI team member/ED physician- no medical need identified • ED Physician staff supporting nursing judgment allowing RN to be more vocal for patient safety

29. Case study remediation • Report given to the inpatient unit with emphasis on CAUTI risk- no catheter placed in ED • With the support of the direct patient care staff, ED director able to speak with the chief of medicine to have the safety concern addressed • Hospital administration supported nursing judgment- no catheter placed- potentially harmful situation avoided • Without effective communication, patient advocacy and most importantly nursing and physician teamwork- This patient would have been potentially exposed to a hospital acquired infection and endless complications

30. Questions

31. ED Quarterly Office Hour Lisa Wolf PhD, RN, CEN, FAENClinical Coordinator Emergency Nurses Association Marlene Bokholdt MS, RN Team Lead Emergency Nurses Association Jeremiah D. Schuur MD, MHS, FACEP Brigham and Women’s Hospital American College of Emergency Physicians

32. Why a nursing champion? • Nurses, both as bedside providers and as unit leaders, provide the environment in which care is provided • They set standards of practice, behavior, and education

33. Nurses own elimination • 96.77% of respondents (180/185) reported that in their EDs, RNs are responsible for insertion of indwelling catheters

34. We start things, we don’t undo them • 65.87% (165/185) reported that they did not have a protocol to remove a catheter prior to transfer from the ED • 41.32% reported that the catheter was never removed before transfer to an inpatient unit if no longer needed • 20.36% reported that the catheter was never removed more than half the time before transfer to an inpatient unit if no longer needed

35. Low priority problem • 20.13% of respondents reported no guidelines or quality improvement initiatives for CAUTI reduction in their ED. • 43.62% report not having a well functioning interdisciplinary team

36. Need for more observation • 70.47% of respondents reported using sterile technique “always” • 38.93% of respondents report no support for a 2-person insertion

37. But…. • 72.48% report having an effective nurse champion in their ED • So, what does “effective” mean?

38. What purpose does the nurse champion serve? • Serves as a “check” for appropriate insertion and indications for removal prior to transfer • Reviews orders and indications (chart review) • Feeds back information to staff (both providers, nurses, and technicians) • Provides real time assessment of technique • Supports and “normalizes” practice change

39. Physician Role in Urinary Catheter Placement • All urinary catheters require an order… • Yet, the decision to place a catheter is not the ED ordering provider’s alone: • ED nurse • Patient & Family • Consultant (e.g. Trauma) • Admitting service (e.g. Cardiology)

40. Role of ED Physician Champion to Reduce CAUTI • Promote reduction of catheter use by championing appropriateness • Review indications / avoidable cases • Review data • Encourage interdisciplinary conversation around catheter use in ED • “Huddle” w/ nursing re: need for catheter • Engage other services around patterns of catheter use • Trauma • Cardiology - CHF

41. Thank you! Questions for our presenters?

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