Preventing CAUTI in Specialized Patient Populations: The ICU

AHA – Chicago
May National Content Call
May 13, 2014
11:00AM CT

Operator: This recording is for Paul Tedrick with the American Hospital Association of Chicago on Tuesday, May 13, 2014 at 11:00 a.m. Central Time. Excuse me, everyone. We now have all speakers in conference. Please be aware that each of your lines is in a listen-only mode. At the conclusion of today's presentation we will open the floor for questions. At that time, instructions will be given as to the procedure to follow if you would like to ask a question. I would now like to turn the conference call over to Ashley Hofmann. Ms. Hoffman, please begin.

Ashley Hofmann: Hi, everyone, and welcome to the May National Content Call. We're so excited to have you with us on today's call which is going to focus on preventing CAUTIs in the ICU. My name is Ashley Hofmann and I'm a research specialist at the Health Research and Educational Trust supporting the On the CUSP: Stop CAUTI project. Real quick before we begin today's presentation, just a quick reminder that this is a webinar, so please be sure to log into that web link that was sent out in the invite. A copy of the slides as well as the recording will be posted on our project website a little bit later this week. So I want to introduce our presenters today. Dr. Eugene Chu is the Director of Hospital Medicine for Boulder Community Hospital and Associate Clinical Professor at the University of Colorado School of Medicine. Board-certified in internal medicine, Dr. Chu earned his medical degree from Taft University and completed a residency in internal medicine at the University of Colorado Health Sciences Center. I'd also like to introduce Dr. Hannah Wunsch who is the Herbert Irving Assistant Professor of Anesthesiology and Epidemiology at Columbia University. She received her undergraduate degree from Harvard University and a medical degree from Washington University in St. Louis, as well as a master's degree in epidemiology from the London School of Hygiene and Tropical Medicine. Dr. Wunsch then went on to complete her residency training as a Virginia Apgar research scholar in anesthesiology at Columbia University, as well as a fellowship in critical care medicine. Dr. Wunsch joined the faculty at Columbia University as an assistant professor in Anesthesiology in 2009, and now as an assistant professor of epidemiology in 2010, and is currently an Irving scholar at the Columbia University. Her research program seeks to understand the relative impact of resources and policies on the delivery of care to critically-ill patients, with an emphasis on the use of large database analyses. In particular, her work focuses on understanding the system drivers of ICU triage decisions, comparisons of critical care resource use across countries, and the impact of critical illness on health outcomes and cost of care. Also here to share their experience in the collaborative from the University Medical Center of Southern Nevada are Ashley Komacsar and John Medina. Ashley's a registered nurse in the surgical and sensitive care unit and neuroscience care unit, and has worked in critical care since graduating from Purdue University in 2011. At the University Medical Center she has filled the role of unit champion for her On the CUSP: Stop CAUTI team. Prior to his current role as manager for the intensive care and neuroscience care unit, John served 20 years as a Nurse Corps officer in the U.S. Navy. And so, without further ado, it's my pleasure to introduce our guest speakers today. Dr. Chu?

Eugene Chu: Great, thanks for the kind welcome, Ashley, and really happy to be here. We're going to be talking about culture change, and then Dr. Wunsch and our colleagues from Nevada will be talking about specific ICU CAUTI intervention. So, for my part, we're going to start with a case. And this is a case that I had when I was at Denver Health Medical Center where I was a hospitalist for about a decade. And this happened not too long ago. I think this was about four or five years ago. We had this woman present to our unit with diastolic heart failure. She was probably on three or four liters of oxygen and she was not very mobile. So, around second day I talked with the resident and the resident talked with the nurse, and they were having a hard time getting Is and Os because of her immobility. And they were also that because of her immobility and functional incontinence that she might develop a pressure ulcer or skin breakdown. So, we decided to put a Foley in and get Is and Os so that we could— we felt like we needed that information to diurese her better and take care of her better. So sure enough, we put the Foley in. We had better information. We diuresed her and about two days later, she was on minimal oxygen, getting ready to go back home, and then she started to develop a fever. So, we cultured her and it turned out that she had a CAUTI. We started her on antibiotics, and again, another couple days later she started to feel better. But then she started to have diarrhea. And this wasn't your regular diarrhea, it was your really particularly foul-smelling diarrhea. So, we cultured her stool and got (0:05:33 indiscernible) and it turned out to be C. diff. So, we started her on Flagyl and she again improved. But by this time she was quite debilitated, so she had to go back to— she couldn't go home. She went to a skilled nursing facility. We transferred her to a skilled nursing facility and then within two weeks she was readmitted, and she was readmitted with recurrent C. diff diarrhea that was now quite severe. So she was on PO vancomycin and I think IVIG at that time. And she slowly improved. We were wondering if she had toxic megacolon at that time. But it was a bad case and she was immobile. She started to get decubitus ulcers from her immobility, very stage I stage II decubitus ulcers. And then on cross-cover one night we were rounding on her and a rapid response call had been called for hypoxemia and hypotension. And she got some fluids, her x-ray was clear, and it seemed to resolve with fluids. But the next morning she was again hypotensive and tachycardic, and then when we talked to her further, she had had some acute-onset sudden chest pain. So now what does she have? Our first question, does she have aspiration pneumonia, an acute coronary syndrome with CHF, pneumothorax, or pulmonary embolism? So, clear chest x-ray. Again, she was in here for CHF before. She had some chest pain and tachycardia, and hypotension overnight.

