The Foley Break Up - We are never getting back together! Cheryl Ruble, MS, RN, CNS Improvement Advisor, Cynosure Health Nebraska CAREs July 29, 2014

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1 The Foley Break Up - We are never getting back together! Cheryl Ruble, MS, RN, CNS Improvement Advisor, Cynosure Health Nebraska CAREs July 29, 2014

2 The break up Foley

3 CAUTI MDROs VTE PU Immobility Urinary Catheter Harm LOS Pt dignity Falls Trauma Saint S, Ann Intern Med 2002;137

4 CAUTI State of the State

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6 Background 50% 5%

7 How do we do this? Keep it simple.. Make sure catheter is really needed Use correct insertion technique Care for catheter properly Remove catheters soon as possible 7

8 Foley CAUTI

9 Where are your Gaps?

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11 Where does the data lead you? How many catheters are placed in the ED, other units? Do they meet criteria for placement? Why are they being placed? Patients with catheters, are they appropriate?

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14 Foley Catheters are not indicated for: ᴓ Incontinence ᴓ Immobility ᴓ Obtaining urine specimens ᴓ Close monitoring of outputs outside ICU ᴓ Patient request/convenience ᴓ Nurse convenience

15 Ensure aseptic technique is used Hand hygiene Soap and water perineal care prior to insertion Appropriate sized catheter Tip 4 hands, 4 eyes

16 Assure appropriate care and maintenance Maintain a closed system Perineal hygiene routinely with soap and water Maintain flow no kinks, bag lower than bladder, regular emptying Use securement device Do not change indwelling catheters routinely

17 Include Everyone Nursing, Physicians, Nurse Aides, PT, OT, Transport, Central Supply

18 Staff Perception Error on the side of caution I know we have an order to remove on POD 1 but what if the patient still really needs it? Incontinence They can t get out of bed But they are an ICU patient!

19 Focus on Nursing Nurses are at the bedside 24/7 It is usually a nurse that places the Foley Most patients with Foleys do not have an order Two Steps: Focus on getting the Foleys out Focus on not putting them in

20 Unit Strategies Foundation Education on risks, appropriateness, and alternatives Annual aseptic insertion competency Adopted insertion and removal criteria Packaged indwelling catheter w/ urometer

21 Unit Strategies Nurse & MD champion Talk to staff? Barriers to aseptic insertion skill or knowledge gap, supplies, etc.? Appropriate indications for indwelling catheters? How to remove barriers? What would help them make it easy to do the right thing, i.e. straight cath supplies located in each patient bay/room

22 Incorporate daily review of catheter necessity Incorporate into daily workflow such a charge nurse rounds Use automated reports from EMR 7 days a week Sustainability

23 Incorporated into existing workflow Prevention Bundle for Rapid Rounds Sepsis Screen completed (first two hours of the shift)? Central Line present? Dressing current? Tubing current? IV fluid current? Line Necessity reviewed? DVT prophylaxis in place? Medication or mechanical okay If mechanical are they on? Ambulation If not, is a PT referral needed? Foley cath present? Does it meet appropriate indication? If not obtain order for removal Mobility progressing, need PT? Fall prevention HAPU prevention

24 Indwelling urinary catheter alternatives: Bedside commode, urinal, or continence pads (moisture wicking) Bladder scanner to assess & confirm urinary retention prior to placing Straight catheter for one-time, intermittent, or chronic voiding needs External condom catheter Scheduled toileting Purposeful rounding

25 Nurse Driven Protocols: Avenue to success!

26 Michigan Hospital Association HEN: What is affecting our network s performance? What are the most significant characteristics that are driving CAUTI performance: For the 30 hospitals showing improvement: addressing decreased use of urinary catheters through nurse driven protocols and reminders. For the 27 hospitals showing no change or falling: Looking to CAUTI as a data collection exercise and lack of empowerment of staff. 26

