Preventing CAUTI: What to Do When it’s Time for Plan B (November 4, 2014)

American Hospital Association – Chicago
November National Content Call
November 4, 2014
11:00 AM CT

Operator: The following is a recording for Kathy Drury with the American Hospital Association. This is the November National Content Call on Tuesday, November 4, 2014 at 11:00 a.m. Central Time. Excuse me everyone and thank you for holding. 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 call over to Ashley Hoffman. Ma’am you may begin.

Ashley Hoffmann: Hi, everyone, and welcome to the November National Content Call On the CUSP of CAUTI. We’re so excited to have you with us for today’s event which is going to focus on what to do when your CAUTI rates aren’t improving. Before we begin today’s presentation, just a quick reminder that this is a webinar. Please be sure to log in through the webinar link in order to see today’s slides. We’ll also post a copy of the slides and our recording on our project website. Now I’d like to introduce our presenters today. Dr. Sanjay Singh, M.D., M.P.H., is the George Dock Professor of Internal Medicine at the University of Michigan, the Director of the VA University of Michigan Patient Safety and Enhancement Program, and the Associate Chief of Medicine at the Ann Arbor VA Healthcare System. His research focuses on enhancing patient safety and preventing healthcare associated infection and translating research findings into practice.

Also with us today is Dr. Sarah Krein, Ph.D., R.N., a research investigation at the Ann Arbor VA HSR&D Center of Excellence, also a research associate professor of internal medicine and Co-Director of the VA’s Diabetes CAUTI Enhancement Research Coordinating Center. Her research interests include understanding and improving management of patients with chronic healthcare conditions, specifically those with complex and multiple chronic conditions. Also with us today is Dr. Kathlyn Fletcher, M.D., M.A., an Associate Professor of Internal Medicine at the Medical College of Wisconsin and the Milwaukee VA Medical Center. She is interested in research about how patient care and patient safety are impacted by medical education. Without further ado, it is my pleasure to introduce today’s speakers. Dr. Singh?

Dr. Sanjay Singh: Thanks Ashley and hello to everyone. It’s really a pleasure to be with all of you this afternoon to talk about preventing CAUTI and what happens when your rates aren’t falling as low as you would like them to go. I’m going to get started, and if I could advance the slides? Terrific, thank you. I’m going to talk in general terms about catheter associated urinary tract infection and how to prevent CAUTI. This will be similar to what you may have heard us discuss in the past and then I’ll leave it to Sarah to talk about next steps when your CAUTI rates aren’t falling, specifically what’s Plan B, C and D. Kathlyn will talk about some research that she’s been doing and then I’ll come back at the end to talk about applying mindfulness in CAUTI prevention. As we all know, UTI is a common cause of hospital-acquired infections up until the time when the definitions changed. It used to be the most common healthcare associated infection, now it’s one of the most common healthcare associated infections. Most of these infections are due to the use of urinary catheters specifically indwelling Foley catheters. Up to 20 percent of inpatients are catheterized sometime during their hospital stay. It can be just for a few hours during surgery, or just a few hours during surgery or for several days or even weeks. It also leads to increased morbidity and healthcare costs. But there are also important non-infectious harms related to the indwelling urethral catheter. In fact, many of these non-infectious catheter-associated complications are at least as common as clinically significant UTIs. These can be as minor as maybe some blood in the tubing or in the bag, or some discomfort or pain at the time of insertion or removal. It can also be quite severe such as creating a false passage during the time of insertion, urethral strictures, urethral trauma, and inadvertent removal of the Foley with the balloon inflated.

I think it’s important to consider both the infectious as well as the non-infectious complications of the Foley. In fact, this is something that our colleague, Dr. Mohammed McKee has spoken eloquently about is that there is a lot of urinary catheter harm. Even though we’re focused on CAUTI, but we also know that patients with a Foley who have it removed may not urinate for several hours in which case that may actually increase length of stay. It also leads to discomfort and trauma as discussed. But the urinary catheter also can act as a one-point restraint tethering the patient to the bed which leads to increased immobility and therefore, pressure ulcers, VTE as well as falls. The complications in yellow are actually targeted by the Partnership for Patients. Since many of you are working as part of the Hospital Engagement Network, as you can see decreasing the use of urinary catheters cannot just decrease CAUTI rates, but also can decrease the complication, decrease the rates of other hospital acquired complications.

