The Emergency Department & Catheter Insertions 1 Mohamad Fakih, MD, MPH St. John Hospital and Medical Center Lisa Wolf, PhD, RN, CEN, FAEN Emergency Nurses.

The Emergency Department & Catheter Insertions

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Mohamad Fakih, MD, MPHSt. John Hospital and Medical Center

Lisa Wolf, PhD, RN, CEN, FAEN Emergency Nurses Association (ENA)

Jeremiah Schuur, MD, MHS, FACEP Brigham and Women’s Department of Emergency Medicine

Learning Objectives

• List 3 ways to improve compliance with the appropriate indications for urinary catheter placement in the emergency department

• Discuss strategies to improve compliance with proper technique for urinary catheter placement

• Summarize the ED physicians’ role in urinary catheter placement

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Could this happen at your hospital? The Story of Mr. Smith (1)

• Mr. Smith is 82 year old and gets admitted because of mild congestive heart failure. In the Emergency Department, a urinary catheter is placed (although he can use the urinal), and he is transferred to the floor but could not sleep. He is prescribed a sleeping pill. He gets more restless, gets out of bed, trips on the catheter and falls. He is found to have a left hip fracture, and undergoes surgery. Post-operatively, the staff notes that his left leg is swollen and he is diagnosed with deep venous thrombosis. He is started on blood thinners.

Could this happen at your hospital? The Story of Mr. Smith (2)

• Because of his immobility, he develops a pressure ulcer on his sacrum. His physician removes the catheter, but now he is having urinary retention related to pain medications. The urinary catheter is placed again. The procedure results in hematuria with the difficulty in insertion and being on blood thinners. Few days later, he develops fever and his blood pressure drops. Blood cultures and urine cultures grow Escherichia coli and he is diagnosed with CAUTI and septicemia. After 6 weeks in the hospital and many complications, Mr. Smith is no longer the same.

Partnership for patients

Venous thrombo-embolism

Different harms are connected!

Why the Emergency department (ED)?

• More than half of the hospitalized patients are admitted from the ED

• Decision to place urinary catheter often made in the ED

• Avoiding unnecessary placement would prevent exposure (complications) during hospitalization, especially for the most vulnerable patients

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Elderly Women: High Risk for Unnecessary Use(Fakih et al, Am J Infect Control 2010;38:683-8)

• Evaluated urinary catheter (UC) placement for all admissions from ED for 12 weeks.

• 532/4521 (11.8%) patients had a UC placed, 69.7% indicated.

• Women ≥80 years: half had a UC placed without indication.

• UC without appropriate indication:1. Women: twice more likely than men2. Very elderly (≥80 years): 3 times more likely than those 50 or

younger

Common Conditions where the Catheter is Placed Inappropriately

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Inappropriate Catheter

Placement

Inappropriate Catheter

Placement

Elderly (especially women)

Elderly (especially women)

IncontinenceIncontinence

DebilityDebility

Use in non-critically ill cardiac and

renal patients

Use in non-critically ill cardiac and

renal patients

Morbid obesity?Morbid obesity?

ImmobilityImmobility

Physician and Nurse Practice

Effect of Establishing Institutional Guidelines in ED(Fakih et al, Acad Emerg Med 2010; 17:337–340)

• Established institutional guidelines for UC placement in ED

• Compared the rate of placement before and after guidelines

• ED physician champion involved• Minimal nursing education/ intervention• Pre- and post-intervention: 3 months baseline,

and 9 months intervention/ sustainability (sampled 5 days per quarter)

Physician Intervention ED (Fakih et al, Acad Emerg Med, 2010; 17:337–340)

• UC utilization dropped significantly after starting the physician intervention from 14.9% pre-intervention to 10.6% post-intervention (p=0.002)

• Physicians ordered fewer UCs post-intervention 4.3% compared to pre-intervention 7.5% (p=0.002)

• Only 47.0% UCs initially placed in the ED had a physician order documented

• Post-intervention: more compliance with indications for catheters placed with physician order, no change for those without

Pilot Work: Ascension and Michigan Hospital Association

• More than 30 EDs involved• Engaged both ED physicians and nurses• Encouraged establishing institutional

guidelines• Looked at change in placement rate and

appropriateness

Indications Based on CDC HICPAC Guidelines (Gould, et. al, Infect Control Hosp Epidemiol 2010; 31: 319-326)

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Pilot work: 18 EDs in Ascension Health

• Results: less catheters placed, in some instances up to 50% drop, average about a third, and increased appropriateness of use

• Physician order documentation for placement increased

• More noticeable improvement in hospitals who started with a higher baseline use

Ascension Pilot of 18 EDs• Reduction in catheter use

by a third!• The results were sustained

for more than 6 months

• Catheter avoidance translates into preventing exposure to the catheter for thousands of patients

How to Improve Appropriate Urinary Catheter (UC) Use in the ED?