27 The Evidence 50% Catheter Use 70% CAUTI Rate Parry, Grant & Sestovic Protocol was linked to the physicians catheter insertion order Physician documentation of catheter insertion criteria Bi-weekly unit specific feedback on catheter use rate and CAUTI rates in a multidisciplinary forum Parry M, Grant B, Sestovic M. Successful reduction in catheterassociated urinary tract infections: Focus on nurse-directed catheter removal. Amer J Inf Control. 41(12)

28 CUSP CAUTI Example

29 ED Staff Perception of Catheter Placement Patient immobile Urine specimen Will make care easier for floor Patient incontinence

30 Foundation Education on risks, appropriateness, and alternatives straight cath is okay! Annual aseptic insertion competency Staff and Physician partnering Adopted insertion criteria Straight cath in ED room, indwelling in Pxysis ED Strategies

31 Foundation Education on risks, appropriateness, and alternatives straight cath is okay! Annual aseptic insertion competency Staff and Physician partnering Adopted insertion criteria OR case time Surgery Strategies

32 Myth: All ICU Patients Need a Foley

33 Myth: All ICU Patients Need a Foley

34 Unit Strategies Nurse & MD champion Talk to staff? Appropriate indications for indwelling catheters? How to remove barriers Culture eats strategy for breakfast!

35 Incorporate daily review of catheter necessity Incorporate into daily workflow such a charge nurse rounds Use automated reports from EMR 7 days a week Sustainability

36 Engage patients and families Pre op teaching Use teach back Review plan at bedside change of shift huddles White board Include family

37 Make your CAUTI Data Transparent Post results Days Since 143

38 Did you contribute to my infection?

39 Integrity. Leadership. Service. Teamwork. Value. One team, One purpose. Above: East Campus; Below: West Campus Bryan Health Lincoln Nebraska 2 South Nursing Staff 39

40 About Bryan Health Bryan Health 672 beds 2 campuses 4,000+ employees Not for Profit Services provided include: Trauma, Neuroscience, Mental Health, Cardiology, Orthopedics, Oncology, Women s Health and Bariatrics. About our Unit-W2S-ICU Trauma ICU unit Neuro Sepsis Respiratory All ICU and pediatric admits for West Campus

41 CAUTI reduced by 44.3% 41

42 Pearls Leadership identified CAUTI as one of the primary Quality areas of focus Engagement of nursing staff Unit specific reports for CAUTI Monthly catheter usage report by unit Case reviews of CAUTI events Daily log review to evaluate necessity of catheter use Nurse driven adult urinary catheter removal protocol Assessments of current culture Catheter maintenance Catheter insertion Urinary specimen collection 42

43 Pearls LEAN projects to address CAUTI risk factors Catheter securement Bag below bladder Lab urinary specimen collection Education Difficult catheter algorithm developed CAUTI Corner debunking myths and sacred cows Live product training Creating Foley catheter super-users on nursing units Training for improved urine collection system Implemented automated Clinical Decision Support functionality to monitor for Foley duration 43

44 Culture and the little things to make a big difference Concentration on transfers and off unit Myth Busters Back to the Basics Integrated into MDR and report sheet Thorough mandatory chart review of CAUTI Foley Audits Results: 12 CAUTI s in CAUTI in CAUTI to date for

45 Providing an exceptional healthcare experience for every patient, every time Jefferson Community Health Fairbury, Nebraska Safety Team: Chad Jurgens, CEO; Erin Starr, CQO; Judy McGee, CNO; Nursing Council & Staff; Jill Duis, Infection Preventionist; Care Transitions Team; Deanna Lierman, Clinical IT Specialist; Ermel Heuer, Surgical Manager 45

46 About Jefferson Community Health Critical Access Hospital: 25 beds Average census: variable 39 bed attached long term care facility Jointly owned attached assisted living facility Services Provided: Medical-surgical unit Obstetrical unit Swingbed/rehab services Surgical services Outpatient/specialty clinic services Physical/occupational/speech therapy Ancillary services 46

