Building a Team and Process to Reduce CAUTI Risk (April 8, 2015)

American Hospital Association - Chicago
April 8, 2014
Onboarding Webinar 1 Call
1:00 PM CT

Operator: The following is a recording for the Onboarding Webinar I call under Conference Leader, Paul Tedrick, with the American Hospital Association - Chicago, on Tuesday, April 8, 2014 at 1:00PM Central Time.

Ashley Hoffman: Good afternoon, everyone, and welcome to the first Onboarding Webinar for Cohort 8 of On the CUSP: Stop CAUTI. We're so excited that you've joined us on today's call, which is going to focus on the process of building your unit team. My name is Ashley Hoffman and I'm a Research Specialist here at the Health Research and Educational Trust and I support the Stop CAUTI project. Real quick, before we begin today's call, just a reminder, this is a webinar, so be sure to log in to the webinar link to see the slides today. If you don't have that webinar link, you can download the slides from the project website and follow along with us. The website is onthecuspstophai.org. You can click the green bar in the middle that says, "Stop CAUTI;" note the address down that appears, and then click "educational session," then "Onboarding Calls." Today's presenters are Dr. Mohamed Fakih and Dr. Barbara Lucas. Dr. Fakih is a Professor of Medicine at Wayne State University School of Medicine in Detroit. He is board certified in internal medicine, infectious diseases, and quality with specialty in patient safety. He is also the Hospital Epidemiologist and Medical Director of Infectious Prevention and Control at St. John Hospital and Medical Center in Detroit. Dr. Fakih serves as the National Infectious Diseases Physician Leader for Ascension Health, a system comprised of more than 100 hospitals.

I'm also pleased to welcome Dr. Barbara Lucas, a pediatrician with over 20 years experience in hospital and health care system administration. She has served as a consultant to the Michigan Hospitals Keystone Center on both the national CLABSI and CAUTI collaborative, as well as initiatives on patient safety, health literacy, and patient and family engagement. And without further ado, it is my pleasure to introduce Dr. Lucas to the call today.

Barbara Lucas: Thank you, Ashley. If you could go ahead and advance the slides for me. I'd like to welcome all of you to our call. We're really happy that you are able to join us today to get an introduction to this collaborative, and we wanted to start out by working on helping you understand how do you build a successful team, and importantly, why are we doing this work? As many of you know, there are two goals for the CAUTI collaborative. First, to improve the culture of safety on your unit, using the model of the comprehensive unit-based safety program; also known as CUSP. And secondly, to reduce your individual unit's CAUTI rate by 25 percent over the course of the collaborative. And both of these goals require strong commitment at both the unit level and at your organizational leadership level, and we'll be talking through how you can achieve that commitment through building a successful team.

Next slide, please. First, it's important for you to be convinced that this team needs to be multi-disciplinary. Now, why do we say that? From our experience working with other states that have preceded you in this work, we found that there are so many roles in this project that it's too great a burden for one individual person who may then be perceived as the unit's quality police. And we definitely don't want your team leader to be perceived in that role. We also have found that for teams that are unable to get a multidisciplinary group together and essentially tell us, "We are a team of one and I'm that person," it becomes too great a risk for burn-out for that individual person to try to carry this work alone. So, what we're asking you to do as you begin this collaborative with us is to pull together a group of individuals that are all committed to work on this together with you. And the required people that we're looking for you to recruit are a team leader, a champion from nursing, a champion from your medical staff, an executive partner, frontline nurses from your floor, and an infection preventionist. Now, many of the teams that we work with also include case managers, discharge planners, and other people in different roles, but at a minimum, those bulleted roles that you see on this slide are the ones that we feel are crucial for you to have success as a unit team.

Next slide. We're going to now walk through each of these individuals and give you some sense of who you're looking for to fill these roles, what we expect them to do, and what these specific paths will be for each of these individuals. So, if we start first of all with the team leader for your CAUTI project, this person should be in an opinion leader on your floor who's already shown to everybody else on your floor that they are committed to patient safety. They should be a team player that has the respect of other people and also empowered by leadership. They also need to have strong organizational, management, and communication skills to fulfill the roles that we're asking of them. And what are those roles? First of all, your team leader will need to recruit the team members and help them understand what their part is in the project. They have to be able to understand and clearly articulate the two project goals that we talked about. Again, improving your unit culture safety and reducing the CAUTI's through the technical work of the project on your unit. They have to be willing to delegate paths and hold other people accountable and lead your team meetings, which we're hoping you will hold at least once a month, and participate in the other collaborative activities to meet the project requirements. And finally, this team leader will be the person that we hold accountable to track the project progress on your floor.

Next slide. So, the specific tasks that this person will be called on to do are, first, to explain the project to unit staff in the management team. In terms of the technical work of reducing the infections on your floor, this person will be responsible to ensure that the staff are educated about CAUTI's and the appropriate indications for catheter use. They also will be responsible to facilitate the development of a process on your floor to review every day the appropriateness of catheter use for those patients on your floor that have a catheter. In terms of the culture work, they will be responsible to implement the CUSP model by ensuring that the staff is educated about patient safety and knows how to use the tools that are in the CUSP model to improve teamwork and patient safety. And you will be hearing more about those CUSP tools on future Onboarding calls.