How do we go about reducing catheter use and preventing CAUTI? We conceptualized that in this project as disrupting the life cycle of the urinary catheter. Just like the organisms that lead to infection have a life cycle, so does the Foley from insertion to maintenance to removal and reinsertion. Let me just quickly go through these one at a time. The first is preventing unnecessary and improper placement. The unnecessary placement has to do especially in the Emergency Department, and to a certain degree the operating room. Many patients who are currently getting catheterized probably don’t need to be catheterized. If they do need to be catheterized, we should make sure that proper aseptic technique is used as recommended by the CDC. Unfortunately, when we’ve looked at this issue both in the Emergency Department as well as the operating room we find that between 20-50 percent of the time when being observed, healthcare workers, and it could be medical students, physicians, nurses, nursing aides, are not using proper aseptic technique. I think there’s lots of opportunities for improvement at least in Step 1, not putting in the catheter unless they’re absolutely necessary; and then if it’s necessary using proper technique. The second area where we can intervene is the maintenance phase and properly caring for the catheters. This has to do with making sure that the bag is below the bladder, that there is no loops or coils that will impede flow of urine into the bag, that there is situational awareness and vigilance about every day. Who has the catheter and whether it’s necessary. That leads into prompt catheter removal which has really been the key focus of the national work. This is actually where most of the research resides in terms of preventing CAUTI and preventing catheter related harm. In fact, there are over 30 studies that have looked at nurse-initiated discontinuation protocols, catheter reminders, whether they be written or computerized. What they found is that there’s over a 50 percent reduction in CAUTI with this approach. No evidence of harm, harm being reinsertion of the catheter. This also of course will address the non-infectious harms of Foley. Ideally, this could be automated or this would be part of the discontinuation protocol. This is again something that hopefully most of your hospitals have in place. Then finally, once removed, we should make sure that the patient does not get the catheter reinserted prematurely. It’s going to be expected that the patient if they’re able to urinate without the Foley when they got admitted, they should be able to urinate without the Foley at some point either during hospitalization or shortly thereafter. But what happens, especially in elderly patients, specifically elderly men with large prostates, once they have a Foley in place, their bladder then can become deconditioned and they suffer from something known as bladder atrophy. Once that Foley is now removed, it may take several hours or even days for their bladder to regain function. We should intermittent straight catheterization until the patient is able to urinate on their own. There are protocols that are available on our website: catheterout.org, and other resources available through the project website that you can use to know when to use a bladder ultrasound scanner. What’s the cut-off in terms of volume in the bladder that will require intermittent straight catheterization?

Let me just spend a moment or two on the ICU because what we’re finding in the national data is that the intervention on the floor, both in the medical and surgical side, have led to about a 30 percent reduction in CAUTI. I think it’s been quite successful. This is in the setting of a much more modest decrease nationally as reflected in HSN data. However, in the ICU we haven’t had as much improvement. In fact, it’s been relatively flat and this is in the setting of NHSN data actually showing ICU rates going up in terms of CAUTI. I wanted to spend a moment discussing the ICU. This is where a lot of catheters are used. In fact, the utilization rate in ICU is somewhere between 60-80 percent depending on the intensive care unit. Much of the justification that is used is that the patient is critically ill and therefore needs strict (isonodes 0:10:42-ph). What we realized­ during site visits and appropriateness panels is that just because the patient is in the ICU does not mean that the patient needs a Foley. What we recommend is that if hourly assessment is needed because we’re titrating pressers, we’re titrating medications, diuretics, etc., then the Foley is the only way to manage that person’s output. However, if hourly assessment is not necessary, and what we’re looking for is daily assessment, then other approaches such as intermittent straight catheterization, a condom catheter that is well-fitting. There are certain condom catheters that fit better than others. I’m happy to discuss that if you have questions on appropriate men who do not have bladder output obstruction. Bedside urinals, commodes.

We’re being much more aggressive in mobilizing ICU patients, even those who are ventilated than we were before. I think once you start thinking about removing the A line, removing the central line, you’re getting patients up and out of bed, and putting them on a treadmill, or other types of things in terms of preventing long-term harm, that’s a good time to also think about maybe I should remove the Foley in this ICU patient even though they still reside in the ICU. Again, the key question for us is our hourly assessments of urine output required itself makes sense to use the Foley, if not, rethink the use of the Foley catheter. That’s our basic approach to preventing catheter-associated urinary tract infection especially focusing on removing the catheter with alacrity. But what if you need further help in preventing CAUTI which often the case? For this I’ll turn it over to my colleague, Sarah Krein. Sarah?

Dr. Sarah Krein: Great. Thanks Sanjay. As just discussed, I’m sure a lot of you are already focusing on those key trategies that Sanjay described for us and have been very busy trying to reduce CAUTI rates at your facilities. But we also recognize that sometimes despite your best efforts, or what you think may be going on at your facility, things just are not progressing as you might hope. In the next section of the talk, we’re going to focus on some potential strategies you might employ. First we’re going to have a polling question. I’d like you to select your top contender for what strategies you have used or considered using if your CAUTI rates are not as low as you might like. We have running up and down the hallway screaming, conducting a focused review or deeper dive to identify improvement opportunities, ensuring competency in insertion using aseptic technique, assessing what indications are being used for catheter use, talking with staff about possible barriers to prompt removal. I’ll let folks select their choice and then we’ll see what people are doing, or thinking of doing if they’re having some difficulties.