47 Keeping CAUTI at Zero 47

48 Your care. Our inspiration. No Patient Will Be Harmed Mary Lanning Healthcare Hastings, Nebraska 48

49 About Mary Lanning Healthcare Mary Lanning Healthcare is located in the center of Hastings, NE. The facility is licensed for 133 inpatient beds. MLH has a: 7 county home health agency, 7 clinics, Psychiatric unit, Sub-acute unit, inpatient dialysis unit, and an Inpatient rehabilitation unit MLH participates in On the Cusp 49

50 Keeping CAUTI at Zero 50

51 Pearls for CAUTI Empowerment Involvement of front line staff drove process change. Data Drove identification of problem areas and positive outcomes. Clarification Processes with rationales support compliance. Collaboration Promoting safety and making the Physician s job easier drove positive outcomes. Communication Meeting twice a day to discuss who has Foleys and why drives earlier removal. 51

52 Culture and Sustainability Speak up for patient safety Team discussions on rationales for Foley Physicians prefer nurses monitor need for Foleys Don t place if possible Remove within 48 hours Annual competency Annual education Communication Nursing driven TEAM 52

53 Pearls for CAUTI The original CUSP information Competitive WTF Educate Update EHR Make it visible (tools, personnel) 53

54 Development of a Nursing Protocol Researched Tweaked Physician approval Educated Attached Listed in EHR 54

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58 INDICATION: Insertion of Urinary Catheter Date catheter inserted: Surgery Date: EXCLUSION: Patients with long- term urinary catheter Date long-term cath inserted: Reason for long-term catheter: 1. Discontinue urinary catheter within 1-2 days following insertion or on post-op day 1 or post-op day 2 following surgery unless patient meets one of the following criteria: a. Need for frequent, accurate measurements of urinary output in critically ill patients b. Hemodynamic instability c. Neuromuscular blockade d. Continuous sedation (patient unable to identify toileting needs) e. Deoxygenation with exertion or position changes f. Relief of urinary tract obstruction/urinary retention or patient has a suprapubic catheter g. Had a urologic, gynecologic or pelvic surgery h. Has epidural catheter i. Has a sacral or perineal pressure ulcer/wound needing catheter to manage incontinence to promote healing j. Catheter placed for comfort in end-of-life patient 2. If patient meets one of the above criteria, maintain urinary catheter and discuss with physician daily on rounds if urinary catheter is still necessary. Post Urinary Catheter Removal Care Document time of removal and amount of urine in bag in the nursing record Encourage oral fluid intake (unless contraindicated) Scheduled toileting Q 2-3 hours to provide opportunity to spontaneously void; out of bed or bedside commode if possible Goal is not to exceed bladder volume > 500ml If patient spontaneously voids >250ml within 6 hours, continue to measure urinary output X 24 hours. If no void or voids < 250 ml within 6 hours: Perform bladder scan Q 6 hours & PRN until spontaneous voiding resumes. If bladder volume >350ml, allow patient to void. If no void or voids but bladder scan >350ml then perform straight cath. If bladder volume <350 ml rescan in 2 hours if patient has not voided, straight cath if volume >350 ml. If straight cath is required X 2, call physician for further orders If bladder volume <250ml and patient voiding, continue to monitor I&O until otherwise ordered. If patient has not voided in 8 hours and has bladder volume < 250 ml, call the physician for further orders. 58

59 They are Everywhere! 59

60 May your days start slowing Your sails always be blowing And your catheters flowing! THANK YOU! 60

61 Table Exercise

62 Table Exercise Do you have a CAUTI Improvement Opportunity? Complete a Gap analysis on your CAUTI program using the Top 10 Checklist Where are your opportunities? Identify what you can do by next Tuesday, in two weeks and in 1 month to move this forward. Outline your sustainability plan Introduce yourself to someone you don t know and share your plan