Ashley Hofmann: We'll give everyone another 30 seconds to get their response in.

Eugene Chu: (0:07:31 Inaudible) —coronary syndrome with CHF, and pulmonary embolism. And the answer is she had an acute pulmonary embolism. So again, clear chest x-ray. She had a submassive pulmonary embolism with hemodynamic instability. So we had to transfer her to the intensive care unit, put a filter in her. We didn't give her (0:07:54 indiscernible). She actually survived this episode and went back to the skilled nursing facility. So, again, yes, she had CHF, but looking back, we probably did not need to put a urinary catheter in her. And then she gets the CAUTI, which results in C. diff, which results in a pressure ulcer, increased length of stay, immobility, and venous thromboembolism. So again, all these things can be related. And just by being conscious of the need or no need or a urinary catheter, we can prevent a lot of patient harm. So we're going to understand the CUSP framework for initiating culture change and then apply that theory to the urinary catheter culture. There are a lot of definitions of culture. The one that I found most useful is this one. And it's really a set of values and beliefs that guide actions and decisions. So, when we're thinking about culture, I always try to think about those things. What is going on in your unit? What are the values and the beliefs of your unit about urinary catheters and how does that guide actions and decisions? So we're talking about the ICU because the ICU, for good reason, has a very high prevalence of urinary catheters. Some ICUs have 80, 90, 100 percent prevalence of urinary catheters. ICUs will probably always have a higher prevalence than most units, but still, when you actually dig deep into the indications for catheters, there's probably upwards of 50 percent overutilization of urinary catheters. And beyond the initial insertion, there are huge gains to be made by removal once those catheters aren't necessary. And again, when we think of the culture of the ICU about urinary catheters and CAUTI, we think about what are the values and beliefs about the indications, about insertion and maintenance, and about removal.  And again, with the ICU culture, decreasing any unnecessary insertions, as well as removing them as soon as they're no longer necessary, and inserting and maintaining them, the correct technique, are the things that we're trying to achieve. So how are we going to get people to start acting differently? Most of the concepts we're going to talk about today are from three— two books and then one change theory, which is CUSP. ‘Switch' is by Chip and Dan Heath. ‘Leading Change' is by John Kotter. And CUSP was developed by Peter Pronovost at Johns Hopkins. And they're all— ‘Switch' and ‘Leading Change' are good reads. They're easy reads. And CUSP is all available on the On the CUSP: Stop CAUTI website. So, in CUSP, we talk about the four Es. And they are engage, educate, execute, and evaluate. And we'll talk about them more in depth as we go through this slide set. For ‘Switch' we talk about directing the rider, motivating the elephant, and shaping the path. And one thing to remember about change is that it's all the same. So, if you're an individual trying to change, we call that ‘self-help.' If you're an organization trying to change, we call that ‘change management.' And if you're trying to change society, we call that ‘activism.' But it's all really the same. So any time you're trying to change, you start off with the same concept, and if it's not working, you can kind of look at the different aspects of change management and see where you may need help. So education is analogous to directing the rider. It's using your rational analytic system. Engagement is analogous to motivating the elephant. So that's tapping into your emotional systems, your intuition and your passion. An execution and evaluation is analogous to shaping the path. So we're trying to create an environment that most facilitates change and makes change highly probable. So we're going to talk about a couple of stories here to illustrate how change happens. So this group, there are two professors at the University of West Virginia, this is in the ‘80s. And they were given a grant to help improve the health status of West Virginia. So West Virginia at the time had the highest incidence of— or the highest prevalence of obesity, and then the downstream effects of diabetes, and heart disease, et cetera. So they were given a grant to decrease— improve the health status as measured by obesity prevalence, diabetes, et cetera. And so, at first, what they did was they went out and they started campaigns on eating healthy, and they showed a lot of these diagrams where you had the food pyramid, and you had meal plans, and carbohydrates, and protein, and just very detailed information, just a lot of stuff. And after a year or two they measured the health outcomes, and nothing was changing.

So, they held some focus groups and the focus groups kept coming back and saying, “Well, all these are really great, but when we see them on commercials and posters, it's a little bit overwhelming. It's like eat healthy, and then there's just so much information that it's hard to know where to start.” So, they looked at the diets of West Virginians and they found that just by changing— so it was a high-diary diet. So they found that just by changing whole milk to skim milk, that they would meet the USDA recommended daily allowance of saturated fat, and proportion of fat, carbohydrates, and protein. So, they started a campaign to use skim milk. And they would illustrate this very prominently by saying 1 gallon of skim milk compared to whole milk, if you're drinking whole milk, it's just like eating two sticks of butter in addition to the skim milk. So, they were also tapping into the emotional systems there, but they were making it very clear. And you need to do is substitute skim milk for whole milk, or whole milk for skim milk. And they found that this was quite effective. They found that skim milk doubled in terms of the amount of skim milk that was bought in West Virginia. And then when they measured downstream outcomes of BMI, and obesity, and diabetes, and whatnot, they found good effects. So, what is this about? Sometimes it looks like they were resisting change— eat healthy, they weren't eating healthy, but it was really a lack of clarity. So, what's really imortant is to give clear directions that people can follow so that you can understand what to do. And in the CUSP sense, that is education. What do we need to do? Again, in the CUSP sense, we do a lot of directing of the rider, a lot of education. And we'll see all of this in the further presentation, so I'm not going to go into these in particular detail.