Ashley Hoffmann: Go ahead and select the radio dial. We’ll give everyone about 30 more seconds to get your answers in. Right, now everyone can see the results.

Dr. Sarah Krein: Oh. We have some interesting results. Most people are thinking about focused review or a deeper drive, which is a great strategy and we’ll talk a little bit about that. Assessing what indications are being used. I think that’s also often an area and as Sanjay just mentioned, one of those areas in particular to focus on maybe the ICU. We have some folks who are talking with staff about possible barriers. A smaller percentage who are thinking about competency with respect to insertion and a couple of you are running up and down the hallway screaming. That’s probably normal as well. Great.

Let’s move on to the next slide. Thanks Ashley. We have a couple of approaches that we’re going to suggest to you as possible alternatives and things that you might consider if you are again, having some of those challenges in reducing those CAUTI rates.

Next Slide. The first is what we call the Tier 1-Tier 2 approach. This is something that we implemented a couple of years ago in working with a network of hospitals in the VA system. We had seven hospitals that were implementing a CAUTI prevention program. But we recognized up front that sometimes there could be some challenges. What we instituted was a tiered approach. In Tier 1 we started out with a lot of the strategies that I suspect many of you are implementing at your facilities. Assessing for daily needs, indwelling catheter, encouraging the use of alternatives, use of standard kit with resealed junction of a closed kit, ensuring proper insertion technique. Then we also have instituted a maintenance and removal template so this would be part of the electronic medical record that would prompt the nurse to do a daily assessment or shift-based assessment of why the catheter was in place, and if not necessary, then prompt removal activity. As we were doing this, we of course were measuring rates. We set up criteria if after six months you did not meet the threshold, which in this case was two CAUTI per 1,000 catheter days, for both the ICU and the non-ICU. We would then shift attention and give some guidance on moving into the Tier 2 protocol. This protocol included some of those strategies that we just saw some folks were already thinking about or using, which was, for example, to do a root cause analysis or some focused review of CAUTI events to see if there was something going on that we haven’t really been addressing quite as well as we should. It also was an opportunity I think often to reassess those indications for catheter use. I know in some facilities really making sure that people understood what those indications were and were using them appropriately, was again the issue of using catheters in the critically ill patient being one of those key areas where potentially there was opportunity for improvement. In the Tier 2 protocol, another enhancement was to be a little bit more aggressive perhaps inassessing and documenting competency of healthcare workers who are doing the insertion. I know we’ve seen a lot of opportunities here as well sometimes, because it’s not something that some nurses do on a regular basis or because we’re very busy and sometimes we forget what the process is. We do not take our time. We may not be performing quite appropriately. This is another opportunity where we would often see room for improvement.

There were some areas where we thought a little bit more intensive focus and activity and a little bit more resource-intensive activity would often help people then move back into that Tier 1 protocol. This is one strategy again is to get a little bit more beneath the hood to see if what you think is happening at your facility, or what you would like to see happening is actually happening, and then also identifying other opportunities for improvement.

Next slide. The second approach that I’m going to talk about is the CAUTI GPS.

Next slide. This is actually a CAUTI prevention guide to patient safety. The purpose behind this CAUTI guide to patient safety is to provide a brief troubleshooting guide to help identify key reasons why a hospital or unit may not be as successful as they might like in preventing CAUTI. Once some of the barriers are identified, help identify possible solutions. I’m going to go into just a little bit of detail about how this was constructed and how you might go about using this tool as it’s a relatively new tool, so we will be very interested also in your feedback on how this might work.

Next slide. The way the CAUTI GPS was developed was through a course of studies and over several years of work in which my colleague Sanjay Singh and I were trying to understand why some hospitals are better than others in preventing infection. We spent a lot of time doing work, both quantitative and qualitative, focusing specifically on device-related infection, but really focusing a lot on CAUTI prevention in particular. This work was funded by a variety of federal agencies. As part of that work as I mentioned, it was both quantitative and qualitative. In our qualitative work we did phone interviews and site visits to hospitals across the United States to learn from them what was going well, what wasn’t going so well and in some cases working with them to see if we could help make some improvements? In the course of this work, I believe we visited probably over 40 hospitals. I shouldn’t say visited, either by phone or in person, over 40 hospitals and talked with well over 400 hospital personnel. This ranged anywhere from front-line commissions up to hospital directors.