63 Foley

64 We are never getting back Baptist Health Video together!

65 Resources at CAUTI Top 10 Checklist 65

66 Resources at 66

67 Resources: guideline2009final.pdf s.itcs.umich.edu.drupal.bladder%20bundle/fil es/_ed%20urinary%20catheter%202012% pdf.pdf

68 Engage the ED and Surgery Insertion Criteria Insertion Technique Track # of catheters inserted in ED / ED visits Track # of catheters inserted peri-operatively

69 Adopt insertion criteria HICPAC Guidelines Acute urinary retention or obstruction Accurate measurement of urinary output in critically ill patients Perioperatively for select surgeries To assist healing of perineal or sacral wounds in incontinent patients Hospice/ palliative care Required immobilization for trauma or surgery Not in HICPAC, but considered acceptable indication: Chronic indwelling urinary catheter on admission

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71 Does Patient Meet Any Criteria to Justify Continuing Foley? No Removal Algorithm Yes Urinary Catheter (Foley) in Place? Yes Continue to Assess Daily Criteria for Continuing Foley Catheter 1Recent urologic surgery, bladder injury, pelvic surgery (i.e. GYN, Colorectal) 2Epidural catheter still in place 3Physician order to maintain catheter 4Known or suspected urinary tract obstruction 5Neurogenic bladder dysfunction 6Urinary incontinence in a patient with Stage III or IV pressure ulcers on the trunk, perineal wounds, necrotizing infections. 7Need for accurate measurement of urinary output in a critically ill patient. 8Gross hematuria in patients with potential clots (for irrigation) 9Post surgical procedures, within 24 hours 1Palliative care for terminally ill Criteria for Removal by RN/LVN 1Patient is awake, alert, oriented, verbally express no trouble voiding before the catheter was placed 2Patient is able to resume their voiding position 3Order for strict I&O discontinued or the patient is able to cooperate with strict I&O monitoring 4If a Foley is present post procedure, confer with physician to remove Foley unless there is a clear reason for not discontinuing the Foley 5Epidural catheter is removed 6A physician order is required for discontinuing Foley for patients who have had recent urologic surgery, bladder injury, pelvic surgery (i.e. GYN, colorectal surgery) and/or recent surgery involving structures contiguous with the bladder or urinary tract. 7Document Indwelling Catheter Discontinued per Protocol DC Foley before 10AM if possible Assess Patient post Foley removal Assessment Post-catheter (Foley) Removal 1Patient is spontaneously voiding 2Patient is not voiding however is comfortable and expresses no desire to void (do not do bladder scan) 3A bladder scan should be done for any of the following: apatient is uncomfortable at anytime whether voiding or not bpatient has an urge to void but is unable to do so cpatient is incontinent at anytime 4If the patient is uncomfortable or has the urge to void and if the bladder scan post void residual is > 400cc, the RN will initiate straight catheterization every 6 hours and keep record of volume output with each catheterization and each void. Yes Remove Foley No Action Needed No

72 Patient Education Safecarecampaign.org

73 References Saint S, Olmsted RN, Fakin MG<. et al. Translating health care-associated urinary tract infection research into proactice via the bladder bundle. Jt Comm J Qual Patient Saf 2009 Sep;35(9): Fakin MGT, Watson SR, Greene MT, et al. Reducing inappropriate urinary catheter use: a statewide effort. Arch Intern Med 2012 Feb 13;172(3): Gould C, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, & the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter associated urinary tract infects Department of Health & Human Services, Centers for Disease Control, and HICPAC publication. Lo E, Nicolle L, Classen D, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol 2008; 29:S41-S50. Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, et al. epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2007; 65S,S1- S54. Guide to the elimination of catheter-associated urinary tract infections (CAUTIs): Developing and applying facility-based prevention interventions in acute and long-term care settings. APIC 2008.

74 Contact Information Cheryl Ruble, RN, MS, CNS Improvement Advisor Cynosure Health