Alright, the next story is about a taste test. And this was done for college students, and college students are always hungry and needing a little bit of cash, so they paid them a little bit to do this taste test. And they said that they were trying to differentiate taste between radishes and cookies. So, one group of college students was told that they could— they were in— so they were all told to fast for four hours. So after breakfast they were told don't eat anything. So it's now lunchtime, so they're all hungry. And they're put in a room with cookies and radishes. And one group was told you can eat either one, and these were fresh-baked, highly aromatic cookies. So that group tended to eat a lot of cookies and they didn't touch the radishes. The other group was told— they were also put into a room with cookies and radishes and they were told don't touch the cookies, if you're hungry you can have the radishes. So they were pretty good, they actually didn't touch the cookies. They went and they were doing what they were told, and they didn't really eat many of the radishes either. So, they went through that phase of the trial. And then they said there was a second phase and they are trying to test intellect and ability to solve puzzles. And both groups were given a puzzle that was unsolvable. They were told to trace a complex figure without lifting their pen off the paper and it was undoable, they had to lift their pen off the paper to trace it, or without crossing over the figure on itself. So it basically was undoable. So, one group ended up trying twice as long as the other group before giving up. And that is our next question: which group attempted the puzzle for longer before giving up? The group that could eat the cookies or the group that could only eat the radishes, or there was no difference? Okay, so it looks like most people, a little bit weighted towards the group that could only eat the radishes. Okay, that's an interesting finding. The actual answer is the group that could eat the cookies. And this has been reproduced in many similar trials. And the idea there is that when you're using your willpower to resist temptation there, you run out of willpower. And at a certain point, you lose motivation. So, the group that had to resist the cookies was already low on motivation. So they were going into it low. And you can look at it the other way where you can say the people that got to eat the cookies were kind of high on motivation. And as we all know, cookies are pretty darn good motivators. So again, how does this make the world a better place? So, when we talk about engagement and motivating the elephant, we want to get people motivated, we want to get people engaged. And how are we going to do that in CUSP? So we're going to talk about our patients, just like we started the session with. And that can be very powerful. One of my colleagues, Ian Jenkins, he tells a story about a urinary catheter that was placed in a patient that was transferred to the ICU for rapid a-fib and hypotension/pulmonary edema, who rapidly corrected his hypotension and only had mild (0:19:58 indiscernible) on 2 liters of oxygen. They'd put the Foley in, tore a urethral stricture, caused urine to go into— out of the urethra into the perineal area. He had to go for an emergent complete protectomy that night. So again, these things can really cause both infectious and non-infectious harm. We can talk about finances to motivate people, especially when you're talking about eating resources in talking to your board of directors, or managers, directors, whatnot. This is from catheterout.org. You can go into that site and do a calculation based on your daily census, average length of stay, and Foley catheter rate to get annual savings. Individual finances sometimes play a role. A lot of physicians and other staff are incentivized now on quality, so that's another way to get people motivated.

Vision. John Kotter talks a lot about vision and creating a sense of urgency through vision. So having a vision about your unit and how Foley catheters are used in terms of no Foley catheters placed without an evidence-based indication, and every Foley catheter out as soon as that indication has waned. And if they really need to be in, they should be in in an aseptic and sterile fashion and maintained that way. (0:21:37 Inaudible). And if all else fails, don't forget the cookies. So, again, John Kotter talks about celebrating early wins and building momentum. And recognition and reward are important parts of motivation. And it doesn't have to be extravagant things. It can be certificates, or cookies, or candy, things like that, just to kind of have position reinforcement about the change that's happening.

Okay, and last story, free popcorn. So, Mel Gibson's movie ‘Payback,' I think many of you've seen it. This was out about 10 years ago. And in Chicago, they screened the movie and they gave everyone free popcorn. These were, again, psychology researchers. And they gave everyone free popcorn. The popcorn did not taste good. It was all stale. And they told everyone again to not eat for a few hours before the movie, so everyone was hungry. And they found that one group consistently ate 50 percent more popcorn than the other group at the end of the movie. They would kind of measure the amount of popcorn people ate. And there was no limit to the popcorn. Everyone had unlimited supply of popcorn.