Next slide. Just to give you a sense of the types of hospitals we visited, it wasn’t just those large city hospitals, although we did spend some time in some large cities as you see there on the left side of the slide. Big hospitals, academically affiliated, tertiary medical centers, but we also spent time in smaller rural hospitals in our own state of Michigan. We visited hospitals literally from Maine to California. Along the way we had a few adventures I will have to admit. It wasn’t all work. We actually did indeed end up in a middle of a field because that’s where the GPS told us that was where it was located. We did go on some rather interesting plane rides in small regional aircraft where you had to get on a scale before they put you on an airplane so they knew where to tell you sit. For any of you who have been to San Francisco and have gone on a taxi ride, I think you’ll know what I’m talking about. It is not the most pleasurable of events. Amongst all of those events, we also did learn a lot about what is going on in these hospitals in ways that we thought we could help them improve especially with respect to CAUTI prevention.

Next slide. I can also tell you that these site visits take a lot of time and a lot of resources. Even though we learned a lot and I think the hospitals benefited often as well because we were able to work with them. We also realized that we needed to distill what we were learning in the things that we were hearing from the hospitals themselves about barriers as well as strategies to address those barriers into something that a variety of hospitals could use across the country, since I don’t think there’s any way that we’ll end up going to all 6,000 plus hospitals in the United States. From all of this work we’ve developed a tool that a hospital or someone at the hospital knew as a CAUTI prevention champion can self-administer to identify some potential challenges and then receive feedback and some strategies for improvement. Over the course of our work we really were able to I think key in on some very specific areas that were consistent across all those hospitals that we were visiting, large and small, academic, non-academic, that seemed to be the areas of greatest challenge. The first part of this tool is the CAUTI GPS brief assessment.

Next slide. The next slide is showing you that assessment and as I said it is very brief. It’s a series of 10 questions, okay well there’s a few more if you parts of question 10. It’s simple yes-no questions. Things like: Do you currently have a well-functioning team or work group focusing on CAUTI prevention? Do you have a project manager with dedicated time coordinate your CAUTI prevention activities? I’m not going to go through all of these, but I think you’re getting the idea that there is really some key areas that we felt were important for CAUTI prevention. Again, those areas where we’re seeing the most difficulty at some sites was being able to accomplish and reduce the CAUTI rates.

This CAUTI GPS assessment tool, we were basically using it in the paper form as we would go out to hospitals. As we talked with people, we would have them complete it. We would look at their results and use it as a way to prompt some conversation and to help them strategize. But we’ve also now taken it and put it into a web-based form so you can go on our website.

Next slide please. And use the tool itself, you can print it out if you want to use the paper form but it’s actually now live online so you can go in and do your own self-assessment. We also now have all the questions linked to some troubleshooting tips. Again, not just to be able for you to say this is an area where I’m having some trouble, but we also wanted to provide some feedback about ways you might address those issues. If you go to catheterout.org, this is actually pretty new. It’s just gone online the last couple of weeks. Again, we’re hoping to get a little bit of use out of it to see what people think.

Next slide please. I apologize, I know this is a little bit tough to read, but I just wanted to give you a sense of the output that you’re going to receive. I actually went in and I did the assessment tool and chose my yes and no answers. As you can see, for example, in Question 2, I said I did have a project manager with dedicated time. I get a little bit of feedback telling me that that’s a good thing and this is some reasons why. But in areas where I work having some more difficulty. An example here is Question 5, where I said no, my bedside nurses are taking initiative to ensure that the catheter is removed when it’s no longer needed. I get some feedback but I also receive additional links that I can now use to get even more specific strategies to help me think through how can I start to address this issue.

Next slide please. If I were to click to on that link, again in Question 5, I would now come to this additional information about some ways that other hospitals have used in order to address getting that timely removal element which is part of that life cycle disruption for the catheter into place. Again, this is all kind of a work in progress and we’re very excited that it’s finally up on the website and actually something that people can begin to use.

Next slide please. I would highly encourage you, if you so choose, to go online and check it out and give us some of your feedback. Let us know what you think, providing the name of one of our managers, Alyssa Gase, who can certainly email and let her know what you think about the tool. If you have suggestions for us we are also interested to hear and make even further improvements and refinements to this tool.

Because we created the tool, we also felt it was important to validate the tool and get some more experience using it¸ because we are researchers after all. But also want to make this utility for folks out there such as yourself who are working on CAUTI prevention. I’m now going to turn things over to Kathlyn who is going to talk about validation project that she’s been engaged in and some of the things that she’s been doing with the GPS.

