Preventing CAUTI in Special Populations: Focus on Procedure-Related Catheter Use (July 8, 2014)

July National Content Call
July 8, 2014
11:00AM CT

Operator: This is a recording of the Paul Tedrick conference, the July National Content Call, on July 8, 2014 at 11:00AM Central. Excuse me, everyone. We now have our speakers in conference. Please note the participation on this call is by express written invitation from the AHA and for AHA members only. Unauthorized participants and/or any party that aids unauthorized participants may be subject to criminal and total penalties under both state and federal law, including the Electronic Privacy Act. At the conclusion of today's presentation, we will pen the floor for your questions. At that time, instructions will be given if you'd like to ask a question. It is now my pleasure to introduce today's first presenter, Ms. Jeanine Resinger.

Jeanine Resinger: Thank you, David. Hi, everyone, and welcome to the July National Content call. We're so excited to have you with us on today's call, which will focus on "Procedural Related Catheter Use." Before we begin today's presentation, just a quick reminder that today's call is a webinar, so please be sure to log into the webinar link in order to see the slides. A copy of the slides and the recording will be posted on the project website later this week. Today's presenters include Dr. David Pegues, who is the Medical Director of Health Care Epidemiology Infection Prevention and Control and of the Antimicrobial Stewardship Program at the Hospital of the University of Pennsylvania. He's a Professor of Medicine under the General Infectious Diseases at the University of Pennsylvania School of Medicine. We also have Dr. Gregory Kennedy, who is a Colon and Rectal Surgeon and Associate Professor of Surgery and the Vice-chair for Quality in the Department of Surgery. He has an academic interest in patient safety and effectiveness. He is the Physician Leader of a CAUTI Prevention Group at the University of Wisconsin. Without further adieu, it's my pleasure to introduce our guest speakers. David?

David Pegues: Thanks very much, Jeanine, and welcome all of you who are participating today in the National Content call. By way of outline, Greg and I will be talking today about the use of urinary catheters in surgical practice and other procedure areas. We're going to review the appropriate indications for catheter use among surgical patients and we're going to talk about strategies that limit the duration of urinary catheter use, particularly around the prevention of management of post-operative urinary retention. Greg's portion of the presentation is going to highlight some of the clinical perils and pratfalls of implementing a protocol to decrease the duration of urinary catheter use in his hospital among his surgical patient population.

Next slide, please. Just by way of brief review, you know that urinary catheter infections are one of the most common healthcare-associated infections. A recent prevalent survey done in the United States suggests that almost 13 percent of all healthcare-associated infections representing almost 100,000 cases per year are urinary tract infections; the bulk of which about 75 or more percent are associated with indwelling urinary catheters, and recent estimates suggest that about a quarter of patients who are hospitalized will have an indwelling urinary catheter at some point during their hospitalization. Most have a short duration of anywhere from two to four days, but many critically ill patients, that duration will be substantially longer, and as a result, their risk of acquiring a device associated infection increases below the probability of developing bacteriuria increases with duration of catheterization; whereby a month or 30 days, 100 percent of patients will have bacteria or bacteriuria associated with their indwelling urinary catheter, particularly associated with the formation of biofilm.

Next slide, please. So, for the first polling question, does your facility currently perform surveillance for CAUTI on surgical patients? The options are yes, no, and no, but we'll have to in January, 2015. And that last option reflects it back that as part of the in-patient CMS quality reporting program, all adult and pediatric patients in both ICU's and acute care units will be reportable in terms of CAUTI surveillance beginning in January, 2015. So, please go ahead and vote. And, Jeanine, tell us how long we need to wait or go ahead and show us the polling results.

Jeanine Resinger: Sure. We still have some people actively voting, so give another 10 seconds.

David Pegues: Sure. Vote early and vote often.

Jeanine Resinger: All right. We'll go ahead and show the results.

David Pegues: Oh, that's impressive. The bulk of people participating in today's call, fully 90 percent, are currently performing CAUTI surveillance among surgical patients, and an additional 7 percent will be performing beginning in 2015. So, this talk, therefore, should be particularly relevant to our audience. That's always good to know.

Next slide, please. This is some recent data from the CDC's national health care surveillance network looking at rates of catheter-associated UTI and urinary catheter device utilization by a variety of surgical ICU and acute care types. And you can see in the blue bars that our rates of CAUTI range anywhere from 1.2 to 3.2 per thousand device days and device utilization ranges from about 20 to 25 percent among surgical acute care units, up to 75 percent in surgical intensive care units in major teaching hospitals.

Next slide, please. The bulk of these catheters in surgical patients are placed in the pre or peri-operative period to manage inter-operative and immediate post-operative urinary output in patients undergoing major surgical procedures, but there are a variety of other procedure areas where urinary catheters may be placed. These include labor and delivery among women undergoing elective or emergency section procedures; electrophysiology labs, particularly in patients with congestive heart failure who are undergoing oblation procedures for current ventricular arrhythmias, and interventional radiology in a subset of patients, particularly those undergoing basic GE procedures, and increasingly in ambulatory surgical centers as well.