Next slide. The specific tasks also include: Data management, and this includes being familiar with the data collection schedule that we're asking you to cooperate with, to ensure that there is timely collection and submission of the data for a number of elements, including your teams readiness assessment and the hospital survey on patient safety at the beginning of the project, the ongoing outcome and process data collection and submission throughout the 18 months of the project, and the team check-up tool that you will hear about on the data call that we will have scheduled for you shortly. In terms of sustainability as the project moves forward, this person will be accountable to support the integration of the CUSP and CAUTI project initiative into your daily workflow and unit operations, so that this project doesn't end when the collaborative ends, but instead changes the way you do work on your floor to make care safer for your patients.

Next slide. In addition to the team lead, we need a nurse champion, and this person will be responsible for facilitating the education of other nurses on your floor. This includes developing and sharing expertise in the technical skills to reduce CAUTI in regard to insertion and maintenance of catheters, for example, the adaptive work of the CUSP model to improve teamwork and patient safety on the unit. And they will be accountable to promote the goals and interventions of the project, not only on your unit, but within the larger organization. Finally, this person will serve as a role model for nurse empowerment, because nurses are absolutely crucial to the success of this CAUTI work.

Next slide. So, who are we looking for in the nurse champion that you choose? Again, this person needs to be very strong in their organizational, management, and communication skills. They should be known to have a strong commitment to patient safety. They should be respected by their peers and advocate on behalf of nurses and have excellent rapport with the medical staff. Preferably, this champion should come from your floor. It could be your nurse manager, a charge nurse, a nurse educator, or a frontline nurse. Now, some of the units that we've worked with in the past have used instead a nurse from the organization at large. For example, a quality improvement professional or infection prevention professional, or sometimes their chief nursing officer, but it's much more preferred on our end that this person be someone from your unit who intimately knows the culture on your floor, who knows the doctors who admit to your floor, and who's respected by the nurses that are doing the patient care on your floor.

Next slide. So, what are the tasks that we'll then expect from the physician champion? This person, similar to what we've asked from the nursing champion, will be responsible for the education of the medical staff about the appropriate indications for urinary catheter use. They will serve as the liaison to promote the goals and interventions of the project to the doctors on your floor who admit to your floor and who will be managing the catheters on your floor as well as to the general hospital medical staff. And they will be actively working with your team and other physicians to develop and implement strategies as you identify barriers to this work. As you begin to round for the appropriateness of catheters, you will find that there are certain physicians or certain physician departments or teams that are more resistant to proper removal of catheters, and this physician champion can be your advocate to interface with those physicians and help explain to them the work of the project, the HICPAC indicators, and why this work is so important to improve safety for the patients that you're all caring for.

Next slide. So, the person that you choose for this role, again, need to have strong communication and quality improvement skills. They should be empowered by leadership and, most importantly, respected by their medical staff peers and the nursing staff as well. They should demonstrate a spirit of congeniality to all the members on your tea. And the possible choices you could consider could be an urologist, an infectious disease specialist, a hospitalist. You may have a quality or patient safety officer that you think is appropriate or any physician that you work with that is interested in improving safety and quality.

Next slide. In terms of your executive partner, we will expect from them that they advocate for the project goals and the teams with other senior leadership as well as your governing body or your board for your hospital. They should be meeting regularly with your team to review your data and your progress and assist the team with prioritizing any safety defects that get recognized in the course of your work. This is the person that you will be asking to do executive rounds with you on your unit as part of the CUSP work for the project. So, you will be expected to be spending time with this person, at least monthly, not only to round on your floor but also to review your data and your progress in this work. This person also will be very important to your team in terms of helping to remove barriers that you may run across in the course of your work. That could be staffing issues; it could be equipment issues, such as having sufficient bedside commodes for your unit, and they can be a great advocate for your team as long as they understand that importance of the work and they have bought in to this collaboration that you've chosen to do. And finally, your executive partner will be a great person to share your project's progress with other senior leadership and your board.

Next slide. The ideal characteristics for this executive partner are that they have strong communication skills and that they're approachable and willing to commit time to this project. They should already have demonstrated to you and to the hospital at large that they are committed to patient safety and quality improvement and that they have the respect of their peers and others with commitment to safety. So, potential candidates could include your chief medical officer, your chief nursing officer, or your chief quality or patient safety officer.

Next slide. Finally, we want to talk about engaging frontline nurses as part of your team. We would expect those nurses to be responsible for inspiring the commitment of other nurses on the unit to the goals of this project, both the culture work and the \technical work with the catheters to reduce CAUTI's. They will be the ones that help to educate their peers formally in presentations as well as buy their example. They also will be the ones that will help your team to identify practical ways to ensure that catheters are inserted properly and maintained properly. They will be the ones that talk through what's the best way that we can daily assess catheter necessity, and they can help you define that rounding process or integrate that rounding process into existing rounds. They will be responsible to improve teamwork with physicians and other staff members and ultimately to make your unit safer for patients. So, it's crucial that you have people that are on your floor working with those patients and their families every day as part of your team to design these processes and to make sure that they're built into their daily routine.