Dr. Kathlyn Fletcher: Thanks Sarah. I’m going to spend the next couple of slides telling you a little bit about the validation project that we’ve been working on from our site. And also tell you a little bit about some lessons that we’ve learned so far from the data collection and the data analysis that we’ve done, that I hope will be helpful as you think about trying to identify areas where you may be able to make interventions if your CAUTI rates aren’t coming down. The goal of this project overall, we had two major goals. One was to assess unit level cultures surrounding the prevention of CAUTI and other hospital acquired conditions. We talked about this a little bit, actually not last month, but two months ago on this call. I know that there has been other work. Even in that call we talked a lot about the work that Sarah and her colleagues had already done. But also as Sarah mentioned, we have been interested in comparing a CAUTI GPS survey answers that the nurse managers are getting to qualitatively derived site assessments. That is really more the focus of today’s talk by me. I’m going to tell you a little bit more about what I mean by that.

Next slide please. We have gone to four academic institutions and done site visits and interviews with interested parties on two units per site. One McHugh at each site and one other unit. The participants that we’ve been interviewing have included nurse managers, staff nurses including clinical nurse specialists, physicians and hospital leadership. By that I mean usually infection control preventionists and quality officers. The data collection has looked like this. One of us interviews the nurse manager after asking him or her to complete the CAUTI GPS survey tool. We interviewed them about the answers that they gave on that survey to make sure that we understand how they were interpreting the questions and why they answered the way that they did. The other one of us then conducts interviews using more open-ended questions with the other staff involved on the floor as mentioned above, like the staff nurses and some physicians who work on the floor. Then we also did observations on the units as well, mostly walk-throughs with members of the staff and looked for evidence of ongoing project relating to patient safety, and specifically CAUTI.

Next slide, please. As we have collected this data, this has allowed us to focus our analysis in the following way. The interview data allows us to do a couple of different kinds of coding. We go through the interview transcripts and do some inductive coding and that means basically reading the transcripts and seeing what things people are talking about. We talked a little bit more about that two months ago when we talked about what people were saying about the culture about CAUTI prevention on their units.

We’ve also done deductive coding which basically means that we went into looking at the transcripts with some ideas about what we were going to find. In this case, we coded specifically for how people talked about the elements that are also asked on the GPS. This allowed us then to look at what the nurse manager said was true of their units on the GPS that they took. We were able to compare what they said to what other people on the unit said in their more open-ended interview about teach of those questions. Today what I’m going to talk about is how some of the other people compared to each other. Not just the nurse manager perceptions compared to everybody else, but also what did senior leadership say and how did that relate to what people on the unit actually said was going on in terms of CAUTI prevention. For example, how did nurses view CAUTI prevention on a specific unit and how did the doctors view CAUTI prevention on that same unit? I think that we’ll find some interesting discrepancies and that leads to some interesting ideas about how the GPS can be better deployed to help identify these discrepancies and maybe point us in a different direction in terms of intervention.

Next slide please. One example of this is I’m just calling this get on the same page. This is some examples of how senior leadership sees potty prevention efforts different than the unit-level workers do. Our observation is that infection control and quality officers are not always on the same page with nurse managers as far as what is going on at the unit level. For example, there may be institutional level programs that are being rolled out that are not necessarily getting down to the level of individual units. I used champions as one particular example where at some institutions they have identified nurse and physician champions at the institution level, but there are people on the units who have no idea who those people are or that they even exist. Another example is that our sense was that infection control in quality officers did not actually what actual preventive practices were being put into place on individual units. They may know that it’s a priority for the hospital to reduce CAUTI rates, but as to what individual units are doing, they often had no specific ideas about that. Then how data is given back to the front lines. This is a much clearer arrow when we’re talking about units where reporting is required. For ICUs and rehab units for example, but in general medicine wards where these rates aren’t necessarily followed yet, especially at the national level, then the reporting back to the front lines is often not as consistent as one might want. While the nurse managers for example know that the data is being collected by someone, the feedback can be pretty spotty, and also not too timely. I’m going to talk a little bit more about that in a later slide. One idea would be to ask an infection control professional or the quality officer in your institution to actually take the GPS with your unit in mind to find out how much they actually know about what your unit is doing. Then maybe to use that as a starting off point to have a bigger discussion about how institutional programs can be better rolled out on your unit and how your unit’s experience can maybe be in form with what the institution is doing.

Next slide. Okay. I think it’s almost intuitive that nurses and doctors may have different ideas about what’s going on with respect to CAUTI prevention on a unit. Our observation was that as a physician I’m embarrassed to say this, but that doctors often have no idea about the formal CAUTI prevention practices that are ongoing in their units. We really went to observe some units that had some pretty sophisticated stuff going on where the doctors really had – it was completely opaque to them. The doctors really have no idea what the nurses do with respect to CAUTI prevention sometimes. The MDs also are not aware of the existence of either MD or RN champions. That led us to think that if we actually asked some key MDs on the floor to take the GPS that could allow for some pretty aggressive education based on the gaps that you identified. It may not be that you have every MD who works on your unit take this, but if you could identify some people who have significant presence there. Maybe on general medicine floors that might be hospitalists and obviously in the mid queue that would be more of the staff intensiveists. Then you could actually design some education tailored based on what the gaps are between what you know the nurses are doing and what the physicians think the nurses are doing.

