Quality Improvement Updates Foley Discontinuation Protocol Surgical Care Improvement Project

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1 Quality Improvement Updates Foley Discontinuation Protocol Surgical Care Improvement Project Barbara J Martin, RN, MBA Quality Consultant, Center for Clinical Improvement

2 Indwelling Urinary Catheters Insertion, Care and Maintenance, and Discontinuation Urinary Tract Infection Reduction Task Force Roger Dmochowski, MD Chair

3 Insertion Policy Key Points Urinary Catheters require an order Clinical Indications for indwelling catheter: Urinary retention not relieved with intermittent catheterization Current regional / epidural anesthesia Terminal illness receiving comfort care or withdrawal of care Stage 3 or greater pressure ulcers Critical illness AND a need for accurate monitoring of urinary output

4 Care and Management Key Points Assess patient especially for continued need q 12 hr; w/ caregiver change; or per unit standard Perform perineal meatal care with soap & least q 12 hr; after BM; & PRN Anchor foley & maintain unobstructed urine flow Use strict aseptic technique when opening or accessing (for specimen) drainage system Maintain drainage system above floor and below patient bladder at all times including transport.

5 Discontinuation Protocol Purpose and Policy Implementation Date September 15 Reduction in catheter-associated associated complications, including infections from indwelling urinary catheters Patients with indwelling urinary catheters are assessed for continued need and catheters are discontinued when clinical indications are no longer present

6 Discontinuation Protocol An order is required for indwelling urinary catheterization When an indwelling urinary catheter is ordered, the provider may order the discontinuation protocol. If the discontinuation protocol is not used, a specific order is required for to remove the catheter.

7 FOLEY-REMOVE DATE/TIME: FOLEY-REMOVE PER PROTOCOL FOLEY-REMOVE BY PROVIDER ORDER New foley orderables Typing foley, urinary, catheter, & similar search words will bring up list of indwelling urinary catheter options in the upper right window foley

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9 Discontinuation Protocol Patients are assessed by an RN for clinical indications for continued use of the indwelling urinary catheter: Upon admission Every shift or with change in caregiver Change in level of care

10 Discontinuation Protocol After the catheter is d/c d, d, the patient is assessed at intervals to determine ability to void, to empty the bladder, and to maintain continence If the patient is unable to void within six hours after the catheter is removed, the nurse may obtain an order for straight catheterization If the patient is incontinent, the nurse takes measures to assist with strategies to improve urinary control.

11 Discontinuation Key Points Consider whether catheter is necessary prior to insertion Default order is by provider order Ordering the protocol allows nursing staff to assess need for catheter, and remove when need is no longer present May order discontinuation at a specific point in time (e.g., 0600)

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13 Objectives Review measures included in SCIP data submission. Identify mechanisms for process review and improvement relative to perioperative care. Describe internal monitoring for maintaining and improving compliance with surgical care metrics.

14 Core Measures: SCIP Core measures are required by the Joint Commission and based on CMS regulatory requirements SIP (Surgical Infection Prevention) measures began in 2004 with antibiotic administration metrics Changed to SCIP in 2006 with addition VTE and cardiac measures

15 SCIP Procedures ICD-9 9 Principal Procedure Code Coronary Artery Bypass Other Cardiac Surgery Colorectal Surgery Hysterectomy Total Hip Arthroplasty Total Knee Arthroplasty Vascular Surgery Major Surgery

16 Inclusion / Exclusion Case / metric exclusion based on clinical and administrative factors Infection prior to induction of anesthesia Chronic anticoagulation Procedure specific metrics Cardiac surgery: postop glycemic control Colectomies: Postoperative normothermia

17 SCIP Metrics SCIP 1: Prophylactic antibiotic administered within 1 hour prior to incision (2 hours for vancomycin or fluoroquinolone antibiotics) SCIP 2: Appropriate prophylactic antibiotic selection SCIP 3: Discontinuation of prophylactic antibiotics within 24 / 48 hours after surgery end time SCIP 4: Cardiac surgery patients with controlled 6 A.M. postoperative serum glucose

18 SCIP Metrics SCIP-6: Appropriate hair removal SCIP-7: Colorectal surgery patients with immediate postoperative normothermia SCIP-VTE VTE-1 1 and 2: Patients with recommended venous thromboembolism prophylaxis ordered and received SCIP-CARD CARD-2: Patients on beta blocker therapy prior to admission who receive a beta blocker during the perioperative period

19 Abstraction Methodology Weekly case sampling by discharge date (80 cases per month) Abstraction from electronic and paper medical record Monthly reports sent to administrators, chairs, and chiefs for review Patient data reviewed by clinicians before submission to CMS Charts selected by CMS quarterly for validation

20 A Note about Abstraction Abstraction is validated internally as well as externally Information must be part of the patient s permanent medical record Conflicting documentation is abstracted as unable to determine Must abstract based on most reasonable interpretation No appeal process for individual cases

21 SCIP Inf-1 1 and 2 Antibiotic Administration Patients with documented infection are excluded Must be started within 60 minutes of incision (120 for vancomycin, fluoroquinolones) Administered in OR by anesthesia ( vanc /quinolones which are given in holding) Verify infusion is started prior to incision Vancomycin usually requires justification MRSA colonization Beta-lactam allergy x

