Cover slide

Reduction in Urinary Catheter Utilization Emory Johns Creek Hospital

Marcia Postal-Ranney, RN, CIC, Infection Prevention Karen Tatoy, RN, Shift Nurse Manager Medical Unit Lynn Talmadge, RN, Charge Nurse, Emergency Department emoryjohnscreek.com

Emory Johns Creek Hospital

 110 Bed Community Hospital in Johns Creek, GA  Opened February 2007  Medical Unit  Surgical Unit  ICU  Women’s Services with level 3 NICU  Cardiac Catheterization lab with PCI emoryjohnscreek.com

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Team Members

Physician Champion – Brenda Friedman, MD Administrative Champion- Hassan Shabbir, MD, Chief Quality Officer 4 Surgical – Roselyn Laxama – Stephanie Liffick 3 Medical – Sayea Vardier – Maila Rallos – Karen Tatoy – Anu Thomas – Muta Okparaocha • • • • • Women’s Services – Melissa Donovan – Lydia Balbuena ICU – – Allison Tomy Donna Dyer Emergency – Lynn Talmadge – Lindsey Meixner Infection Prevention – Marcia Postal-Ranney Newnan Hospital – Dr. Karen Clarke emoryjohnscreek.com

Medical Executive Committee Approval

– – – – Physician champion brought indications for indwelling catheter insertion to MEC Cardiology Chairman approved guidelines for cardiac patients will not require indwelling catheter for accurate I&O outside of the ICU Nephrology Chairman approved guidelines for dialysis patients to not require indwelling catheter for accurate I&O outside of the ICU Alternative methods of daily weights and number of wet sheets per day would suffice emoryjohnscreek.com

Emergency Room Catheter Insertion Indications

Indication for urinary catheter insertion (Why are you inserting this catheter) Check all that apply

           Hemodynamically unstable Precise measurement of urinary output needed in ICU Acute urinary retention or obstruction Stage three or four sacral decubitus in incontinent patient Select surgical procedures- urinary and GYN Prolonged immobilization End of life care- Hospice Epidural/ Lumbar catheter in place Replacement of current indwelling catheter Continuous bladder irrigation Other-Obtain from provider_________________ emoryjohnscreek.com

Posters for Approved Use of Indwelling Catheters

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Daily Review for Necessity

• • • • • • • • • Appropriate Reasons for Indwelling Catheter Hemodynamically unstable- accurate I&O in ICU Obstruction of urinary tract Need to monitor accurate urine output in ICU Preoperative catheterization Urinary tract hemorrhage Palliative care Continuous lumbar epidural anesthesia Incontinent patient with stage III or IV decubitus Chronic Foley catheter prior to admission • • • • • • Inappropriate Reasons for Indwelling Catheter Nursing convenience Not checking daily to see if catheter can be discontinued Urinary incontinence with no skin breakdown No clear reason for placement of catheter Intermittent catheterization is possible Patient request emoryjohnscreek.com

Patient Brochure

Laminated card in the patient room explaining the EJCH philosophy for not using an indwelling catheter emoryjohnscreek.com

Nurse Attitude

• • • • Nurses want to make sure that the patient does not get a CAUTI Importance of a faster recovery to get the patient up to bedside commode or toilet Purple pad helps by absorbing one liter of fluid without patient feeling wet. Pads improve ease of changing the bed SIBR rounds requires nurse to pick a designated indication to keep the indwelling catheter in place emoryjohnscreek.com

6,00 4,00 2,00 0,00 CAUTI Slide 14,00 12,00 10,00 8,00

Catheter Associated Urinary Tract Infection (CAUTI)

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Urinary Catheter Utilization

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Catheter Removal Diagram No Continue to assess Nurse-Driven Indwelling Urinary Catheter Removal Algorithm Daily assessment: Does the patient have at least one indication for an indwelling urinary catheter?

No Remove indwelling urinary catheter, utilizing alternatives if needed (see list) Symptoms of urinary retention? (see list) Yes Bladder scan Yes Continue indwelling urinary catheter. Assess indications daily.

• • • Indwelling Urinary Catheter Alternatives External catheters Toileting schedule Bladder scan • Intermittent catheterization • • • • Symptoms of Urinary Retention Urinary pain, fullness, or distention Change in voiding pattern Failure to void in past 6 hours in spite of adequate hydration Frequent voiding with volumes <100 ml < 300 ml, wait 2 hours and re-scan >300 ml residual, begin intermittent catheterization Q 6 hours Continue to assess for symptoms of retention LR 12-13 Notify provider after intermittent catheterizations x 3, continue to assess for symptoms of retention

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Ultimate Outcome- culture change

Each adult unit is seeing a reduction in catheter utilization Indwelling catheters are not placed immediately in the Emergency Room for every admitted patient Staff convenience is no longer a reason for a catheter Attitudes changed and staff felt truly concerned when a CAUTI occurred Culture was changed to see this and other aspects of preventable harm as a patient safety issue Each employee felt committed to personal responsibility for prevention of hospital acquired conditions . “ Many infections are inevitable; some might be preventable” “Each infection is potentially preventable, unless proven otherwise ” emoryjohnscreek.com