So, what were the characteristics that were different between the two groups? Age, gender, BMI, all of the above, or none of the above? Okay, very good. This is very representative of what people usually think. The typical answers are that these are personal characteristics that drive the difference between behavior. And this was actually— so the answer is ‘none of the above.' The difference between— so they actually randomized the two groups into groups that had huge containers of popcorn that were unfinishable, to groups that had ultra, ultra huge containers or popcorn that were unfinishable. And they found consistently that it was the group that the ultra, ultra huge containers of popcorn that ate more, even though in either case no one was finishing their popcorn. Okay, so what does that talk about? What looks like a people problem is often a situation problem. So it wasn't the people, they were completely randomized, and it was just the fact that the environment was more conducive to more popcorn eating. So when we execute it, when we execute and evaluate, how are we going to shape the environment with our resources, overcome barriers to make things are (0:24:37 indiscernible) as possible for us to do what we want to do, and evaluate things so people get feedback and can act on good information in terms of what's going on. So, for CAUTI we're going to create structures that facilitate change, that make change more likely. So having condom catheters available, urinals— female and male urinals now, bladder scanners, et cetera. For the ICU, making sure that urimeters are available in the PACU and the ED so that you don't have to change out the— break the seal and change the collecting device. So creating structures and processes that improve likelihood for success, and we're going to talk about a lot of these processes in the next presentation. Then finally, evaluating, so getting the data that allows us to know if we're successfully changing or not, and giving that data back to individuals, and to units, and to organizations. Okay, so to get people to change we need to do a few things. We need to engage them. We need to get them motivated and passionate about it. We need to get them understanding what to do, specifically, and then we need to create an environment for success. And so, we start off that way, and as things aren't going well, we look back and say where are we not exceeding - in engagement, education, execution, or evaluation? And again, that way we can change the values and beliefs about urinary catheters that guides our actions and decisions, and hopefully change our ICU culture about urinary catheters and decreased CAUTI rates, which we'll hear about with our next presenter. And with that, I'll give you to Dr. Wunsch. Thank you.

Hannah Wunsch: Thanks very much for that. Again, for those of you who maybe joined a little bit later, my name is Hannah Wunsch. I'm at Columbia University in New York, and a good afternoon to you for those of you on the East Coast and good morning to those on the West Coast. I am a practicing intensivist. I work in a surgical ICU primarily. And I'm not someone who's an expert the way you just heard about sort of how to get people to change. But I want to give you a little bit or perspective, both from my own experience and also from my research, which really is focused on sort of how people behave and what we do to people in the ICU. And so maybe give you a little different perspective on thinking about how to tackle issues in the ICU. And I think it's important really to understand what are the unique areas in the ICU population, because I think it is more challenging in the ICU and people, I think, have struggles with how to really decrease CAUTIs and decrease catheter use in this patient population. And I want to also kind of talk about trying to reduce CAUTI and reduce use of catheters with some other related similar issues that have gone on in the last 10 to 15 years in care of ICU populations.

So, I'm going to start again with a real patient of the morning, one that I've struggled with. And I don't have any polling for you, but just to think about. It's my last patient in the morning on rounds, so it's 11:45, everybody's tired. They're 75 years old, male, not very exciting history of hypertension and diabetes. And they came out of the operating room about 24 hours earlier for monitoring after a Whipple, a pancreaticoduodenectomy. They're doing well. They've got good urine output. They're not on any vasopressors. And the question comes up of should we take the Foley catheter out. And I put it up there because I don't think there is an easy answer to that one, and certainly different people have very different views in the ICU about whether a catheter is appropriate and necessary, and whether the benefits of having it in are going to outweigh the risks that we know very well. And so, I think that kind of gets to the crux of why do the ICU patients feel special. And kind of all of these are issues in ICU patients. If you touch them, they desaturate. If the patient with ARDS who you're afraid to even move, let alone put a bed pan under, and so certainly that catheter is not going to come out. They're on high doses of vasopressors. They're kidney function is tenuous. Everybody's very worried about them. They're at high risk of a sacral decub. You already kind of heard the alluded to in the prior patient presentation. Or they're at risk for abdominal compartment syndrome. You're monitoring closely the urine output and in fact you're checking bladder pressures on them. Or if they're just in this category, they're sick and we need to know the ins and outs. And again, the kind of concept of the importance of ins and outs in ICU patient every hour was brought up in the prior presentation. And so, I think it really is important to recognize in that sense that there will always, as was mentioned before, there's always going to be the need for urinary catheters in the ICU. That's not going to go away. But what can change is how many of our patients need them and for how long, and then sort of how do we get there. I think there are a number of barriers in the ICU besides just the patients themselves, and a lot of that has to do with the people taking care of them, and our perception, and the structure of the ICU itself. And so here are a couple of barriers to think about that go on in I think most ICUs. That you may have a nurse or physician in the unit who wants to take the Foley out, but then a surgeon who's also been involved in the care of the patient comes by and says, “What are you talking about? Please don't take that Foley catheter out on my patient,” as an example, not to beat up on the surgeons. But there's also the fact that everyone still is focused on ins and outs every hour, and the idea that if you roll through the doors of the ICU, that's one of the things that should be monitored like your heart rate or blood pressure, and therefore how could we possibly have someone sitting in an ICU bed and not have that information. And then in ICU patients, they're so complicated and there are so many things to go over with regard to their care, that sometimes the fact that they have a catheter in gets lost in the shuffle. And so I just want to kind of talk a little bit about each of these issues that go on in the ICU. So this issue of having sort of different opinions from different people involved with care. And I think it's important to recognize that ICU care is very complex, even in what we call a closed unit. So even if there's one physicians or one team of physicians making decisions technically for these patients, the ICU team is a big team of a lot of people invested in the care of that patient. You've got maybe an intensivist, pharmacist, respiratory therapist, nurse, surgeon, infectious disease specialist. If you work in an academic center, there are residents, and interns, and med students, and a lot of people looking at that patient, gathering information, helping to take care of that patient. And I've exaggerated here in terms of the emergency medicine patient sitting in the emergency department, but I think it is generally a little bit simpler in terms of the fact that that patient's really being cared for by a team that's usually an emergency medicine physician, maybe a resident as well, and a nurse. And because they're not there as long, and that's one of the issues too that I want to highlight is things like in the emergency department the time they're cared for in that environment is shorter. The time they're in the ICU is very long. You're looking at them day in and day out, 24 hours a day, trying to figure out what to do for them, how to care for them, how to get them better. And so, I think that all of those factors do play a role in the fact that when we talk about engaging people, we've got to not only engage the people who are physically in the unit all the time, but also all those people who comes through and are providing their opinion on the care of that patient.