Next slide. So, the type of person that you're looking for, again, needs to have strong teamwork and communication skills, strong commitment to patient safety, and very importantly, sufficient experience or tenure on that unit so that people know them and respect them and will listen to the educational areas that they introduce to them, and also to advocate for them if they're running into any barriers with this work. They should be practical, flexible, and willing to speak up and not intimidated by medical staff. You will hear often in the onboarding calls that we do with you in the future about how important it is for nurses to drive this entire process for reducing catheter use on the units, but that does involve speaking up with the medical staff, finding out who their advocates are in the medical staff, and leveraging that to make sure that we're only using catheters when absolutely necessary.

Next slide. Finally, the remaining role that we'd like to see you build into your team is that of the infection preventionist. This person will be expected to meet regularly with your team to review your data and your progress, and they often may be the person that you decide to designate as the one that will collect the data and enter the data. As you've heard on some of the introductory calls, you will be collecting the number of CAUTI's on your unit, your patient days, and catheter days, and often that role is given to your infection preventionist, so you have to have someone that's comfortable doing that.

But perhaps more importantly, they will be serving as your content expert or infection prevention consultant to your team to help you understand HICPAC guidelines, to moderate and review whether or not this is, in fact, a CAUTI, and is it, in fact, attributable to your unit. They will help your team think about and develop and implement and monitor appropriate infection prevention strategies and communicate the project goals and progress as appropriate in wider infection prevention meetings throughout the hospital and in other settings across your campus. So, they're a resource to you on your floor as well as to the hospital at large to help people understand the work that you're doing and can spread it throughout your institution.

Next slide. The ideal characteristics for this infection preventionist, again, a team player with good communication skills and they should be very knowledgeable about the CAUTI definitions, the HICPAC guidelines, and evidence-based infection prevention practices regarding catheter use.

Next slide. So, just to summarize, before you begin your work on the collaborative, it's important to think about these key issues. Do you have commitment from your leadership? Are they aware that you're starting your work in the CAUTI collaborative and have they endorsed it? Have you shared the two project goals; the goal of reducing CAUTI's and improving the safety culture on your unit, both on your floor and within your organization? And do you feel that you're ready to build a multi-disciplinary team, rather than just handing this project off to one person? Are you able and ready to communicate the technical work and changes needed to your stakeholders, principally, your nurses and physicians on your floor? Are you ready to build a rounding process to check for catheter appropriateness, not just medical record review, but actually rounding every day to see if there's a catheter in place and is it still necessary? And can you commit to regular data submission and review?

Next slide. Because we know from our work with other units that have joined the collaborative prior to Cohort 8, that to achieve both the culture goal and the CAUTI reduction goal, you definitely need a multi-disciplinary unit level team strong backing from your organizational leadership, a respected and effective team leader, and at least one committed physician and nurse champion that will drive this work, because both nursing and physician ownership of the work is necessary to make care safer for your patients. I'm now going to turn the presentation over to Dr. Fakih, who will continue on talking about the technical work of the project. Dr. Fakih?

Mohamed Fakih: Thank you very much, Dr. Lucas.

Next slide, please. Now, to let you know, I think the main issue is the first 20 slides. I think a huge aspect of this work is really the behavioral one and having two medical champions through the work, so my part is a little bit easier. In fact, because it's just the technical aspect, which is kind of well-established. So, we're going to start with the indications for catheter use, and what we've done in Cohort 1 through 8 so far is we adopted the national guidelines, the CDC/HICPAC guidelines that were published in 2009 for appropriate urinary catheter use.

Next slide. What I'm going to do is I'm going to – this is the table that discusses all of them. I'm just going to list them and then I will be addressing each one by itself. So, these guidelines were consensus guidelines that were brought by an expert panel, and what they had is six different indications of appropriate indications that they recommended to use the catheter for, and they also listed some uses that are not appropriate or not consistent with what we consider as acceptable indications. So, those that are appropriate indications are: Urinary retention or bladder outlet obstruction, at least what the sense of not being able to empty the bladder. The other one is the need for accurate measurement of urinary output in the critically ill patient, and I'm going to discuss a little bit more about what “critically ill” means. The third one is really the surgical pieces, and it has four points and it's the perioperative use in certain surgeries. And one of them would be urological or surgeries that are close to that urinary tract. The other one is for prolonged duration surgeries. The third one is when the surgery is anticipating a large amount of fluid to be given. And the last one is there's another need for inter-operative monitory of urinary output. So, this is three indications. The fourth indication is the healing of open wounds that are close to the groin area. And the fifth one is prolonged immobilization linked to either trauma or risk of de-compensation if you move the patient. It's usually, like, motor vehicle accidents. The last one is end of life care. It really depends if it's needed by the patient or not. Listed are some inappropriate cases, including those cases that are for convenience, for either the patient or nursing, or even physicians in the hospital. Also, for diagnostic tests, if there's another way to do it, and post-operative use, which has been really much better now with enforcing a lot of .removal early, postoperative.