Next slide. If many of you have participated in previous national content calls, you'll probably be familiar with Jennifer Meddings and Sanjay Saint's nice model of the life cycle of the urinary catheter emphasizing that at each point along the life cycle of the urinary catheter, from insertion, maintenance, removal, and reinsertion, there's an opportunity for evidence-based practices to decrease the use of urinary catheters and to insert and maintain them appropriately. And I just highlighted here that three of the four life stages, if you will, are particularly relevant to management of urinary catheters in surgical patients focusing on unnecessary and improper placement, prompt catheter removal in the immediate post-op period, and the use of post-catheter removal protocols that decrease the need for reinsertion of catheters among patients with urinary retention.

Next slide. So, let's get down to the meat of the matter, so to speak. Why are urinary catheters used peri-operatively? And there are three major reasons. First and foremost, of which is monitoring urine output during and after major surgical procedures. For patients with excessive inter-operative blood loss, they're an important tool to have guide inter and immediate post-operative volume resuscitation. And in a portion of patients, particularly those undergoing elective surgical procedures or receiving certain types of regional anesthesia, they have an important role to play in preventing the risk of post-operative urinary retention.

Next slide. So, harkening back to the 2009 HICPAC guidelines to prevent catheter associated urinary tract infection, I've highlighted here in red appropriate peri-operative indications for the use of indwelling urinary catheters that involve certain surgical procedures, particularly those that are involving the urologic tract or continuous GU tract for patients who are undergoing prolonged surgical procedures, whether it's clearly an opportunity to remove them in immediate post-operative setting in the PACU; for those patients undergoing or anticipating undergoing recent of large volumes of infusions and/or diuretics during surgery, for patients who have preexisting urinary continence, and for those where there's need for inter and immediate post-operative monitoring of urinary output.

Next slide. With respect to inappropriate indications that are felt to be present when catheter use is excessive in terms of duration without an appropriate indication, such as repair of a urethra or contiguous structure, or prolonged acts of epidural anesthesia, and for routine use in patients receiving epidural anesthesia or analgesia. In other words, just because you're getting an epidural for pain relief or inter-operative anesthesia is not a reason that the patient required an indwelling urinary catheter.

Next slide. Let's go back more than a decade ago with the advent of SIS, the precursor of the SCIP program for surgical improvement program. This is looking at data from 2001 with almost 36,000 patients undergoing major surgical procedures. You can see impressive overall prevalence of catheter use of 86 percent, and something that I think you will agree is intuitive with catheter duration, longer than two days, you see an early divergence at about six or seven days and the risk post-operatively of developing catheter associated urinary tract infections. And clearly, this utilization more than a decade ago, in excess of 50 percent of patients with catheter use for more than two days was an opportunity to decrease catheter use in the surgical population by early post-operative removal.

Next slide, please. So, polling question two: What is your compliance with the SCIP infection nine process measure? Less than 80 percent? 80 to 90? 89 percent? 90 to 95? Greater than 95 percent? And for some of you, what is SCIP infection nine? Please go ahead and vote.

Jeanine Resinger: We have about 15 more seconds.

David Pegues: Of participants today, 55 percent fully indicate that they're compliant with SCIP infection nine is greater than 95 percent. I included the last question: What is SCIP infection nine to indicate that, and not surprisingly, that some people don't know that this is a publicly reported process measure. So, let's talk about what SCIP infection nine is.

Next slide, please. SCIP infection nine is a CMS incentive for Medicare services mandated SCIP process measure. The measure states that patients whose urinary catheters need to be removed on the first or second day after surgery. Currently, it's one of 12 of these clinical process of care measures that will have in fiscal year '15 a domain weight of 20 percent. Historically, in recent years, it's been given an even greater weight. But the patient experience is being increasingly valued. Importantly, and I think consistent with our poll results, the current compliance rate, that's rate not rat, is 97 percent, so it's nearly topped out. Many hospitals that are focused on that have achieved these high rates overall of compliance through the use of pre-printed post-operative order sets and other process of care that limit the duration of catheter use. It's important to note that there are exceptions in patient populations. Patients undergoing procedures where they may require a more prolonged duration of catheter use, like urologic or gynecological perineal procedures, as we emphasized before in the appropriate use criteria. But there's also an opt-out, if you will, patients who had a physician, advance nurse practitioner, or a physician's assistant documentation of a reason for not removing the urinary catheter. So, let me show you an illustrative study that I came across recently.

Next slide. This is from Emory University, and their aim in using a retrospective case control study design was to correlate compliance overall with this SCIP process of care measure removing the urinary catheter post-operative day one or two with monthly rates of UTI among general and vascular surgical patients. And I just included the process measure there; the exemptions, and how the CMS requires documentation.