What about this aspect of everybody still wanting ins and outs every hour and kind of clinging to that? And I think that that's an area where we really have the most room to change people's perception of what they need regarding information on their ICU patients. Not all of them. Again, there's always going to be those patients who really are so sick where hour-to-hour information is essential. But I think we have a lot of patients who sit in our units where we feel better knowing what the urine is, but it's not really essential to their care. And this is where I want to liken it to some of the other things that have changed in ICU care. So it used to be that a lot of our patients got Swan-Ganz catheters, right? Everybody wanted a wedge pressure on every sick patient that came into the unit. So if you were on vasopressors or septic shock, you automatically got a Swan in many places. And what's been encouraging about this is as we started to question whether or not we actually needed all of that information all the time on patients, again, just because they were a sick ICU patient. What we found was that the use of Swan-Ganz catheters really has decreased. And this line actually does go out to 2006 there, not just stopping in 2003. And it's very encouraging, I think, because I think it really shows that we are capable of changing our use of invasive monitors and things that we stick in patients in the ICU, and that we're able to embrace change as a community in terms of the care of critically ill patients. But it doesn't happen overnight and I think this graph shows you that this is years of work. The other thing to note here is that it doesn't go to zero. There are still patients who receive Swan-Ganz catheters, and like urinary catheters in the ICU, I don't think that's ever going to change.

What's also interesting, this is some work we did, again, looking more closely at ICU patients who get pulmonary artery catheters to see kind of what are the trends going on out here till 2008 on this graph. And this is medical ICU patients. And what it's showing you is for each unit, each medical ICU, what's the average percentage of patients who received Swan-Ganz catheters. Back in 2001 to 2003 it was 3.5 percent, and how it's dropped to an average of 1.1 percent. So that's a pretty— in absolute percentage, not that high, but a pretty impressive drop in terms of use. And the other thing to note there is there was a big range of use back in 2001 to 2003 in the MICU, and that we've actually decreased that range. But people are much more in line with this general trend. Similarly, this is looking at mechanically-ventilated and then ALI/ARDS patients and patients with vasopressors, all groups who were perceived as needing Swan-Ganz catheters. What you can see is that we've been pretty good across the board at decreasing use. And so again, even in the patients where initially there was a lot of resistance saying, “No, no, no. Not in my patient on 10 of norepinephrine,” that we've really been able to change that culture. So I think these are encouraging data in terms of what can happen in trends in ICU care, and that there is precedent for the fact that  we're able to think about changing what kind of information we need on our patient in the ICU.

But I think it's also important to recognize where there are sort of maybe some holdouts, or where the trouble is in terms of getting people to change practice. And what we found looking at who was still most likely to get a Swan-Ganz catheter was that patients in surgical ICUs were still getting them more frequently. And interestingly, down here at the bottom you can see if it was a patient in the unit with no critical care consult, so presumably being cared for by physicians and nurses with maybe a little bit less experience with the care of these patients, that you can see the likelihood of getting a Swan was still very, very high in comparison. So, I think having research data on where are the holdouts and who do we need to target is really helpful, and again, particularly in places where we have so many different people coming in and out taking care of these patients.

Finally, there are so many other things to discuss on rounds. And I think this is always going to be a problem in the care of ICU patients. There's so much talk about (0:37:18 indiscernible). And I want to go back to the four Es and emphasize sort of a few little additions in there, some of which have already been discussed, but really put it in the context of the ICU patient. So engaging, educating, and then really empowering people. And this is kind of harkening back to Peter Pronovost's work on fighting against CLABSIs to say when putting in a central line we really need to empower the nurse taking care of that patient to stop things if they're not being done appropriately. And having that empowerment of the people involved in the care I think is essential. And then executing. But also—and this was mentioned with the cookies—celebrating, and really celebrating what we're doing for our patient as a positive thing.

And so, just going back to the list of all the many people, and I apologize if I've left off others who are involved in care, you only need one of these people on rounds or in the care of a patient every day to speak up and say what about that Foley catheter, or does this patient need to have a catheter in. And so, I think that really making it an inclusive opportunity for improving care of patients is essential, and that the ICU is really unusual in that regard for being so multidisciplinary, and it's so important that everybody is engaged in those decisions and in those care models.