Next slide, please. So, when we talk about acceptable indications, what that's been suggesting is that each institution defines what's acceptable for them or to them. And when this happens, it's going to be much harder for physicians to say, “Well, I don't believe in this.” So, for each institution, will define what are the appropriate indications and, hopefully, base their indications on the HICPAC guidelines. And then you have, hopefully, much less resistance to adoption by clinicians, and it'll help the physician champion and the nurse champions have at least some ammunition to support their work.

Next, please. So, the more clear these indications are the better. So, we talked about different indications, but it's not enough to just say, for critically ill patients, what does critically ill mean? Or perioperative monitoring in surgeries, what does this mean? So, if we define very clearly what each of these items mean, then it will be much easier for those that are doing the audits, and also the health care workers to figure out if a catheter is indicated or not.

Next, please. Let's start with accurate measurement of urinary output in critically ill patients. We see this indication applicable to the intensive care units. And when we started work initially, we had a lot of discussion about the critically ill on the floor, but it was really tough to figure out if we look at the critically ill on the floor, which one will be considered critically ill? Is it someone who's 95 years old who needs a catheter because he looks very frail? Or someone who is on an incredible amount of fluids with the excess of being sedate and gong to the ICU? So, what we decided at that point, early on, is that critically ill would be someone who you are taking care of and that is in the intensive care unit and looked more at the ICU as the critically ill area. We have discussed this with different authorities also within the country and very similar views about the critically ill definition.

Next, please. So, acute urinary retention or obstruction is there's two ways to look at; those that have outflow obstruction and those that have acute urinary retention, not related to an obstruction. And there are different reasons for each of them. So, for outflow obstruction, the common one would be prostatic hypertrophy with obstruction or urethral stricture or obstruction, and sometimes it's the hematocelian clots that do cause also obstruction. On the other hand, the acute urinary retention may be medication related or related to a medical issue, such as melaturnic bladder, or a trauma, such as a motor vehicle accident where they have an injury to the spinal cord.

Next, please. The difference between the two, the urinary retention that's absolute obstruction versus retention, which is medication or neurogenic, is that the second one, the neurogenic bladder or medication related, you can use for a period of time a straight cath or in and out and you avoid having a urinary catheter in versus the first one is much harder. So, this is another thing you can consider when you are doing your intervention in your hospital.

The next appropriate indication is the perioperative use in select surgeries and we can look at it in two different ways. One is an inter-operative and the other one is physical site where the surgery is going to be done. So, for inter-operative use, it would be either because the traditional surgery is prolonged, and you need to monitor for fluids or if you're giving very large infusions of fluids during that surgery. I mean, these are the main issues for inter-operative. And rarely would you need to keep the catheter much after the surgery is done. For the surgical site, urologic surgery, often you think urinary catheters and other surgeries close to the urinary tract. So, we think of it a little different from each other; these two items.

Next, please. Now, what about spinal or epidural anesthesia? And this was listed under the potential inappropriate use of urinary catheters. And the reason why we look at this as inappropriate is not every patient who has an epidural anesthesia will end up needing a urinary catheter. So, if the patient develops urinary retention, why this is worrisome is that if we do the epidural anesthesia or spinal anesthesia for a long period of time, what you may end up having is two things; first, you may end up having urinary retention, but the other thing that we less often talk about is that these epidural catheters can risk infection at the epidural catheter site, so it is very important to look at these catheters and directly after surgery, think about moving these catheters, because of the risk to both devices.

Next, please. Assisting healing with a perineal or sacral wound in certain patients. A long time ago when we started doing the work at my facility, a lot of the nurses and even physicians used to think incontinence is an indication for urinary catheter placement, and it took us some time to change that. When we found it was other interventions to reduce the risk of skin injury or damage, but many hospitals may think that regular incontinence is an indication for a Foley, and incontinence happens for a lot of patients when they're at home, elderly, so it's not an indication for urinary catheter. So, the only time when we see the indication is if it's coupled with skin breakdown and a perineum, and you have a risk if you don't have the catheter in that that skin breakdown will break down or worsen. So, that's how we should view that indication.

Next, please. Hospice, comfort care, end of life care, doc's care, this is, again, it's going to be a tough decision. Thinking about this patient population, having a catheter in will increase the risk for infection. So, we really should not be placing it unless it's going to make a huge difference as the patient's comfort.

Next, please. The required immobilization for trauma surgery, the examples would be an unstable thoracic or lumbar spine, so a nurse or physician comes in and looks at the patient and says that if this patient moves, they may end up having worsening of the injury or multiple traumatic injuries, such as multiple fractures, and you worry that, again, movement will worsen the condition of the patient.. This is not related to immobility that's related to someone who is debilitated, completely different. Immobility related to being frail or debilitated is not an indication. In fact, urinary catheters will make people more immobile and it may end up resulting in worse outcomes

Next, please. These are the chronic urinary catheters. So, you're an ED nurse or an ED physician. You get someone coming from a nursing home and there's no documentation why the catheter has been there and it may have been for a month, two months, a year, two years, and there's no documentation. This is a tough issue. We do suggest that these patients need to be evaluated for appropriateness, but we need to get more information about why they have the catheter in. I think it's very important for them to have a good follow-up and to make sure that the catheter was not placed without an appropriate reason. And if it is the case and the catheter does not have an appropriate reason, then continuing to watch the catheter and watching the patient for retention is important.