• Establish clear guidelines for UC insertion in the ED.

• Engage nurses (significant role in UC use).• Engage physicians (significant role in UC use).

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Nursing Considerations in the Emergency Department

Lisa Wolf, PhD, RN, CEN, FAEN

Problem• The emergency nurse at both the initial patient

encounter and throughout the trajectory of care makes clinical decisions that affect patient safety, efficacy, efficiency and cost-effectiveness of care involving– Problem identification– Acuity assignation– Need for resources– Patient advocacy

Problem

• Clinical decision-making takes place in a social context.

• The attitudes and biases of each participant can affect the decision-making process.

• The overall culture of an emergency department can challenge or enhance good clinical decision-making.

Who is driving patient care in emergency settings?

• Nurses?• Physicians?• Hospitalists?• Intensivists?• Patients?

What’s different about ED nursing?

• Rapidly shifting priorities• Quick turnover of patients• Chaotic environment• Potential for rapid deterioration of

patients• Range of ages/developmental stages• Unclear diagnosis/etiology of symptoms

EDs as a unique setting

• Higher levels of autonomous practice• Nurse-driven environment• Use of protocols/care guidelines• Collaborative practice

The Framework• An integrated, ethically-driven environmental model of

clinical decision-making

• The model is an open environmental model with each element influencing the others.

• Core elements– knowledge base – critical application – moral agency

• Immediate elements – unit leadership– nurse-provider relationship

• Influential elements – institutional leadership– environment of care

An integrated, ethically-driven environmental model of clinical decision-making (Wolf, 2011)

Influential elements

Immediate elements

Core elements

Core elements exert influence on accuracy in problem identification and decision-making.Immediate elements of the practice environment can be influenced by the core elements of leadersInfluential elements will also reflect the core attributes of leaders, managers and administrators in the health care environment.

Elements of the individual

• Knowledge base – what does the provider know?

• Moral reasoning – what drives questioning and assessment?

• Drive to act – able to operationalize moral agency?

What are the elements in the environment?

• Environmental structure– Standards – what is expected of each level of provider?

– Communication – how does information and concern get transmitted between providers?

– Teamwork – are all providers working with the same agenda and goals?

– Autonomy of practice – who is able to make decisions about acuity and resources and under what circumstances?

Fostering excellence in clinical decision-making

• Needs to address all aspects of the model– Individual

• Knowledge and critical application• Moral agency• Drive to act

– Environmental• Context in which decision making occurs and is acted

upon– Unit level– Institutional level

Urinary Catheter Utilization

• About 15 - 25% of patients will have a urinary catheter placed during their hospitalization.

• Many are placed in:

– ICU

– ED

– OR

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Reducing CAUTI

• Avoid use if no indication

• Remove as soon as possible

Why we think putting in a catheter is a good idea – but it’s not

• Facilitates I/O measurement• Keeps patients from having to get up to

urinate, protecting them from injury• Protects skin in the incontinent patient.• Saves time for the bedside nurse.

Indications for catheterization

• Patient is critically ill and will require accurate output measurement

• Urinary retention/obstruction– Bladder scanner or bedside ultrasound first

• Immobilization needed for trauma or surgery• Incontinent with open sacral/perineal wounds• End of life/hospice• Chronic or existing catheter use

– Re-evaluate need and discuss with provider• HCPAC Guidelines

“Not” indications for catheterization

• Substitute for frequent toileting• To obtain a specimen if the patient can

void freely• Patient preference• Dementia• Obesity

Patients at high risk for inappropriate catheterization

• Elderly Women• Incontinent• Obese• Immobile• Non-critically ill cardiac and renal

patients– Monitor does not necessitate catheter

Reducing inappropriate placements reduces

• Infection rates• Cost• Antibiotics use• Length of stay• Morbidity• Patient discomfort

Attributes of the Individual Emergency Nurse

• Knowledge base:– Assessment skills– Indications for placement/non-placement of catheter

• Critical application– Under what circumstances catheter is placed– Autonomy of practice

• Moral agency– Ability to advocate for safe patient care– Promotes beneficence and non-maleficence

Putting systems in place

– Environmental: Context in which decision making occurs and is acted upon

– Unit Leadership• Must set standards of practice• Must maintain ‘sunnum bonum’ for patients• Must promote collaborative clinical decision-making

and care

Nurse-Provider relationships and communication

• Central to decision-making and action• Assess for mutual respect and autonomy

of practice• Institutional level – foster teamwork,

autonomy and control over practice. – Ethical standards drive practice– Interdisciplinary training, governance, practice

committees

Communication with providers

• Clear understanding of indications• Commitment to nonmaleficence (doing

no harm)• Patient focused care

Implications

• Environment:– In settings with problematic decision-making or

change process implementation, the attributes of the practice environment should be examined and managed as well as the skill level of individual nurses who practice in that environment.