Next slide. So, what did they find? I don't expect you all to be experts in linear aggression, but that R is a small number and basically showing an inverse relationship between the rate of UTI's and the risk or the compliance with SCIP infection nine, but there is no significant correlation. That's what that large P value means. When you look at the figure on the right, relationship between UTI cases and exemptions, the green line shows the overall number of cases by month of catheter associated urinary tract infections. And the sort of orange/brown line immediately below it shows essentially that all the urinary tract infections or the vast bulk of them were occurring in patients who were exempt from SCIP infection nine, because of physician, nurse practitioner, or a physician's assistant exemption or certain surgical procedures. The odds for developing UTI, the highest odds were associated with patients who had exempt status, and the author's take home point for this study is way too many exemptions exist for SCIP infection nine to be an effective driver reducing the overall urinary catheter use among all surgical patients and reducing their risk of post-operative CAUTI's.

Next slide. So, let's talk about post--operative urinary retention and clearly one of the important reasons for the use of urinary catheters in surgical practice. This is in a sense to be comprehensive, but simply indicate in a variety of general and special surgical procedures, the incidence of post-operative urinary tract prevention were poor can be quite substantial, up to almost 85 percent of patients undergoing rectal or low perineal resections, surgical procedures, particularly for colorectal carcinoma. Risk factors; again, not comprehensive, but not surprisingly, include peri-operative, inter-, and post-operative risk factors. Peri-operative risk factors include some demographics, like age, gender, benign prostatic hypertrophy, previous surgery, or underlying neurologic diseases that may be associated with neurogenic bladder and use of certain medications, which increase the incidence of urinary retention. We're going to talk at some length about the role of anesthesia and a choice of anesthesia causing post-operative urinary retention, both in the inter- as well as the post-operative period.

Next slide, please. So, let's get a more recent estimate of what the incidence of post-operative urinary retention. And the management is in a selective surgical procedure with a high prevalence of catheter use totals only the last five years. In this case series, almost 290 consecutive patients undergoing total knee or total hip arthroplasty were assessed in terms of their complications, risk factors, and management of post-operative urinary tract infection. Not surprisingly, it's 73 out of 286 patients who had post-operative urinary tract infection had a tow and a half times greater risk of developing the UTI, and on average, had one additional day length of stay related to their urinary retention. And I think this study was important because it showed the risk of post-operative urinary tract retention varies by the type of anesthesia, being greatest for those patients receiving epidural, compared to patients in total analgesia, and lowest for patients undergoing continuous peripheral nerve block. Management in patients, about a quarter of patients required only about a single in and out straight catheterization following the use of a bladder scan. An additional 10 percent required two straight caths, and a number of patients, almost two-thirds, required replacement of the urinary catheter for up to 48 hours.

Next slide, please. So, there are useful scoring systems which can help pre-operatively predict a patient's risk of developing post-operative urinary retention. And one of these risk models is the International Prostate Symptom score. American Urologic Association designed it a couple of decades ago and there are seven simple and straight-forward questions scored on the basis of one to five in terms of the frequency, including incomplete bladder emptying, urinary frequency, intermittency, urinary urgency, weak stream, straining, and nocturia, where the score is given for the number of episodes per night. And the risk of post-operative urinary retention varied, depending on what the score is, with the maximum score being 35. The usefulness of this IPSS score for predicting post-operative urinary retention in patients undergoing total arthroplasty has been somewhat variable, however.

Next slide. Here is one recent study from England of 100 consecutive male patients undergoing either total knee or total hip arthroplasty. Of these, eight patients were excluded because they required a pre-operative urinary catheter for urinary retention. Their mean age was 68 years. All of them underwent spinal anesthesia and an additional third had a peripheral nerve block. Those with mild, moderate, or severe IPSS scores were assessed far and away. 50 percent had mild and IPSS scores, and had a risk of short-term urinary retention, and requirement for catheterization of about 25 percent. In contrast, those who scored a severe, having scores anywhere from 20 to 35 on their IPSS score, had a risk of post-operative urinary retention and need for catheterization in excess of 80 percent.

Next slide. So, if we've found that male patients, particularly those who are in their sixth or seventh decade of life with underlying benign prostatic hypertrophy and symptoms reflected in the IPSS score are at risk of post-operative urinary retention, what can be done peri-operatively to decrease that risk? And this is a study that was published recently in a Brazilian urologic journal that looked at a small but prospective randomized double-blind placebo-controlled study done at a single teaching hospital; 232 male patients undergoing elective GU or urologic surgery; that include fair field surgery, (PH :00:20:52) engrohernialorthy, or scrotal surgery. Patients were randomized to receive (PH 00:20:57) Pancelozin or placebo and the drugs were given two hours pre- and 10 hours post-surgery, and they looked at the incidence of post-operative urinary retention, and found overall that those receiving Pancelozin had a 6 percent, compared to a 23 percent, so a one-quarter risk of post-operative urinary retention. So, there not only are patients at high risk of post-operative urinary retention based on their IPSS score, but once you identify high risk patients, Pancelozin or another alpha-blocking agent can potentially decrease the risk of urinary retention and the need for intermittent catheterization or replacing the indwelling urinary catheter.