Next, please. Some of the unacceptable reasons for placement. So, as we discussed initially, urine output outside of the ICU – the main areas may be someone has congestive heart failure. They are requiring some abstinence implementation, but they are not ICU material and the technologist wants to follow-up on their I's and L's. Another place would be someone who has been recently diagnosed to have an acute renal failure and their nephrologist wants to do a 24 hour urine collection. There are other means for us to collect and consider instead of having a catheter that can lead to infection and also trauma. Incontinence, I did talk about incontinence. It should not be a reason to place a catheter in. The prolonged [Inaudible 00:33:23]; there was a push to skip on the modern catheter within two days of surgery. I think the surgeons have done a great job in being cognizant of this and there has been an improvement on surgical wards. And other places which are quite interesting, the transition from ICU to floor, I feel is a very high utilization place. The floor is a lower utilization place, which have 15 to 80 percent of their patients with urinary catheter, and on the floor it can range between, in fact, some units in our hospital have, like, 5 percent. So, let's say, 10 to 15 percent. Our national cohort has higher than that. They have about 18, 20 percent utilization on the floor. You see a huge change from the ICU and the floor. And it makes quite a bit of sense that at the time of discharge, of transfer from the ICU, evaluation for the catheter is very important and, if not needed, remove it. So, you may see these patients on the floor coming from ICU and they do not have the catheter out. Morbid obesities and other inappropriate reasons with catheter: Confusion of dementia and patients' request. Dementia, patient has dementia and they have incontinence. There's no reason when they come to a hospital to have a catheter in. They have been living without a catheter at home. The other thing is that we really have to, and I think I'm being limited on it here, but if we clearly define all the indications to avoid using catheter inappropriately, it makes it much easier for those that are doing the work.

Next, please. So, we talked about the indications and how do we create a process of urinary catheter need? And a lot of this has been based on work that has been done a long time ago with nurses and work at our facility where engaging the nurse and staff through another turnaround makes, hopefully, at the end, the regular nurse, the bedside nurse own the process of taking care of the patient and looking at whether the catheter is needed or not. So, initially we educate the nursing staff on the appropriate urinary catheter utilization or we provide them with educational materials, lectures, posters, pocket cards, and it doesn't have to be all of the, but you can choose whatever is most feasible for your institution. The main thing, however, is that whoever is engaging, whoever is the champion engaging the nurses, that they discuss case by case the indications for urinary catheter use with the nurses. What you're trying to do is you're increasing the importance of reducing the harm risk for these patients by highlighting whether a patient has a catheter or not, and then asking if there's a reason, true reason, for use. And if it's not, then to remove that catheter. And with time, the nursing staff will feel that the natural part is not to have the catheter in, not the opposite.

Next, please. So, these are examples. The stuff in yellow are pocket cards. We have posters; the stock poster, the most necessary catheter poster, the most unnecessary urinary catheters poster. So, we have different ones and these can be customized to your hospital, and they're downloadable from the CUSP: Stop CAUTI website.

Next, please. So, the health care workers, usually a nurse – when we started writing this, we had kind of a different view. We thought more about the infection preventionist or quality improvement person, but honestly, the closer that person to the unit people, the better it is. So, a nurse would be probably the best. And that nurse needs to be knowledgeable on the indications for urinary catheter utilization. And that person will participate in the daily nursing rounds, and I'm not going to beat these things, but Dr. Lucas has done a wonderful job presenting them, but you have the members of the team present. The nurse manager's role is to make sure that everyone knows this is something very important as far as patient safety to our unit, and she or he will get the support to that work, so everyone knows that the catheter being there without a reason is not acceptable. So, that type of nurses are key because they're the ones that will adopt this process and the longer be the champions for their patients.

Next, please. So, the question is triggered: Does the patient have a urinary catheter? And if it is yes, then the other question is: Why does the patient have the catheter? What's the reason? A lot of times they may say, “Well, I don't know.” Or “Because they're incontinent,” or “Because whatever.” And then what needs to be done is discuss what are the appropriate indications or what are not the appropriate indications? And even if that nurse, the bedside nurse says, It's incontinence,” what would need to be done by that champion is to push for how to mitigate the issue with incontinence. So, if you have someone who's incontinent, how can I make the life of that beside nurse a little bit easier and at the same time, not have that catheter in for incontinence? So, provide the bedside nurse with some solutions to these barriers that he or she is visualizing. And if you continue that process, initially you do it more often than, hopefully, you do it maybe a little less often, but at least do some audits. What you want to make sure is that at the end, since the patient's bedside nurse will own the process, so there wouldn't be any loss of your benefits that you gained through implementation.

