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On the CUSP: Stop CAUTI in the ED
ED Mini-Presentation to Accompany March 3, 2015 ED Coaching Call

Janine: Hello, everyone, and thank you for listening today. My name is Janine Rissinger, and I'm a program with the Health Research and Educational Trust. Welcome to the first recording in the Cohort 9ED Educational Webinar Series. Today's webinar topic is ED Physician Engagement.

For Cohort Education we are using these recorded mini webinars to bring important concepts and education to you, the frontline staff, so that you may learn together as an ED team. Please gather your team around and spend the next 15 to 20 minutes learning about CAUTI prevention together.

At the end of today's presentation there are a few discussion questions that we ask you to talk about as a group before joining the March 3 ED coaching call hosted by the New Jersey Hospital Association. During the March 3 coaching call all ED teams will be invited to share the outcomes of their discussion. It's a great opportunity for peer learning and we are excited to hear from all of you.

Today's presenter is Dr. Margarita Pena. Dr. Pena is an emergency physician at St. John's Hospital, the medical director of the observation unit and the associate program director of the Emergency Medicine Residency Program. She is also a clinical associate professor in the Department of Emergency Medicine at the Wayne State University Schools of Medicine.

Dr. Pena has worked with Dr. Mohammed Fakih on preventing CAUTI as the ED physician champion since 2007 and has since published four papers with Dr. Fakih on CAUTI in the ED. I'd now like to turn the presentation over to Dr. Pena.

Margarita: Thank you. It is a pleasure to share with you our experience and success with reducing unnecessary urinary catheter use in the emergency department. I hope that you can take away some helpful information to assist your facility in this important endeavor and that this presentation generates some further discussion points.

Why is it important that efforts to reduce CAUTI include the emergency department? Well, since about 50% of patients that are admitted to the hospital come through the emergency department, it is important that efforts to reduce CAUTI include the emergency department.

Furthermore, a catheter that's placed in the ED is much more likely to be removed once the patient is dmitted. In order to accomplish this it's important to change the culture of urinary catheter placement in the emergency department. This involves heavy buy-in from all the ED staff, from the physicians to the nurses to the techs.

This presentation is mainly going to focus on the physician piece. Through our work we found that there are three steps, three keys to success that are required to change culture in the emergency department. The first is to establish a collaborative guideline for ED catheter placement. The second is to involve physicians and obtain their buy-in. The third is to recheck, revise and to review.

In order to successfully establish ED urinary guidelines you need to first identify an ED physician champion. This champion will serve to collaborate with infection control and inform and educate the ED physician staff. In this manner, indication for urinary catheter use has easy input to identify any indications beyond the CDC HICPAC guidelines that may be unique to emergency department.

After discussion, any new ED indications for UC placements can be mutually agreed upon and clearly identified and then added to any hospital specific guidelines. In our institution, Dr. Fakih is the infectious disease specialist that leads this effort with whom I've collaborated with.

In the second step, which is physician engagement, this is a crucial step in ensuring success. We accomplish this in a multi-prong manner. I first presented this during our physician department meeting. I talked about CAUTI and the importance of decreasing urinary catheter placement in the emergency department and then I presented a draft of the guidelines.

Dr. Fakih was also invited. All the comments and the feedback regarding content and the wording were discussed, any changes made and then agreed upon. The final draft of the guidelines were then distributed to all the ED physician and resident staff during subsequent department meetings and lectures. We also placed to guidelines on pocket cards for easy reference. These were distributed to physician and the nursing staff.

This is an example actually of our final guidelines that we have and it includes changes that we actually made to our initial guidelines. A study in 2010 that we published after first instituting our initial guidelines we found that catheter placement was appropriately indicated in about 75% of the patients if they had a documented physician order.

Only about 50% of urinary catheters had a physician order documented. Furthermore, patients without a physician order only 52% were appropriately indicated. This is the reason why we highlighted the phrase, “Always obtain a physician order before placing a urinary catheter”. This is why we felt it necessary to place it both in the front and in the back of the cards.

The final step to ensuring success is to recheck regularly for compliance. Identify any reasons for noncompliance and then identify opportunities. For example, we found that because we are a teaching hospital and we have emergency medicine residents who write many of the patient orders it was very important to have their buy-in.

We identified a resident physician champion who then presented information and educated his peers about reducing urinary catheter use in the emergency department similarly to what I had done. You may also find it necessary to revise the guidelines. For example, we did revise the guidelines for patients that are requiring [inaudible 00:05:52] catheter for acute mental status changes with agitation. We found that this was not necessary. Actually, this was a requirement that was easily conformed to.

The second was to work with radiology and collaborate with them and find that we really did not need a urinary catheter for emergency pelvic ultrasound and this could only be used on a patient-by-patient basis. Finally, you want to review your guidelines periodically with all your emergency department staff. This regular feedback as well as information will assure that the information is processed and placed through all the appropriate ED staff, including any new staff members.

In our 2010 study, we did find the physician ordered about 40% less urinary catheters after these processes were placed. This translated to urinary catheter utilization for emergency department admitted patients to only about 10%. This process did work and you can do it too using the three-step method.

Number one, to summarize, finding collaborative guidelines using both emergency department and infection disease champions. Number two, ensuring physician buy-in. Number three, the three Rs, which is re recheck, to revise, and to review, and this will ensure your success.

Some other discussion questions that I think will be important with bringing this information to your institution are, number one, do you already have an ED attending physician champion? Number two, what is the greatest barrier that you anticipate in establishing this project? Number three, what successful methods have you used in the past to ensure physician buy-in of clinical processes?

Thank you very much for your attention.

Janine: Thank you, Dr. Pena, I really appreciate your time and expertise on this matter. As Dr. Pena mentioned, the discussion questions on the screen right now are the discussion question we would like for you to take back to your ED team and discuss before joining the March 3 CAUTI coaching call. We hope that'll have a lot of peer-to-peer learning and sharing amongst the team members who are on the call about what they're doing to engage physician champions in their emergency department.

Thank you very much for your time and attention today and just a reminder that your feedback is very important to us. If you please take a moment to fill out an evaluation of today's webinar. The link is on the screen here but then you can also receive it through your state lead in the communication they sent about this recording.

We hope you'll join us for the upcoming March 3 ED coaching call at 2:00 pm eastern, where Dr. Pena will be available to answer any questions you may have from today's webinar. Thank you again for joining us and have a great day.