Next slide. And this was a recent systematic review from the anesthesia literature showing a large number of studies looking at the mean incidence and competence intervals around the risk of post-operative urinary retention associated with different routes and forms of anesthesia; overall risks associated with general anesthesia was 17 percent. Those who are undergoing regional blockades had similar incidence, but the highest incidence overall was associated with patients undergoing epidural anesthesia.

Next slide. So, polling question number three: Do you know whether urinary catheters are routinely inserted in patients receiving epidural anesthesia at your facility? And the choices are: Yes, all patients; Yes, but only in selective patients; Never; or don't know. Please go ahead and vote.

Jeanine Resinger: Okay. We've got about another 10 seconds.

David Pegues: We're pretty evenly split between al patients, selected patients, and don't know. And if you would ask me this question a year or more ago, I would definitely have voted that I didn't know. Okay? So, the important point is, and I think emphasized by the HICPAC appropriate use criteria that just because a patient is receiving epidural anesthesia does not require the use of an inter- or post-operative indwelling urinary catheter.
Next slide. So, the risk of post-operative urinary retention varies by sight of epidural, by the choice of anesthetic agents, or analgesic agents, as well as by the dosage. And so, this is just a brief review that urinary retention occurs more commonly when the epidural is placed in the lumbar compared to the thoracic position. It's more commonly associated with longer acting local anesthetics; hydrocyclic opioides that cross the blood brain barrier more effectively. That's particularly true for morphine; opioides with high new receptors to electivity. That includes morphine and sentinel epinephrine. And, I think, more importantly in terms of working with your anesthesiologist to find a lower and a higher risk group; the higher doses of (PH 00:24:57) Lucidacane as a regional anesthetic is associated with urinary retention, so doses below 0.1 percent versus even lower incidence in patients receiving this dose need not necessarily receive an indwelling urinary catheter.

Next slide. What about the duration of post-operative urinary catheter use? Appropriate duration for urinary catheter use for patients undergoing thoracic epidural catheters has been looked at in this randomized clinical trial, looking at the risk of UTI among patients with thoracic epidurals who were scored preoperatively having low risk of poor, early removal versus standard care, which basically involved removing the catheter at or before 48 hours versus keeping the catheter in place until the epidural catheter was removed. They looked at outcomes, including UTI rates, the frequency of intermittent catheterization, and the need for repeat catheter insertion. Overall, the urinary tract infection rate was decreased 86 percent among those with early removal of the catheters. The risk of intermittent catheterization was increased four-fold, but typically these patients required one or two intermittent catheterizations. Only 2.8 percent of patients overall required replacement of the urinary catheter for an additional 24 hour period before subsequent removal. So, the take home point is that early removal of the urinary catheter following epidural anesthesia reduces the risk of CAUTI with an acceptable rate of short-term urinary retention that can be managed in all good patients by one or two intermittent catheterizations and the use of a bladder scan.

Next slide. So, what about the duration of catheter use in patients undergoing anal rectal surgery? We mentioned that this is an appropriate indication for a catheter and the exemption for the catheter removal SCIP infection nine measure post-operative day two. Studies suggest that duration of use is all over the map; anywhere from a mean of three to 10 days. And the incidence of poor reported in the literature varies widely over ten-fold, anywhere from 5 to 58 percent, and the risk of CAUTI, however, is substantial in this patient population overall, about 50 percent of patients undergoing these procedures in some series of developed symptomatic urinary tract infections. It's important to note that patients who lack respect or support who are undergoing anal rectal surgery. In other words, they don't have preoperative dysuria. They don't have positive lymph nodes associated with rectal cancer. There is evidence to suggest early cath removal can and has been used successfully to limit the duration of catheter use, and the risk of CAUTI associated with excessive duration of use.

Next slide. So, urinary catheter use for selected urogenital surgery procedures; what does this say? Using urinary catheter versus not using your urinary catheters has been studied. In a recently updated cognitive systematically review using a urinary catheter is associated with a lower incidence of urinary retention. Well, that makes sense. When you have a catheter in place, you're not going to retain urine, but it also shows that the risk of developing a symptomatic urinary tract infection is increased modestly, about 35 percent overall; although, the competence intervals overlap one. Re-catheterization is also increased in patients who use an indwelling urinary catheter versus those who don't. Another question that was discussed in this review includes short-term versus long-term catheter use. I think a more relevant comparison - urinary tract retention, the frequency of urinary tract infections, and the need for re-catheterization were both looked at. There was no significant difference in the risk of urinary retention among patients with one versus three days of catheter use. However, the risk of urinary tract infection was substantially lower, reduced by 50 percent in those with short duration of use compared to one versus three days, and the risk of catheterization or re-catheterization was not different.

Next slide. So, what about a special population – the duration of post-operative catheter use for patients undergoing geriatric or weight reduction surgical procedures. My take home point here is that immobility is not synonymous with immobilization patients who cannot be moved are different than patients who may choose not to move. The goal of early recovery in patients undergoing complex bariatric surgical procedures is to improve early post-operative mobility and a urinary catheter in these patients is an inhibitor to getting them up and about. So, the goal in patients undergoing bariatric surgical procedures is the same as other general GI or abdominal surgical procedures with a catheter should be removed by 24, 48 hours, at the latest.