Next, please. So, the key factors of success is the nurse manager supporting the initiative. Of course, this would look like the leader and holding the staff accountable. The facilitator is the one that will be discussing these issues with the catheter with the nurses, so you have that champion that is discussing why do we have the catheter in and what are the other options?

Next, please. So, the final and the end result would be that the bedside nurse will own the process and will check on the catheter need every day; in fact, every shift, and I'm going to show you some data, and that's (indiscernible 0:41:08). So, the bedside nurse at least needs to know if a patient has a catheter or not and what the indication is. And this will be when he or she is prompted, “Okay, does the patient have a catheter in?” They don't know. They remember next time when these questions will be asked, but look a little further. So, what you're trying to do is change their behavior. And the best way to do it is to integrate it into the patient's daily nursing assessment. A successful way to do it is through the EMR.

Next, please. So, it's not enough to just tell them, “Okay, it's not an indication. Don't put the catheter in,” because even if you say that to a health care worker and you don't provide solutions, it is very likely that there won't be any good progress in reducing catheter utilization. You need to give them solutions. So, for example, if someone is incontinent, bundle the changing for incontinence with skin care and turnic. If someone needs fluid monitoring, offer either urinals, hats, or wings for these patients.

Next, please. So, let's say, you're at a facility where you cannot have nursing rounds or whether it's to be announced, do you have any other option/ Now, what we've seen that's different, people are quite innovative and they look at their units and then they figure out what's the best way to do it. The main thing is to push for that change and evaluation of lead for the urinary catheter. So, you can have a nurse champion who goes with each nurse, one on one, and say, “Okay. Do you have any patients with catheters? Tell me about your six patients. Who has the best evaluation?” And then ask about that reason for use. I've seen in other units at our facility where the nurse manager, in fact, and the PA, physician assistant, rounded on patients daily to evaluate the devices. So, the trauma, regular floor unit, and whenever they did not find a reason, they discontinued the catheter. Now, what's not good about this is that the nurse is not owning the catheter evaluation. It's the nurse lead in that situation. So, it may work in certain areas, but what you worry about is what would happen if that process where the nurse manager stopped doing it? What would happen to the evaluation of the catheter? So, you'd like it to be that the nurse, the bedside nurse, would be the owner of that work.

Next, please. Okay. Another one is looking at different units and what I do call a multi-disciplinary multi-department or approach. So, you work with other units in the ED or ICU, but also at time of admission to that unit or transfer, when you're evaluating a new patient coming into your unit, make sure that these devices are not kept, if they're not needed, if they're no longer needed. The multi-disciplinary approach would include other stakeholders, so case managers work very well for our hospital. And when we did this in 2006, urinary catheter issues and CAUTI was not a popular thing, but the way we sold our case was that keeping a urinary catheters for the last day would give you about six hours of keeping the patient end, because you need to wait for them to empty their bladder or urinate after removal of the catheter. A physical therapist would talk with them about ambulation and that the catheter would be [Inaudible 00:45:51]. Wound care nurses, we talked about, the pressure associated with the Foley catheter is helping. For those that have seen a lot of cases, you know that sometimes the catheter itself can cause pressure on the side. So, an infection for that chance is, of course, a catheter-associated urinary tract infection, inappropriate utilization of antibiotics for urinary bacteriuria and increasing  (0:45:57 ph).fetous. You can make your case to a lot of stakeholders. You can't imagine how many people are involved with the urinary catheter.

Next, please. So, what are the important issues? You want to see a reduction in urinary catheter utilization and this is the marker for your program's success. And the longer the catheter's in, the higher your chances or risks for CAUTI. So, it is important – if you have a catheter where the physician was resistant to removal the first day, second day, third day, I would never quit, Because the longer the catheter is in, the higher the chances for that patient to get an infection. So, you don't want that catheter to be staying for a prolonged period of time. It's so very worth it to address this daily.

Next, please. And, as I said, the ICU's have high problems. Intervening in the ICU is very important and some of you may be ICU teams, and when we look at the ICU, it needs to be like before evaluation of the catheter every single day for need and, of course, as it's on the unit. The ED, we're doing a wonderful intervention. In ED, I think we have more than 150 ED's so far that are part of this, and it does work. We just recently published a paper on 18 hospitals where there was a reduction of about a third in utilization in ED. So, these are areas that you may want to look at. The Operating Room is another one, talking to the surgical leaders and nursing leaders in the OR and make sure that the catheters are only placed when they're needed for surgery. And if they're needed for surgery, they can either remove them directly in the OR after the case is done or in the anesthesia care unit.

Next, please. So, we're coming to the end of the presentation, so how to get successful results? Both the nurses and the physicians should be evaluating the cases for urinary catheter utilization. The physicians should promptly discontinue catheters when no longer needed. We don't want this to be only the nursing effort. I think it's a partnership between nurses and physicians. And nurses evaluating catheters and finding no indications should contact the physician for promptly removing the catheter. There are certain hospitals that have evaluation by nursing and automatic discontinuation through an order or standing orders that would even bypass the call for the physician and, depending on the culture you have in your facility, you may consider something like this. Partner with different disciplines, such as case management, nursing, infection prevention. You can successfully achieve your goals.