I want to mention an example of empowerment that I recently heard about. I was in a meeting in New Zealand and someone was talking about how they improved their adherence to (0:39:00 indiscernible), to try to get the head of the bed at 30 degrees. And what they said was that they involved not only the nurses and physicians in the care of those patients in the ICU, they involved the cleaners in the ICU. So, the cleaners were not empowered to go and actually change the head of the bed on the patient, that wouldn't have been appropriate. But they were encouraged to speak up and actually mention if they went into a room to clean and the head of the bed was not at 30 degrees. And when they actually celebrated the success of improvement in their adherence, there was a picture of a kick, and there was a nurse, and a physician, and a cleaner, and they were all sitting there smiling, sharing in that success. And so I thought that was a very cool example of the way an ICU really is unique and really requires involvement of so many different people. The other thing is that ICU is a lot of doing of things and people are attracted to working in ICUs I think because the care of these patients requires lots of activity and feeling good about doing stuff for people. Placing the Foley, central line, monitoring those ins and outs, placing the A-line, sending off to the lab and following it up, intubating, it goes on, and on, and on, and it's very satisfying to feel like you're doing the next test and doing the next thing for your patient to improve their care. And I just want to mention— whoops. I've blacked out her face here. That wasn't quite supposed to come up yet. But this is Linda Lewis who you can't see there in the picture. And she was actually a physician at Columbia, and she coined the phrase, or actually, the phrase was described by Jerome Groopman, who was a writer for The New Yorker,who trained with her, that she really emphasized this concept of “don't just do something, stand there.” And that is a very hard thing to do, particularly in ICU patients who are sick to feel good about not having information and not doing things to people. And that may include not putting in that Foley catheter. And I think that that's where really emphasizing sort of the cookies, but really even without cookies, just the celebration of feeling good about not doing something to someone, or improving their care by removing something from them. And so, as an example, on rounds I really try to make an emphasis, particularly when teaching our next generation, the medical students and the residents I work with, to get them to feel really good when we make that decision to take the Foley catheter out, and to say that's a great thing we're doing for that patient. You should feel good about that. They're going to be more mobile. We're decreasing their risk of infection. We're decreasing the risk of trauma. That's a great thing you're doing for that person. And it's amazing how after just saying that once or twice on rounds, suddenly those people on rounds with me are the ones bringing up the catheter. They want to feel that satisfaction about focusing on something like removal of a catheter. And it is kind of infectious once you start doing that. So I would definitely emphasize, as was mentioned in the last talk, the importance of celebrating those little successes along the way and really bringing people on board that way. So I'm going to stop there as sort of my perspective on things, and let us move on to the next two speakers who I think are the final speakers of the hour. Thank you.

Marlon Medina: Alright, good morning. Thank you. My name is Marlon Medina and I just wanted to give you a perspective of our experience here at University Medical Center of Southern Nevada. I started working here at the ICU about two years ago. I was then approached by my director to participate in a Stop CAUTI project. And at first, I was not bought in with this concept. I still had this old school mentality that all patients in ICU got a Foley. And so, I did my own research with evidence-based practice and browsed through the CAUTI and CUSP websites, and educated myself on the importance of decreasing CAUTI. So, what I did was I assembled a team and I want to introduce to you a nurse who's been instrumental in the success in our department, and actually put a major dent in the change in culture in our organization. Her name is Ashley Komacsar.

Ashley Komacsar: Thank you, John. Boy, this has been quite a journey through this project and I just want to share with you a little bit of what we experienced over our last 18 months with being involved in On the CUSP: Stop CAUTI. This is kind of our honey-do list of things that we needed to assemble, as John mentioned, when we got on board with this project. We did state-wide implementation meetings, got our team together. Just like making a good cake, you need the best ingredients, and that's what we tried to do was assemble a team that was going to work well and (0:44:13 indiscernible) together very well. We did a safety survey that gave us a baseline data of where we stood on our unit, and just kind of looked at our policies and procedures and just kind of participated, just as you are all now, through these calls, and kind of guided our experience through this.

On the next slide, this is just a little snapshot of who was involved in our team. We had our unit manager, instrumental of course with kind of rallying the troops and kind of giving some structure with our charge nurses. The team leader is peer champion, which I had the pleasure of serving with there to kind of coordinate projects and kind of help empower the staff from more of a peer level than from kind of a hierarchical type of structure. Without the staff nurse participation, this project wouldn't have happened, those catheters wouldn't have come out. We coordinated extensively with our infection control department to help us with our data collection and submission, and really helped us kind of analyze the data, which was something I was kind of new to as a staff nurse when getting involved in this project. We had a terrific physician champion who was one of the medical ICU attendings with our ICU team who really helped to coordinate efforts with the residents who see a majority of our patients and really kind of coordinate it with the rounds. And we asked our chief financial officer to be our executive champion and to kind of bridge the C-suite to the bedside and kind of help efforts on that end, because this is about a comprehensive safety program and we wanted everybody to be involved.