Next slide please. We also found some interesting things about physician involvement in CAUTI prevention activities. Our observation was that physicians are often only passively involved in the efforts. For example, most people agree that when we talked about this the GPS survey and in our open-ended interviews that physicians aren’t totally on board with CAUTI efforts and I’ll refer back to my previous slide which is that they may not even know about them. It’s fairly uncommon that people identify them as an actual barrier. This makes me feel that there’s room for more active partnering with MDs to move the dial more towards fully embrace rather than more towards being a barrier. Again I think the GPS can help us understand where we are on the unit so that we can decide whether this is something that would actually be beneficial for your particular unit.

Next slide. Then Share the Outcome data. Our observation is that data is not consistently getting to the frontline MDs or RNs especially as I said on the general medicine units. For example, many people know the data is collected. Many don’t know exactly what data is collected, but they know it is. They don’t even necessarily know by whom. Fewer know how it’s used and few actually see the results. I didn’t write this here, but even the ones that see the results, it’s often not even in a remotely, timely way that could allow them to really do their own deeper dive into situations to figure out what went wrong.

My idea, our ideas here were to really think about Questions 8 or 9, which is: Do you collect the data and do you feed it back? Look at how both MDs and RNs on your unit answer that question. If it’s true for your unit that the MDs and RNs often don’t know whether data is collected or whether or not, or say that it’s not fed back, then I would suggest reassessing the feedback mechanisms. Data can be a very powerful motivator. I saw that also on Sarah’s slide on why to do this. I think people really like to see how they’re doing as a unit and also how they’re doing compared to other units in the hospital. I think that this is an important one and the GPS can really help you understand whether this is something that is lacking on your own unit.

Next slide. If those ideas don’t work, there are other excellent resources available. For example, this book which is authored by some of our other esteemed colleagues presenting today. This can offer some very good suggestions as well for preventing hospital infections, not only CAUTI, but I recommend this. With that, I will turn it back over to Sarah and Sanjay.