• Administrative support• Nurse-physician relationships• Practice culture

The take home

• Clinical decision-making is not a matter of information in, decision out

• Elements that encompass both characteristics of the individual as well as the context in which the individual functions are crucial to fostering excellence in decision-making

The take home

• Commitment at the unit and institutional levels is required to support and facilitate excellence.

• Both physicians and nurses need to model ethically-driven, patient focused, collaborative care

• The environment of care must change to afford behavioral change

ED Physician Champions for CAUTI

Jeremiah D. Schuur MD, MHS, FACEP

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Objectives

• Review ED physicians’ role in urinary catheter placement

• Identify strategies for improving appropriateness

• Review role of physician champion in CAUTI project

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)

ED Workflow and Culture & Urinary Catheter Placement

• ED workflow requires physicians and nurses to work in parallel

• Nurses often assess a patient and consider a catheter before the ordering provider

• Patterns of ED catheter use have developed over time and reflect local practice patterns

• It will take teamwork from physicians, nurses and others to reduce catheter use

Role of ED Physician Champion to Reduce CAUTI

• Promote reduction of catheter use by championing appropriateness

• Encourage interdisciplinary conversation around catheter use

• Engage with other services around patterns of catheter use

Improving Appropriateness

• Review appropriate indications for catheters with medical staff– CDC/HICPIC Guidelines– Pathway

• Implement appropriateness criteria in workflow– Ordering process: Computer physician order entry or

Paper order sets– Pathway

• Give feedback to medical staff on catheter appropriateness

Physician Task 1: Champion Appropriateness

• Have ED physician champion work with nursing to develop / review ED policy addressing appropriate indications for urinary catheter placement1. Start with CDC/HICPAC guideline2. Define both indication and contraindications3. Consider any ED specific modifications4. Have reviewed by infection control Implement

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Physician Task 1: Champion Appropriateness

• Have ED physician champion work with nursing to implement ED policy 1. Require order for placement of catheter2. Require documentation of indication with order3. Include prompts of indications/contraindication

1. Possible in EHR or on paper form

4. Have ED physician speak ED to physician group about CAUTI and policy

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Other indications for urinary catheter:Urinary retention/obstruction?

o Use bladder scanner firstImmobilization needed for trauma or surgery?Incontinent with open sacral/perineal wounds?End of life/hospice?Chronic or existing catheter use?

o Re-evaluate need and discuss with provider

Insert catheter and treat signs of shock:HypotensionDecreased cardiac output/functionDecreased renal functionHypovolemiaHemorrhage

Re-assess after intervention

Do NOT insert

Explore alternatives

Still critically ill, requiring accurate output measurement?

Insert or maintain catheter Remove catheter

prior to admission

Is the patient critically ill and will require accurate output measurement?

Physician Task 2: Address Specific Clinical Patterns

• Have ED physician champion work with nursing and other services to address local patterns of care1. Identify specific clinical conditions where

catheters are used, but can be avoided2. Liaison with Physician leaders from other

services around patterns of care3. Develop context specific improvement plans

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Identify Common Patterns of ED Catheter Use

• Measuring urine output in stable patients– CHF

• Assessing bladder volume– Urinary retention from possible spinal injury

• Protocolized care for trauma

• Incontinence without open sacral or perineal wounds

• Pre-operative placement, outside other indications

• Specific Conditions– Small bowel obstruction

Case Study: Trauma

• Historically most trauma patients received a catheter as part of evaluation & resuscitation– ATLS 8th edition recommends urinary catheters for

assessing hemodynamic status– Often placed by junior trainee

• Identify current practices• Review protocol with ED and Trauma leaders• Set clear criteria for catheter use• Designate appropriate staff to place catheters

– RN not junior resident

Case Study: Congestive Heart Failure

• Many CHF patients get a catheter to monitor urine output

• Identify motivations for pattern of care– Medical necessity? -- Not if able to regularly void & stable– Patient convenience?– Staff convenience?

• Strengthen protocols for tracking urine output• Meet with Cardiology to examine practice

Physician Task 3: Collaboration with Nursing

• Encourage communication at the time of catheter ordering/placement– “Huddle” re: need for catheter– Acknowledge nursing’s deeper knowledge of

patient and ability to care for self

Ongoing Physician Champion Roles

• Share data on catheter use with medical staff– Break out by physician if possible

• Circulate descriptive summaries of any CAUTI cases that are attributed to ED placement

• Communicate with other medical services about specific patterns of care

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.”

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