We began first by looking at what our Foley policy was when we started this project. At the start of this project, this is a physician-driven process and daily order needed to be assessed. And we were also doing daily bundle checklists that the nurse at her shift change would complete when the care was done. Like I had mentioned, we had an executive champion. We had the pleasure of stealing her away from her very busy duties up in the C-suite to come around with the staff, give her an explanation of what we were doing, and give her a chance to speak with some of the staff members, and maybe have some of their concerns heard about what this implication is, and help allocate some resources for us to continue. Team member participation, just like this call here. We sat and listened to the national content calls which was greatly inspiring, and have us a lot of good ideas, and kind of when we got stuck gave us ideas on where we could go with things. And as always, the state coaching calls kind of helped to keep everybody in the state on goal and gave us a chance to talk with our neighbors about what's going on in their hospital, what's working, and offer support and assistance. It was a great communication tool. And then as well as on our unit as a team leader we had CAUTI team meetings, usually quarterly. And donuts are a great incentive. We had our staff nurses, our unit manager, and whatever staff was available to come in and reflect on— share the national content calls with staff who weren't able to attend them, as well as brainstorm ideas for where we're going to move forward with our project. We also attended state-wide learning sessions in Reno. Dr. Chu who you heard from was actually at those, so that was very great to meet him in person, and got us a chance to state wide meet face-to-face and talk about barriers, and goals, and strategies, and really was a good opportunity to see how everybody else is doing it and maybe help us get through some of the humps and hurdles that we were having. We wrapped up our project in February of this year. So we shared our final data and as kind of a positive thing we were presented award certificates. Our unit got most collaborative and we were pretty excited about that, so it gave us a nice little recognition for the staff. And  we proudly display the plaque that we got on our unit, so for all he staff and family to see.  On the CUSP in action. Some of the changes that we were able to make through this project include CUSP information boards, we put a decision tree algorithm which is available at onthecuspstophai.org. We used a lot of the tools that were available through the website and I encourage you all to do that. So we put those Foley decision trees in each of the rooms as kind of visual reminders to staff and family of hey, do I still need this. And still continue to have the CUSP meetings quarterly to discuss that we can do. House-wide we were able to have our catheter supplier come and give us some testing, and provide some training for us so we can train some superusers. We also made more catheter alternatives available. We brought in a different type of condom catheter for men. We (0:49:22 indiscernible) staff on female urinal use and we also started revising our Foley policies and procedures, and worked on developing a nursing-driven Foley removal protocol. This is a little look at the information boards that were placed on the unit to kind of give everybody a little information on what CUSP is and what CAUTI is, and why this project is important. So, it's been a great conversation piece for family as they walk through the unit to say hey, this is what we're working to help make your loved ones safer. This is a look at our version of the Foley decision tree that's available at On the CUSP: Stop HAI toolkit resources. So this is placed in every room and you would put the Foley insert date. And it was just kind of a quick little visual algorithm to do through and decide hey, am I still on task for what I'm doing with that Foley. We also— one of my favorite things that came out of this is when I started with this project, part of the problem is I found a barrier was we don't know when these infectious are occurring. So, through coordinating with infection control, I developed this CAUTI alert. This was a quick SBAR style tool to get the information about the infections to the staff in a very non-punitive manner and for us to do a quick root-cause analysis of what happened with certain staff members. And we kind of looked at who was involved. It was (0:50:46 indiscernible) privately, but this was just a very generic way of getting information out there, and as well as educating people on the standards that we're held to with NHSN for reporting these infections. So, it's been a great tool and a lot of the other departments have been adapting this as well. The training, once again, our catheter provider came in and was able to do some classes and we got superusers trained. Our education department worked with them to develop some departmental testing and incorporate it into skills there. I'm just going to touch briefly; we were able to inservice staff on the female urinal use. And we created this little handout here on how to use it because that was kind of a big barrier, nobody knew how to use the urinal. And they were well received by the staff. We also made sure that catheter trays were being stocked appropriately in the ICUs. We like our urimeter bags, so a lot of people were routinely changing Foley bags out to switch it, and since that wasn't recommended, we worked on stocking the appropriate supplies where they needed to be so this wasn't happening. And we collaborate with our nursing students and were able to incorporate them into our project. And this was a board that they created for us to keep staff aware of our CAUTI infections, and it was really a great learning experience.

And just a couple of our brags. This was us at Learning Session 3. We were also featured in a special CAUTI handout on using CUSP strategy and that was very exciting. We also had the pleasure of serving at our quality improvement organization's winter plenary, and sharing our experience, and as well as getting to talk to all of you today. Our barriers were kind of inline with probably a lot of other things that are here. Buy-in, time, and resources. We're at a county hospital; there isn't really a budget for anything. We had big projects rolling out as well, and plus the anxiety of a new thing coming. This really, this is where we're at. We're really advocating for the use and we've had a little bit of bumps towards the end of our year, but we're still continuing with this effort and our administration is very proud of what we've been able to do as a unit with this project. And once again, thank you and I really encourage you to use your resources on On the CUSP: Stop HAI. That has really helped us with our project tremendously.

Ashley Hofmann: Great, thanks so much, Ashley. We really appreciate you guys sharing that story about your journey through the CAUTI project. Operator, can you begin the Q&A session by first giving instructions for asking a question, and then we'll also address some questions from the chat as well. So, Operator?

Operator: Yes, ma'am. 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 ‘1' 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, please press ‘star 2.' Again, to ask a question, please press ‘star 1' now.

Ashley Hofmann: And then, Doctors Chu and Wunsch, we had some questions in the chat about a process for limiting Is and Os. I don't know if either of you could kind of address that or if you've been reading through the chat and the conversation that's going on there.