Next, please. And identify – so, how to sustain your success? You have to make sure, and we have the presentation later on about sustainability, but what you need to do is hardwire your work, and I think the best way is to make sure it's part of the nursing routine every single day. Incorporating it into the electronic medical records is also very important. There are a couple questions that can be asked every time, if they're on nursing rounds, the patient has a catheter. What's the reason for use? And if you want to use it as a more global thing, you can look at all devices in these units; the patient has a central line, urinary catheter, and what's the reason. So, it's a patient safety issue rather than only a one device issue. And get feedback on performance, the nurse managers related to the prevalence of utilization. It's very important for people to know how they're doing. If you don't tell them how they're doing, they may not think it's working or they may think it is completely fine and they don't pay attention to it. And if there's not improvement in utilization, then look at the appropriateness when you do your audits and see if there's a trend. And the final result is to have really the bedside nurses owning the process of the evaluation of catheter need, and discontinuing the catheter if it's no longer needed.

Next, please. So, this is what I was talking to you about the nurses owning the catheter. This is a survey we've done to our nurses, about 30 bedside nurses, and this is after years of work, so our initial work was in 2006 and what we did over time was multiple intervention. The first intervention was a nest of multi-disciplinary rounds went through all the hospitals and this was in 2006. And in 2007, we intervened in the Emergency Department with much less urinary catheter utilization and we've had some intervention in ICU. But on the floor over a very long period of time till now, we ask them to send us point graphs on Tuesdays and Thursdays on whether the devices, whether the patients have the urinary catheter or not. So, this is something we did in 2012, and we asked them: Who is on the unit responsible for bedside, if a urinary catheter is needed? And what I want you to see here that we have multiple answers and many of them have the nurse as part of the nurse caring for the patient. Modern surg. singled out that these are the nurses caring for the patient that they are the only people that are responsible, but when you look at the last item, nurse caring for patient, you find a nurse manager, 47.6 percent. You add them all together, it's, like, very high 90's, scrub-in, 97 percent, thought that the nurses caring for the patient, the bedside nurse is the one who's responsible. Now, there may be other people with her or with him, but this is how they viewed it. So, they viewed that they own the catheter evaluation, which is a great thing. So, how often does the nursing unit evaluate urinary catheter presence and appropriate need? We had 90 percent saying daily, which is a great thing, and how often per day? So, how many shifts? And 80 percent said, all shifts, and 13 percent said, the morning shift. So, this is an example that with hard work, we can reach a situation where the nurse will own the catheter evaluation daily.

Next, please. So, we asked them about (indiscernible 0:53:15) if it helps identify a no longer needed catheters, and about 80 percent strongly agreed or agreed about that. So, it also was something that they found useful. And this is what I mentioned to you about the point prevalence, doing urine catheter prevalence evaluations on Tuesdays and Thursdays helps our unit focus on removal of unnecessary catheters, two-thirds strongly agreed or agreed.

They didn't feel it as strongly as the multi-disciplinary rounds, because it's more interactive than multi-disciplinary rounds. And that's the beautiful one. The last one is I'm confident in my knowledge of urinary catheter indications. Almost all of them felt that they feel comfortable with that. They knew the indications.

Next, please. So, Dr. Lucas talked about leadership importance; it's crucial. Defining the barriers to implementation is very important. Obtaining physician and nursing buy-in is also very important and provide alternative to the Foley catheter.

Next, please. So, I think this is the last slide. Think about the whole picture, and I talked about the multi-disciplinary department or approach. It's almost like synergy. So, if we all work in different units on improving appropriateness of catheter use, we will see global improvement. This is quite similar to what we're trying to do the last few months is pairing Emergency Departments with in-patient units as was their intervention and hoping that both will work together to reduce the utilization of the catheter that's not necessary. I think that's the last slide.

Next slide, please.

Ashley Hoffman: Yes. Thank you. Dr. Fakih. So, here are just some references, and I can post them in the discussion area as well. Different resources that are available on the CUSP website to help you in these first steps, so assembling your team and then also the data collection schedule. And then I want to go over some next steps, so this afternoon, what should you be doing? So, again, fill out your team commitment forma and then have your CEO sign a hospital commitment letter; give those to your state leads. You can also find those pocket cards and posters on our project website, and then the next step, in two weeks, right back here, we'll be hosting our second Onboarding Webinar on April 22 at 1:30PM Eastern time. And that's going to feature Tina Adams and Katherine Allen-Goodson that will go over the CAUTI definitions. And I want to open it up now for questions. Operator, can you give the instructions?

Operator: Yes, I can. At this time, we will open the floor for questions. If you would like to ask a question, please press the “star” key followed by the “one” key on your Touchtone phone now. Questions will be taken in the order in which they are received. If at any time you would like to remove yourself from the questioning queue, just press “star two.” Please limit your questions to one at a time. Again, to ask a question, please press “star one.” And our first question comes from Vira Gabbard with the University of Kentucky.