Next slide, please. To conclude, I tried to summarize some of the teaching points, with respect to peri-operative urinary catheter management and support. Patients at low risk of urinary retention include patients undergoing outpatient surgical procedures in ambulatory surgical centers, short duration procedures, those requiring low volumes to small volumes of intravenous fluid hydration, and local anesthetics. In these patient groups, a urinary catheter should be avoided under most incidences. Among patients undergoing surgical procedures that put them at higher risk and then patients getting most surgical procedures that are more prolonged; i.e., more than two hours or an half an hour who require up to or more than a liter of fluid, they can managed with short-term catheter use with a catheter removed in less than 24 hours. For the small group of patients undergoing anal rectal surgical procedures, lumbar anesthesia or analgesia, there may be a benefit to maintaining urinary catheter for 48 hours with attempted early catheter removal, bladder scan, and an intermittent catheterization, if necessary, for up to 24 to 48 hours.

Next slide.  And finally, polling question number four: To provide your facility utilize a post-removal protocol to manage post-operative urinary retention among your surgical patients. We talked a lot about bladder scanning. Do you have a systematic way of approaching it in your surgical patients who have their catheters removed? Please vote.

Jeanine Resinger: We'll give it another 20 seconds.

David Pegues: Two-thirds of patients in your facilities have the benefit of a post-removal protocol. In the remaining quarter, to one-third, you either don't have a protocol or are considering it, and almost everybody knows what a post-removal protocol is.

Next slide. It's a recommended intervention. This is taken from the updated guideline to prevent CAUTI, published by the Society of Healthcare Epidemiology and Infectious Disease Society of America. They suggest that all hospitals should develop a protocol for management of post-operative urinary retention, including the use of a nurse-directed intermittent catheterization and the use of bladder scanners. To have a removal protocol, you need bladder scanners.

Next slide. So, at our own institution, whether providers who order urinary catheters choose to select a nurse-driven protocol for catheter removal, choose to select a pre-specified condition time or date for catheter removal, or choose to assess on a daily basis the ongoing need for urinary catheter. Once the catheter is removed, in our patients, whether they're surgical or medical, all patients receive the benefit of a post-removal protocol with the use of intermittent bladder scanning for patients with significant urinary retention and inability to void as assessed by the use of a bladder scanner four to six hours after catheter removal.

Next slide is my conclusion. So, to finish this first part of the presentation, if the goal is to reduce procedure-related urinary catheter use, you need to limit the indications to selective procedures in patients who are at increased risk of poor. You need to limit the duration of catheter use by using pre-printed order sets or nurse-driven removal protocols, and you need to limit the risk of reinsertion by the use of the post-removal protocol with bladder scanning. So, that's all fine and good. I've talked about some of the evidence supporting the use of urinary catheters and the need to remove catheters early, following most major surgical procedures. Dr. Kennedy is going to talk a little bit about the implementation science part of things and how sometimes the challenge of evidence butts up against the reality of busy clinical practice. Thank you.

Greg Kennedy: Great. Well, thank you, David. That was an excellent presentation. I wanted to share with the members on the call just the experience we had at the University of Wisconsin in trying to implement our own bladder protocol and decrease our CAUTI rates. Our basic problem, this is in 2011; we started this work. Our basic problem was our CAUTI rates were high. Our device utilization was high, and our SCIP infection nine compliance was low, less than 80 percent. And I did say that the CAUTI rates and device utilization rates were high in both the medical and the surgical patients. So, really we undertook this to, hopefully, reduce both CAUTI and device utilization across the hospital.

Next slide, please. Our approach was to really put together a multi-disciplinary team, and the team leader, RN team leader. We also had a team leader from the C Suite; this was our vice-president of quality. We invited unit nurses to participate as well as some of our clinical nurse specialists, and then, of course, our infection control specialist was invited to participate.

Next slide. To begin, as you laid out, David, we really divided our CAUTI framework into three parts; the insertion, maintenance, and removal. And we thought that to really prevent CAUTI, we'd have to focus on these three areas, but really doing it in a systematic fashion. Insertion, we felt, would require a fairly standard approach. Something that would look more like our CLABSI work with systematic insertion protocols. Maintenance, not exactly clear what to do with maintenance. I think the data is somewhat lacking here, so we felt that that might not be quite the right place to start. And, of course, removal, we thought this would be a really low-lying fruit and a good starting point. So, we went ahead, tried to develop a protocol for removal.

Next slide, please. To do this, we thought, first and foremost, we wanted to empower the unit nurses to remove urinary catheters, based on specific criteria. And, of course, an issue of bladder management protocol that you had been mentioning, David. I'll just note that actually this work was started in 2009 by a much smaller group, really a nurse, really the executives and the hospital really started the work. Put together a bladder management protocol and initiated it. And it completely flopped. The reason it flopped is it was just lack of buy-in by physicians overall. Essentially we got an email one day that said, “Hey, we're starting this and this is going to happen.” And there was really an uprising, for the most part from some of the surgeons really. We really led the charge against it. There were really no considerations from valid root concerns, specifically some of the post-operative urinary retention in our high risk patient population. Catheter removal in patients with epidural weren't considered. So, we felt learning from that early failure we had to get physician buy-in early on.