Hannah Wunsch: Yeah, this is Hannah Wunsch. Yeah, so I've just been reading through and I mean, basically it's great questions and I think I don't have any good answers off the top of my head of sort of how do we limit that. I do think that that's definitely a culture change that goes back to what Dr. Chu really talked about, and I think is in that barrier to being able to move towards taking out catheters, that we have to address that first and educate people to feel comfortable without that. I think it was pointed out that sometimes we say we're getting ins and outs every hour, but they aren't recorded for many hours. So I do think in the ICU, one of the things is there's a lot of communication back and forth hourly between nurses and the other staff. And so, even if it's not recorded, often people definitely are paying attention to it. And it is a crutch and who needs it, and I'm not aware of any good guidelines on it. And I don't know if Dr. Chu has other views on that.

Eugene Chu: Yeah, this is Eugene. I agree. I think that it's something that we're used to. I think the analogy with the (0:55:35 indiscernible) is very good and that on the floor we've almost completely eliminated any Foley catheters for Is and Os measurement for CHF. And what you realize is that you can do just fine without them. You can use Is and Os through urinals. You can use daily waste. You can use jugular venous distension assessments, peripheral edema, (0:56:03 indiscernible), chest x-ray. There's so much data that you have to assess volume status, and we have (0:56:10 indiscernible), all sorts of things that are far less invasive and risky that a Foley catheter or urinary catheter. In our ICUs we have a similar situation where it's very difficult, I mean, our nurses, you have to really, really push to get a urinary catheter in. I mean, it really has to meet indications. Our culture has totally changed where urinary catheters are seen as necessary evils and not necessarily friends of the providers. But I think (0:56:48 indiscernible) when you have and you're not sure if it's dry or wet, I mean, we have something very clear there. But I think just really being conscious about whether you're really going to use the information. We have intubated patients that we don't put Foley catheters in, because they're (0:57:13 indiscernible) intubate them and their cardiopulmonary status is mostly just airways protection. So I think really developing a culture of do we really need this information, because again, I think there isn't a great guideline for that.

Operator: Thank you, our first question comes from— I'm sorry. Our first question comes from Monica Fontes with Carondelet Health Network.

Monica Fontes: Hi, good morning. Again, I think you more or less answered the question before I could take myself off queue, but that was to see if anybody had had any success in developing any type of guideline, or again, a decision type of a tree for addressing Is and Os, because that is our crutch. And again, you've answered the question, I think.

Hannah Wunsch: Wish we had a better answer.

Eugene Chu: Yeah. It's tough. And really, it's one of those things we're day to day just saying do we really need this, do we really need this, and are we really using this information and really making the culture such that you recognize the dangers of the intervention of the catheter, and are consciously questioning whether you really need that. I think once you do that, the providers will gravitate towards an understanding of when they actually are using the data and when it's just something that is habit.

Operator: Thank you. Again, ladies and gentlemen, if you would like to ask a question, please press ‘star 1' now.

Ashley Hofmann: This is Ashley Hofmann with HRET. Ashley and John, would you guys be willing to share those resources that you developed? Some of the staff alerts and those things?

Ashley Komacsar: Oh, absolutely. I can forward them to you, Ashley, and (0:59:22 indiscernible). I know I saw on some of the chat that some people are very interested, and I would be more than happy to share because we found it was a great tool to get everybody on board.

Ashley Hofmann: I'll get those from you and then we can post them on the project website. So everyone should be able to find that under the content calls (0:59:39 indiscernible) additional resources under the recording and PowerPoint from today's presentation.

Operator: Again, ladies and gentlemen, to ask a question, please press ‘star 1' now.

Ashley Hofmann: Looks like there's another question in the chat as well. The—I can't pronounce that word—pharmacologically-induced coma. Is that a criteria for the Foley?

Ashley Komacsar: Ashley, can I go ahead and take a shot at this? We recently revised our policy to roll out with a nurse-driven Foley removal protocol. And with that, we were looking at that blanket acute care, or the ICU Is and Os. We decided to include that as a reason because of the side effects on those meds are urinary retention. And we were finding as we were pulling some of the Foleys out on these patients that had this, we were having a lot of urinary retention with that. So we made that an appropriate indication, if they were on certain types of meds that would have kind of those anticholinergic side effects, that that would be a reason to keep the Foley in the patient. But we would first try to remove it.

Ashley Hofmann: Okay, thanks so much. And kind of just to intersect for everyone's (1:00:59 indiscernible). I know that we are over, so if you guys want to post questions in the chat, definitely feel free to do that. We'll leave it open for a little bit. You can also email us at onthecuspstophai@aha.org and we can send those questions out to our presenters and get them answered, and then post them on the website as well. And then I do want to turn it over to my colleague Janine really quickly to give a preview of what's coming up next month.

Janine Reisinger: Thank you, Ashley. Hello, everyone. Thank you so much for participating in today's call. Hopefully it was very fruitful and you have some lessons to take back to your own organization. Your feedback is very important to us, so we would appreciate if you'd take a moment to fill out the survey evaluation of today's presentation and let us know your thoughts. Then also, if there are other future topics you would like to hear about. And a preview for our upcoming call. So, our next call will be taking place on June 10, and it'll be Dr. Scott Flanders and Dr. Arjun Srinivasan talking about specifically antimicrobial prescribing. Thanks again to our speakers today, Dr. Eugene Chu, Dr. Hannah Wunsch, and the team from Nevada. We appreciate your time and look forward to speaking to you all again on the June National Content Call. Thank you very much.

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