Vira Gabbard: Yes. Actually this is UK. I have a question. I rounded today in my unit on Foley catheters, which is a cardiovascular-thoracic unit, and I want to know what other places have done people that are on Propofol, sedated. I have a patient today that's on BMX, Nimex, and Propfol that's very sedated and very ill, and her Foley is in. And so, what do you suggest doing for people that are sedated and on the ventilator? This was a woman, too, which makes it that much more difficult.

Mohamed Fakih: I can try to answer that. So, there are patients in the Intensive Care Unit that will need the catheter for a certain period of time. What we're looking for; I admire what you're doing. So, you're looking at every single patient. If they're critically ill, then this is an indication for utilization, if you want to monitor their I's and L's, but I don't expect that person to be sedated and on the vent for prolonged period of time. Or even if they're on the vent, but they're improving, then this is a time where we can consider removal of the catheter. What I try to do, and we've given this, I think, very recently a presentation about the ICU. I can share it with you. I think I gave it to AHA. Link it to other things that happen in your ICU. So, if the patient is awake and they're intubated and you have an early mobility program that pushes people to pull that catheter out. We see things like septic shock or [Inaudible 00:58:32] shock, you will need the catheter for that time, but a few days later, they will improve and then, hopefully, you can remove that catheter.

Vira Gabbard: Yeah. This is on a person who's been intubated for five days. They're had their catheter for five days, and they're just too sick to actually come off their sedation, yet from sepsis. So, I just wondered if you'all had any special magic things you could tell me.

Mohamed Fakih: I can tell you there's no magic that I have and, Dr. Lucas, do you have any comments about that?

Barbara Lucas: No. I agree with your Dr. Fakih. That's a very difficult situation. But, again, that situation would meet the HICPAC criteria, but it's important that you continue to question it. And, as Dr. Fakih said, if you're implementing early mobility in your institution and it's at all feasible to consider if that person can be taken off the catheter, gradually as they're waking up and becoming less ill, we want to encourage people to do that. And just not be in the mindset that just because they're in the ICU that the catheter is mandatory.

Vira Gabbard: Thank you.

Dr. Fakih: Uh-huh.

Operator: Okay. Our next question comes from Christina McGruder with the John Muir Health.

Christina McGruder: Yes. With so much emphasis being put on taking catheters out early wherever needed, I wonder about the interventions of daily catheter care and insertion techniques. And I know you mentioned this earlier, but shouldn't these be given great emphasis also for those patients who may need to have a catheter in-dwelling longer?

Mohamed Fakih: Can you start again what you're looking for? So, we talked about the time about appropriate need, so not to put the catheter in, and removing it as soon as possible. So, the question is: How can you clean the catheter? Or –

Christina McGruder: If the catheter does need to be in, is there data that shows proper insertion and daily care, cleaning of the catheter can reduce CAUTI's as well. I'm wondering if that shouldn't be an equally great emphasis that we give to our staff members.

Mohamed Fakih: Most of the data is related to how long you use the catheter, multi-interventions. The interventions about insertion are not as strong and we can review the HICPAC guidelines. They give you how the terms of the evidence. It makes complete sense for us to have an aseptic insertion in all hospitalizations and also not to break the seal of the urinary catheter for maintenance and to have an emptying of the bag appropriately. I mean, not to have any introduction of organisms into that closed system. But, honestly, the main studies have shown success with reducing utilization, and to a lesser extent, the maintenance would not be as strong as reducing utilization. So, both are important, but what I'm trying to say is we cannot be [Inaudible 01:02:19] when the catheter is no longer needed.

Christina McGruder: Yes. Okay. Thank you.

Mohamed Fakih: Uh-huh.

Operator: Again, if you'd like to ask a question, please press the “star” key followed by the “one” key on your Touchtone phone now. There are currently no questions in the queue at this time.

Ashely Hoffman: All right. While we wait for you guys to come up with these questions for Dr. Fakih and Dr. Lucas, just want to highlight the next call coming up in two weeks with Tina Adams and Katherine Allen-Goodson that's going to go over some of the background and key terms of the project. Also, it's going to cover the CDC's NHS and then talk about the data collected for those projects, so that will come in process data. So, that's coming up on April 22. There's also a listing of the rest of the Onboarding calls that we're hosting all the way up through June 18, so be sure that these are all on your calendar so you can join us.

Operator: There are currently no questions in the queue at this time.

Ashley Hoffman: Okay. And you can also post your questions in the discussion area, if you don't want to voice them.

Operator: Okay. Still currently no questions.

Ashley Hoffman: All right. So, if there's no more questions, we'll give you guys back 10 minutes of your day today. We do ask that you take a few minutes and fill out the evaluation of today's webinar. That link is on the left side of the screen in the discussion area at the bottom; it's a SurveyMonkey link. Take a few minutes to give us your feedback about the webinar and the presenters. We really appreciate your feedback on that. I also want to thank Dr. Lucas and Dr. Fakih today for saying this information with us. And thank you all for joining us. We hope you have a happy and productive afternoon.

Mohamed Fakih: Thank you.

Operator: Thank you. Ladies and gentlemen, this concludes today's teleconference. You may now disconnect.