22 Other Considerations: Preop ABX Patients on antibiotic therapy Appropriate coverage provided? Redosing indicated? Is indication documented prior to surgery? Appropriate weight-based dosing Redosing prior to incision when prophylaxis is given in the ED

23 Specifications Manual for National Hospital Quality Measures Discharges (3Q09) through (2Q10) SCIP Inf SCIP Inf-2 Antibiotic Selection Antibiotic Selection

24 SCIP Inf-3 3 Antibiotic Discontinuation Cardiac Surgery Patients: Five doses for antibiotics given every 8 hours; OR Three doses for antibiotics given every 12 hours; OR Seven doses for antibiotics given every 6 hours. All Other Surgery Patients: Two doses for antibiotics given every 8 hours; OR One dose for antibiotics given every 12 hours; OR Three doses for antibiotics given every 6 hours.

25 Antibiotic Discontinuation No indication for prophylaxis beyond 24 hours Therapeutic antibiosis must be justified Document known or suspected infection Signs, symptoms and interventions will not meet CMS requirements If consulting service extends antibiotics, reason must be documented

26 Hair removal If hair removal required, clippers or depilatory must be used All cases evaluated Compliance for FY 2008: 100% All razors removed from OR Abstracted from OR Nursing Record

27 Postoperative Normothermia Currently colorectal surgery only Within 15 minutes of leaving the OR 36 C Route not specified If no temp documented within 15 minutes, measure fails

28 VTE Prophylaxis Mechanical and Pharmacologic Procedure-specific Cardiac and vascular excluded Procedure dictates required prophylaxis Heparin / enoxaparin/ warfarin (requires order to be abstracted) SCDs / TEDs Order within 48 hours, start within 24 hours Preop administration meets criteria

29 Perioperative Beta Blockade All cases evaluated Patients on beta blockers prior to surgery must have administration of a beta blocker documented within 24 hours before surgery through discharge from PACU, or within six hours after surgery if not in PACU postoperatively

30 Beta Blocker Documentation Patients admitted day of surgery Document BB taken at home on the day of surgery. If taken the night before, requires time taken Contraindications must be specifically documented Bradycardia (HR < 50) is a contrainidcation

31 SCIP Performance FY 2009 Indicator FY O9 SCIP Inf 1: Abx within 1 hour before incision 96.9% SCIP Inf 2 Appropriate proph abx 98.5% SCIP Inf 3 Proph abx d/c within 24 / 48 hours 96.1 % SCIP Inf 4 Controlled glucose: Cardiac surgery 90.2% SCIP Inf 6 Hair removal 100% SCIP Inf 7 Postop Normothermia: Colorectal surgery 75.4% SCIP Card 2 Perioperative beta blockade 81.5% SCIP VTE 1: VTE ppx ordered 99.0% SCIP VTE 2: VTE ppx received 98.0% SCIP Perfect Care 88.4%

32 New SCIP Measures: Oct 2009 SCIP Inf 9: Urinary Catheter Removed on POD 1 or POD 2 Exclusions Urologic, gynecologic, and perineal procedures Infection prior to surgery ICU and on diuretics Documentation of continued need for catheter

33 New SCIP Measures: Oct 2009 SCIP Inf 10: Surgery Patients with Perioperative Temperature Measurement Documentation of active warming intraoperatively, or documentation of at least one temperature > 36 C within the last 30 minutes prior to or the 15 minutes immediately after Anesthesia End Time.

34 Public Reporting

35 Outpatient Surgery Measures OP 6 Antibiotic Timing OP 7 Antibiotic Selection Included Procedures Cardiac (PPM / AICDs) Orthopedic/Podiatry Genitourinary Gastric / Biliary Head and neck Neurological Gynecological Vascular

36 External Metrics: Internal Review

37 Maintaining Compliance Reminders Electronic forcing functions Redose reminders Concurrent reporting VPIMS SCIP reports M & M Review of failures Service chief follow-up of successes / failures Surgical services Anesthesiology

38 Opportunities Antibiotic administration Inpatient antibiotic redosing / timing / selection Emergency Department > OR antibiotic timing Holding room to incision timing for administration Glucose control Evaluate protocol compliance Monitor patient variables affecting hyperglycemia timing Beta blockade Preoperative instruction Documentation mechanisms in VPIMS Normothermia Evaluate system and process issues r/t equipment and documentation

39 Future SCIP Measures? Expanded beta blockade requirement Intraoperative antibiotic redosing Surgical site infection rate Postoperative VTE Rate

40 Beyond SCIP Wash your hands Control the environment Monitor and enforce infection prevention practices Address breaches yourself, or have them addressed Be constantly vigilant Every Patient, Every Time

41 SCIP Improvement Initiatives R. Daniel Beauchamp, MD, FACS Chair, Section of Surgical Sciences Michael S. Higgins, MD, MPH Chair, Department of Anesthesiology Nancye Feistritzer, MSN, RN Associate Hospital Director Stephanie Randa, RN, MHA Administrative Director, Operative Services Susie Leming-Lee, Lee, MSN, RN, CPHQ Director, Perioperative Quality Management Thomas R. Talbot, III, MD, MPH Chief Hospital Epidemiologist