Sanjay Singh: Thank you Kathlyn and Sarah for that overview of what to do in terms of Plan B, first discussing Tier 1 and Tier 2, and then the CAUTI GPS, and then Kathlyn’s work validating the GPS. I’d like to now turn our attention to something that is not as well developed and it’s more a work in progress. I wanted to share it with out to elicit your feedback and thoughts because this is another approach that may be useful in terms of preventing CAUTI. This has to do in applying mindfulness to CAUTI prevention. If I could just have the next slide or have control of this. Thanks. Since we’re all in healthcare, we realize that there is this dilemma that confronts us, and that is much of what we do, especially in the chaotic environment of a hospital is reflexive. If a patient is hypoxemic, we give oxygen without even really thinking about it. Low blood pressure, we push IV fluids. If positive blood cultures, we give antibiotics as soon as possible. And if a patient complains of urinary frequency, urgency dysuria we diagnosis UTI and then again provide antibiotics. These rote responses are usually helpful, however, this reflex like approach can lead to problems. If a patient is sick enough to be admitted from the Emergency Department, they’re deemed sick enough for a Foley even though we know that a large percentage of patients who have Foleys who are admitted to the Emergency Department, probably don’t need a Foley. We could collect their urine using a bedside urinal, a condom catheter using intermittent straight catheterization, those types of things. The same thing is true if a patient has no symptoms, they have a Foley catheter in and they have a dirty urine, even though they feel fine, we give them antibiotics. For most of the time this would not be appropriate, they shouldn’t receive antibiotics. There’s this tension between rote responses that are helpful most of the time, but those same that seem positive processes that underlie those rote responses kind of lead us astray part of the time. The one possible solution to this dilemma is medical mindfulness. What mindfulness means is that we should be in the moment and we should consider decisions carefully before jumping to reflexive action. It’s based in large part on the work of the Nobel Laureate Daniel Coniman in his book Thinking Fast and Slow where he talks about two systems of thought. One is System One which focuses on intuitive which is fast, automatic, effortless and quite difficult to alter. This is a system that we use when we drive home from work every day. Kind of on auto-pilot. We’re not even thinking about making a left turn here or a right turn there. If we are told that we need to stop by the grocery store to pick up some milk or bread, often go right by the street where we’re supposed to turn because again, we’re operating under System One, which is intuitive and this is the rote reflexes that I previously discussed. The second system really has to more with reasoning. This is System Two. It’s much slower, much more effortful. Because of that we tend not to use it that often, but when we do use it, it’s more flexible. The kind of thinking about what we’re doing and therefore it’s easier than to alter our driving pattern if we need to do something other than go straight home. In medicine we’re constantly toggling back and forth between reflexive and the complex. How do we apply this to everyday practice in general, and how do we specifically apply this to catheter associated urinary infections? One of our colleagues, Hiroko Kyoshi Kio, who is a nurse researcher now in Oregon - she came up a model of applying mindfulness to bedside nursing, specifically focusing on catheter-associated urinary tract infection. I have the reference there in case you want to learn more about it. What she would recommend is that we should take a 3-5 second pause before doing various things, such as inserting an indwelling catheter, or emptying the drainage bag or transporting the patient and asking during the brief pause, is it absolutely necessary to use an indwelling catheter in this patient? Can I use an alternative like a condom catheter? Should I be using intermittent straight catheterization? Does the patient need any type of external device or any device at all? Are they able to use a bedside commode or bedpan or urinal? If the patient does need the Foley the pause can be used to question whether or not we’re using proper aseptic technique. Do I need to ask for help because the patient’s body habit assessed that it may be difficult to insert this catheter without touching the inner thigh. Then also, every day and ideally every shift that the bedside nurse is asking the questions to themselves, can the catheter be removed today and what do I need to do to make sure that that happens? This is something that has not actually been systematically studied to an intervention, but it’s something that I just will mention to you because it may be something useful and I think it can also be bundled with other types of mindful approaches to prevent diagnostic error, or reduce other hospital acquired complications such as falls or pressure sores. Let me just conclude and then we’ll open it up to questions, answers and a discussion that hopefully we convinced you that CAUTI and indwelling catheter use are important patient safety issues. Not only will there be infectious harms due to the Foley, but there are also important non-infectious harms to the Foley many of which are being targeted by the Partnership for Patients. Removing the catheter soon or not putting it in in the first place will have benefits in terms of reducing the CAUTI rate, but also some spill-over benefits in terms of potentially reducing other complications. There are proven approaches to reduce catheter use. It’s been studied extensively. It’s what we’re using in this 950 hospital study, and at least when it comes to patients on the floor, it’s been successful, with about a 30 percent reduction. Additional approaches, however, are available to you if you’re still unhappy with your CAUTI rate, especially in the Intensive Care Unit. It could be a tiered approached as Sarah mentioned where you ensure that everyone is doing Tier 1, but that if your rates are still higher than what you would like, then you can focus much more on insertion indications, aseptic insertion technique and doing focused reviews or mini-root cause analyses. Every time you have a CAUTI or every time you find that patient has an indwelling Foley for inappropriate reasons. The GPS can also be used. This is something that is still in the testing phase. As Sarah mentioned, please give us feedback. We’re happy to modify things. As you can see from Kathlyn’s discussion, we’re formally studying this. Because we want this to be a model not just for preventing CAUTI in an acute care setting, but perhaps it can be modified to prevent CAUTI in the long-term care setting. We’re in discussions with the CDC to use something like this or having them develop something like this for antimicrobial stewardship which has all kinds of problems, or other types of hospital-acquired infections such as Clostridium difficile infection or especially CLABSI due to use of pics. Then finally I just introduced the concept of mindfulness. I realize that it’s still preliminary, but I think it’s intriguing and it’s something that patients are increasingly interested in. I think there could be some relevance to us in healthcare especially when it comes to bedside nurses who want to further reduce CAUTI rates.

I leave you just with my thanks for the work that you’ve done, the work that you continue to do. I think all of us are inundated with challenges. Right now Ebola is chief among them, but in addition to dealing with personal protective equipment and screening for patients who may have this potentially life-threatening illness, is that focusing on some of these endemic problems such as CAUTI remains important, and will cntinue to be important. Thanks for listening to us. At this time, Ashley we’ll turn it back to you and open it up to questions.

Ashley Hoffmann: Yes. Operator, can you please give the instructions for participants if they’d like to ask a question.

Operator: At this time we will open the floor for questions. If you would like to ask a question, please press the * key followed by the 1 key on your touchtone phone now. Questions will be taken in the order they are received. If any time you would like remove yourself from the questioning queue, please press *2. Once again, to ask a question that’s *1. Our first question comes from Kathleen Steinmann. Ma’am please go ahead.

Kathleen Steinmann: We have, through our revealing of our CAUTI cases found that our long-term neurologically impaired patients in the ICU can be part of the root of our high CAUTI numbers. A lot of our straight cathing protocols address somebody who has, where you can restrict their fluid intake and such so then the straight cathing and the bladder scans you can set relatively easy criteria for somebody who is stable. What are some guidance for the patient who might not need a Foley but is going to be in the ICU for a long period of time that’s not the stable type of straight cathing protocol doesn’t apply?