Next slide, please. To do this, we started really a pre-implementation observation period. So, we collected data prospectively in January of 2012 on our general surgery ward, including patients undergoing elective operation that were requiring admission to the hospital. Why did we choose the surgery ward? Because this is where we were finding our most resistance was from our general surgeons, of which I am one. We looked at 96 patients in the collection; seven were excluded. They did not have an operation. And two of the 89 patients ultimately had a catheter associated tract infection.

Next slide, please. We found our epidural utilization that month was about 32 percent. And what we noticed in the epidural, there was 48 percent of patients with an epidural experienced urinary retention when we removed their catheter early. Six and a half percent of those patients developed urinary tract infection, and 22 percent of patients, full on 22 percent of patients had a reinsertion of their catheter.

Next slide. Our overall rate of urinary retention was around 28 percent, and about 11 percent of those patients ended up with a urinary tract infection. Forty percent required a catheter replacement and 18 percent of patients, who were reinserted, who experienced reinsertion, developed urinary tract infection.

Next slide, please. So, in short, what we ended up doing with this data is we really went back to our anesthesiologists and showed them our rate of post-operative urinary retention in the epidural population. As you pointed out, we expected that rate to be somewhere around 15 to 20 percent. What we found was much higher, closer to 50 percent. It turns out that there was some error in placement. They were actually placing the epidurals a little bit low, so those rates have now dropped down to the more acceptable, around 20 percent. We also fed our data back to the faculty, to our surgical faculty, to release some of the concerns regarding post-operative urinary retention. Just from the hallway talk, the sense was that post-operative urinary retention was going to be over 75 percent, if we removed catheters within the first 24 hours or earlier. What we found was more like 30 percent. This was early removal on everybody. So, I thought that was actually not an unreasonable place to start.

Next slide, please. So, we implemented this early removal and management protocol, really nurse-driven removal, in bladder management protocol. We defined the indications for a catheter. We put those in our electronic medical record; really requiring the providers to select the indication. There was no opt-out button here. There was no “Because I said so,” sort of selection. This was a defined indication for catheter. We documented the presence of a catheter as part of our inter-disciplinary rounds; made sure that we talked about the catheter every day in those rounds, and we knew what the indication was. We implemented a full-on education of the nurses to empower them to remove the catheters. We made this mandatory training sessions for all nurses in the hospital, so it's a pretty onerous actually. We had multiple sessions a day for about a week to get all the nurses in our hospital to come through. We presented the protocol to all physician departments at various venues to garner support; grand rounds, various faculty meetings, and myself and another physician went to all these different grand rounds, or all these different venues, and presented the protocol to everybody, to really get buy-in.

Next slide, please. What we saw over the next couple of years, as our rates of device utilization as highlighted by the blue line on the top, really started to drop down to our current rate of around 0.22. Our CAUTI rate also went down, but not significantly. Remember, CAUTI is a funny definition of a number of urinary tract infections per thousand days. So, as our device utilization rate will drop, our CAUTI rate may actually increase simply by the definition, and we did see some of that early on, but that seems to have plateaued and our CAUTI rates seem to be generally going down. You can kind of get a sense of the trend in the orange bars of perhaps going down. You can see the rates in 2011 are 4.2; 3.5 in 2012, and 3.1 in 2013.
Next slide, please. Where we haven't seen much improvement is in the ICU. Our rates in our ICU have stayed flat, as highlighted here by the blue bar; 58 through 60, the blue line. But our rates in our general wards have continued to go down every year. These are just raw numbers of CAUTI's in the non-ICU units. In the green, you see 96 in 2011 down to 39 in 2013.

Next slide, please. On our surgery ward, dramatically decreased as did our device utilization. So, our surgery ward here is highlighted by the blue arrow; general surgery. You can see our CAUTI of 1.4, and you remember that that rate was closer to 4 in 2011 when we started, so we did see some success in our CAUTI rate in our general surgery unit.

Next slide, please. SCIP infection nine compliance – we had a couple of different working groups going at the same time to improve our compliance with SCIP. But you'll see in 2011, when we started, which is right around December, so 2011. Our rates were less than 90 percent. Over time, we sent out letters to surgical staff. We initiated the best practice alert in our electronic medical record. And you can see that our compliance is now greater than 95 percent, hovering close to 100 percent on a monthly basis here in the last several months.