Sanjay Singh: Kathleen, this is Sanjay. Let me first address this and I’ll see then if Kathlyn or Sarah would also like to address it. Let me just ask you question. When you say they’re not stable, are you talking about hemodynamically stable and therefore, that you need frequent assessments of their urine output because they’re on pressers or diuretics or getting fluid resuscitated? What do you mean by unstable or potentially unstable?

Kathleen Steinmann: They’re neurologically unstable, so not where they’re needing the pressers. Part of our criteria for strict I&O we would leave the Foley catheter in. But when you get beyond that where they’re hemodynamically stable, but they’re neurologically unstable, and they’re still in the ICU, we’re struggling with being able to get the catheter out of these patients.

Sanjay Singh: Are these patients able to urinate on their own or do they have urinary retention because of injured spinal cords or those types of things thereby making condom catheters nappropriate men not an option.

Kathleen Steinmann: That is the case, yes.

Sanjay Singh: Yes. I’m glad you brought up this important issue. We’ve actually done site visits and specifically in a couple of places where they like you have also had issues in their neuro ICU patients for a couple of reasons. One is that these patients often have high temperatures, not because they’re infected, but because of central reasons, because of their neurological problem. Then as you know, someone spikes a temperature, and someone has a Foley catheter and you culture the urine and it goes out something, then you’ve got yourself a CAUTI. Even though, the vast majority of those patients when you ask the clinicians are you going to treat the patient for catheter-associated urinary tract infection the answer is no. But still in terms of rates, it would count against you. My ecommendation is that if your need daily Is & Os then somewhere between a q 4 to q 6 hour ISC protocol would make the most sense. I think the most frequent you can do ISC in most places is about every q 4 hours. But the fact that these patients reside in the ICU so therefore the nurse to patient ratio is actually pretty good. I think q 4 hours would make a lot of sense, as long as they’re not getting a lot of fluids or a lot of diuretics and you’re using intermittent straight catheterization, I think that that protocol also makes sense. The cutoff for non-ICU patients, the non-neurological patients tends to be between 250-350 cc’s. I think in the ICU setting you can kind of change that depending on what else is happening to the patient. Clearly it should be an ISC if the amount of urine in the bladder is more than 500 cc’s. But if you wanted to increase it up to maybe 400 cc’s from the usual 300 cc’s you could do that as well. Especially because it does not sound like in those patients reassessment is required because you’re making changes based on that hourly assessment. It’s more every day or perhaps every 8-hour shift or 12-hour shift where you kind of want to have a general sense of there Is and Os. Would that potentially work in your place?

Kathleen Steinmann: I think it may. What we had done was that we had just set across the board, across the institution a straight cathing protocol and it doesn’t seem to be sitting very well for our ICU patients that are hemodynamically stable. Yes, you are bringing up Kathleen, another important issue and that is often a one-size-fits-all strategy does not work. In fact, a one-size-fits-all strategy even for ICU patients may not work. That each unit, I mean at our place we have a surgical ICU, a medical ICU, etc., and the cultures are different. The medical director is difficult the nursing manager is often different. So that I think it’s fine to have one general recommendation, and the general recommendation would be bladder scanning with an intermittent straight catheterization protocol is better than having a Foley catheter in, but that it can be tailored for the individual unit and the patient population. Then even further tailored for the individual patient in that particular unit.

Kathleen Steinmann: Thank you very much.

Operator: Once again if you’d like to ask a question, that’s *1 on your touch tone phone now. At this time I’m showing there are no further questions.

Ashley Hoffmann: Okay. While we wait for the participants to think of questions for our guest presenters today, I do want to remind everyone take a moment after today’s webinar, and complete our evaluation. I’ll put the web blank over in the chat area, you can click on it directly and that will open up the Survey Monkey Link. We’d appreciate your feedback and your suggestions on future content calls as well.

Operator: At this time I’m still showing there are no further questions.

Ashley Hoffmann: I’m also going to take a moment to highlight our two upcoming content webinars for December and January. December is going to feature Dr. Lisa Lubomski and she will be presenting on the staff safety assessment. Then coming up in January Dr. Jennifer Madine Linda Green will be presenting on the National Policy surrounding CAUTI. We hope you’ll be able to join us for those two events. Any final thoughts from our guest presenters today?

Sanjay Singh: This Sanjay. I don’t have anything else to add, but if people do have questions, they should feel free to reach out to us either through our website catheterout.org or through our email addresses. Mine is Singh@umich,edu and I appreciate your time.

Ashley Hoffmann: Great thank you. If anyone has questions feel free to email the project team and as I mentioned the recording of today’s presentation along with the PowerPoints will be posted on our project website. We appreciate you all joining us today and hope you have a wonderful afternoon. Thank you.

Operator: This concludes today’s teleconference. You may now disconnect.