Next slide, please. Now, our work does continue. While we started this in 2011, we feel our removal and bladder management protocols have been a modest success. We think we have a lot of work left to do. One thing we've noticed is that when talking about insertion, we're not even sure what is getting inserted as far as catheters go. When we started this work, we looked at our inventory of catheters, literally hundreds of catheters in our inventory, from silver coated to regular catheters. Nobody knew what should be used. We're phasing out all of the silver coated catheters, just to try to save some money, and put in a standard 16 French catheter on all units. So, every unit will have the same kit for insertion. An urometer be standard to avoid breaking connection to monitor urine as needed. And other side of the configurations will be available, but we're also implementing more of a consult service, if different sizes or different types of catheters, such as a Coude catheter, are needed. We've implemented a new tray design. The old tray, we felt, was somewhat cumbersome. Multiple trays, cotton balls instead of swabs, stat lock, the locking device for the catheter wasn't included with the tray, so we found a new tray with betadine swabs instead of the cotton balls. The stat locks included in the tray. It's a single layer tray, and that has been implemented in use in the hospital. Now, we're working now on insertion protocols and really standardized insertion, using more of a CLABSI type approach with required draping and trial observers for insertion. Empowering the observers, so if they see a break in sterile technique, they can even say, “Hello. We need to stop this and restart because of a break in sterile technique.” We're hoping that that will result in even more of a decrease in our CAUTI rate. We're also implementing some better patient level data to just assess impact of location insertion and catheter's impact on catheters from outside hospitals; reinsertion frequency, etc.

Next slide, please. So, in summary, what have we learned? A multi-disciplinary team is critical. The size of team can't be too cumbersome, but you really have to get the critical stakeholders, especially the most vocal naysayers. I suspect your hospitals are much like our hospital. Our surgeons tend to be our most vocal naysayers. They tend to have the biggest egos, I suppose, and think they have the most to lose in any of these types of implementation protocols. So, I think embracing those naysayers and trying to get somebody on your side is really important. Part of that, we also have to show the data back. We have to collect data. We have to share it. Until people, both try to allay their fears, as well as share with them how they're doing as they participate in these types of protocols. I think it's important to have thick skin here. Change is hard. Conflict is inevitable. There's going to be a lot of people complaining and, again, having your champions with thick skin is going to be important, and maybe, again, it comes down to involving surgeons in these protocols. Giving the people with the biggest egos to participate. They tend to be the hardest to rile in that case. So, I think that's al' I have.

Next slide, please. I'd be happy to take any questions.

Jeanine Resinger: Great. Thank you so much, Dr. Pegues and Dr. Kennedy. Operator, would you please give the instructions for asking a question?

Operator: Absolutely. Ladies and gentlemen, at this time, the floor is open for your questions. If you would like to ask a question, you may do so now by pressing “star one” on your Touchtone phone. We will take questions in the order they are received. If at any time you need to remove yourself from the questioning queue, press “star two.” Again, to ask an audio question, please press “star one” now.

David Pegues: While we're waiting for our first question, this is David Pegues; I'd like to sort of highlight a couple of things that Dr. Kennedy just mentioned. The first seemed simple, but when not attended to, may be a substantial issue with respect to variations in care, and that's optimization and standardization of the insertion kit. And the other thing that I was really pleased to hear is the evaluation of an observer program, and this is sort of a question for Greg as to who the observer. We've mandated within the last year that all urinary catheters inserted by nurses be observed by a second nurse. This really reflects the practice predominately on the floor is that I'm just wondering about how that might be implemented in the operating room. In thinking about this presentation, I know that determining who inserted the catheter in the operating room is often an issue, and as is actually having an order for a urinary catheter when placed in the OR, because oftentimes triggers for catheter removal depend upon the presence of an order to insert the catheter in the first place. Greg, do you have any comments about that?

Greg Kennedy: Oh, yeah. David, great points; all of them actually. So, as far as our observers on the floor, a second nurse is required. That's how we've implemented that protocol. In the operating room, this was a big area for me and my partner, who's the director of surgical operations here, to really tackle. (1) We tended to view the operating room as an opportunity for us to teach the medical students to put in Foley catheters, and they would often do it for the first time on an asleep patient without ever having practiced. So, we eliminated that practice. First and foremost, we made it so the medical students had to have some type of a simulation event where they've actually seen the catheter tray. They kind of know how to put it in, and they've had that signed off before they're ever allowed to put in a catheter on a live patient, asleep or awake.

David Pegues: Do they have a little yellow dot on their ID badge?

Greg Kennedy: Yeah, exactly; something like that. Yeah. The second thing that is they're then watching by the circulating nurse, not the resident or the physician, the attending surgeon, but the circulating nurse watches them. If I put in the catheter in my operating room, which I do frequently, the circulating nurse watches me as well, so we've assigned that role to the circulating nurse. The circulator puts in the catheter, then another nurse comes in and watches her put in, so we definitely have an observer. So, it's a great point. As to your point on the order in the operating room, we found the same thing; lack of an order is pretty frequent. So the nurse has now been inserting the order at the time of insertion. So, in addition to documenting that it was placed in the operating room, she puts an order for the catheter placement. So, that's how we've tackled those problems. But also, encourage my surgeons to remove catheters in the operating room. So, what I didn't share with you is on our observation, about 15 percent of the patients had catheters removed in the operating room. These are patients who had bariatric procedures as well as colorectal procedures, and the rates of urinary retention were no higher; actually they're a little bit lower, around 10 percent. So, we've encouraged that as well.

David Pegues: David, are there some questions from the audience?

Operator: Yes. Our first question comes from Robin McElliott with Bay Care Alliant Hospital.

Robin McElliott: Hi. How are you? This is a great presentation. I have two questions. When you say, “nurse inserts the catheter,” do you mean an RN? And the second question is: What are you doing with outside catheters for patients coming in with catheters already in?

Operator: David, are you there?

Greg Kennedy: David, do you want to take that one first?

David Pegues: I can speak to the second question first, and then the first question second. With respect to outside catheters, we do not recommend routinely exchanging catheters or obtaining urinalysis or urine cultures on patients who come to a facility with an indwelling urinary catheter. Now, that's not restricted to surgical patients; that's true for all of our patients. With respect to your first question, do we require RN to insert urinary catheters? I think generally the RN is the individual in the operating room or in a unit on the floor who inserts a catheter, but any provider, as Greg has emphasized, ought to have demonstrated competency. And it's the competency more than the degree that matters about whether you should or shouldn't insert a urinary catheter.

Greg Kennedy: Yeah.

Robin McElliott: Thank you.

Greg Kennedy: I agree, David. So, at UW, we don't actually use – nurse means RN in our institution. And as far as the outside catheters, the same protocol that you just outlined applies here as well.

David Pegues: Yeah. Robin, what I can tell you is that we'll allow LPN's or nurse helpers to do daily peri care, but in general, they're not the ones who are inserting the urinary catheters.

Greg Kennedy: Right.

Robin McElliott: Thank you.

Operator: Our next question comes from Peggy Thompson from Tampa General Hospital.

Peggy Thompson: Hi. Thank you. Also, great presentation. I'm really enjoying it. I have two questions as well. One is for Dr. Kennedy, and that is: We have a nurse-driven protocol for removal of catheters and we also made the mistake of not involving surgeons in that. We did involve urology surgeons, but not the rest of the surgeons. So, that was our mistake. And we're in the process of trying to develop the standardized orders for insertion. So, I was wondering if you would share yours. The second question is for both of you actually. Do you have a standard protocol to change Foley catheters that don't have the tamper resistance seal on the catheter?

Greg Kennedy: Yeah. I'd be happy to share our order, our insertion order protocol, with you. I mean, I can email it to you, if you want to send me an email, and I'd be happy to send you all of our protocols that we've put into our electronic medical record, if you'd like. That's no problem. Or put you in touch with the nurses on the team who've been involved in this from the beginning as well. Our insertion protocols, our orders, are very simple, but we just made a drop-down menu where we have to select an indication for it. So, if somebody selects an inappropriate indication, it's flagged. Not to say they can't put the catheter in necessarily, but they have to have a proper indication for the most part. It allowed us to then go back to the provider, who just says, “Because I said I want one.” And say, “Well, that's not really an indication, at least provide some education.” By the way, we don't see that anymore, that indication anymore. But I'd be happy to share it with you, if you'd like.

Peggy Thompson: Thank you. I would appreciate that.

Greg Kennedy: Okay.

David Pegues: Peggy, your second question had to deal with the tamper resistant seals, and I'm not sure I have the answer to that. I know that our nurses who look at, on a monthly basis in all of our units, process of care measures about catheter maintenance do note things, like positioning of the collection bag with respect to the bladder and whether the seal is intact or not. But I don't believe that we have a written requirement or policy that prompts catheter removal when the seal is broken. I think there's a clear trade-off; the goal is to limit the number of times the seal is broken, but whether and how the patient benefits from catheter exchange or maintaining the catheter with a broken seal, I don't think it's been well defined. Greg, did you have any insight on that?

Greg Kennedy: No, we agree. We don't have any protocol as to removing the catheter when the seal has been broken. We have found, and maybe you guys have the same issue, our seals get broken because of people ordering to flush the catheters for some unclear reason to make sure the catheter isn't clogged. So, we've tried to limit that, at least; this mandatory flushing of the catheters so we don't break the seals, but we don't require the catheter to be changed once the seal has been broken.

Peggy Thompson: Great. Thank you very much.

Greg Kennedy: Uh-huh.

Operator: At this time, we have no other questioners in the queue.

Jeanine Resinger: Great. Thank you. Well, this at the top of the hour now, so if anyone has any other questions that you have for our speakers, you can always email those to onthecusp.ahai@aha.org, and we'll make sure that they get to the speakers for answer. Just want to have a quick reminder about our next national content webinar, which will be occurring in August. The topic will be, “Leveraging Culture Change to Reduce Urinary Catheter Use,” and the presenter is Linda Green. So, I want to thank everyone for your participation today and especially thank our presenters. Dr. David Pegues and Dr. Gregory Kennedy, for a wonderful presentation. Please remember to fill out the evaluation link that was posted on the left, and then, everyone, please have a happy and wonderful day. Thank you so much.

Operator: Ladies and gentlemen, that concludes our presentation today. You may disconnect your phone lines and log off your webinars and have a wonderful afternoon.