Do No Harm: Evidence Based Basic Nursing Care Strategies to Impact Patient Outcomes. Disclosures

Transcription

1 Do No Harm: Evidence Based Basic Nursing Care Strategies to Impact Patient Outcomes Kathleen M. Vollman MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist/Educator/Consultant ADVANCING NURSING Northville, Michigan Vollman 2016 Disclosures Sage Products Speaker Bureau & Consultant Hill Rom Speaker Bureau Eloquest Healthcare Speaker Bureau & Consultant Bard Speaker Bureau 1

2 Objectives Create the link of patient advocacy to the basic nursing care Outline evidence based nursing strategies to reduce hospital acquired pneumonia Understanding the circle of safety Outline evidence based strategies for promoting patient mobility while address patients skin risk and potential for care giver injury Notes on Hospitals: 1859 It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. Florence Nightingale Advocacy = Safety 2

3 Protect The Patient From Bad Things Happening on Your Watch Interventional Patient Hygiene Hygiene the science and practice of the establishment and maintenance of health Interventional Patient Hygiene.nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies Incontinence Associated Dermatitis Prevention Program 3

4 INTERVENTIONAL PATIENT HYGIENE(IPH) VAP/HAP Oral Care/ Mobility HAND Patient HYGIENE Catheter Care Skin Care/ Bathing/Mobility CA-UTI CLA-BSI SSI HASI Vollman KM. Australian Crit Care, 2009;22(4): Achieving the Use of the Evidence Value Factors Impacting the ability to Achieve Quality Nursing Outcomes at the Point of Care Attitude & Accountability CNO s Vollman KM. Intensiv e & Critical Care Nursing, 2013 Oct; 29(5):

5 Building Resiliency Into Interventions Forcing Functions and Constraints Automation and Computerization Strongest Standardization and Protocols Checklist and Independent Check Systems Rules and Policies Education and Information STRENGTH OF INTERVENTION Weakest Vague Warning Be More Careful! Missed Nursing Care Any aspect of required patient care that is omitted (either in part or whole) or significantly delayed. A predictor of patient outcomes Measures the process of nursing care 5

6 Hospital Variation in Missed Nursing Care Kalish, R. et al. Am Jour Med Quality 2012;26(4): Patient Perceptions of Missed Nursing Care Table 2. Elements of Nursing Care by Ability of Patient to Report and Extent Missed* Frequently Missed Sometimes Missed Rarely Missed * IV, Intravenous. Fully Reportable Partially Reportable Not Reportable Patient assessment Surveillance IV site care Mouth care Listening Being kept informed Response to call lights Response to alarms Meal assistance Pain medication and followup Ambulation Discharge planning Patient education Medication administration Repositioning Bathing Vital signs Hand washing Kalisch, B, et al. TJC Jour Qual Patient Safety. 2012;38(4):

7 Preventing NV HAP Through Evidence Based Fundamental Nursing Care Strategies Slides Courtesy of Barb Quinn Build the Will: NV HAP? HAP 1st most common HAI in U.S. Increased morbidity 50% are not discharged back home Increased mortality 18% 29% Extended LOS 4 9 days Increased Cost $28K to $109K 2x likely for readmission <30 day Understudied, under addressed Focus has been on the other HAP VAP Surveillance not required.yet Kollef, M.H. et.al. (2005). Chest. 128, ATS, (2005). AmJ Respir Crit Care Med. 171, Lynch (2001) Chest. 119, 373S-384S. Pennsylvania Dept. of Public Health (2010). 7

8 Compelling Incidence Data Study Incidence Mortality +LOS Cost J. Davis (2012) Pennsylvania HCUP National database (P) 5,600 /3 yrs 18.9% Not queried $28,000 2/100 pts 14.5% 4 days $36,400 CDC (2014) 13% of all HAIs 19%-50% 4-9 days $40,000 Slide courtesy of Barb Quinn Davis, Pt Safety Authority (3). Giuliano,K. et al. (2016) APIC Podium 2016 Magill, S.S. et.al. (2014) NEJM. 370(13), p Results: Mortality Incidence Total deaths Total cost Wide spread Retrieved on 4/24/13 from 8

9 NV-HAP SMCS Research Findings: 2010 Phase 1: Inclusion criteria: All adult discharges, ICD-9 codes of pneumonia not POA AND met CDC definition of HAP Incidence: Cost: 115 adults $4.6 million 62% non-icu 23 deaths 50% surgical Mean Extended LOS 9 Average age 66 days Common comorbidities: 1035 extra days CAD, COPD, DM, GERD Common Risk Factors: Dependent for ADLs (80%) CNS depressant meds (79%) Quinn, B. et al. Journal of Nursing Scholarship, (1):11-19 Impact of NV HAP in the ICU HAPPI 2 Preliminary Data 23 hospitals in U.S.; 2014 data; 1306 total cases 28% occurred in ICU 26% occurred on Med/Surg units and were transferred to ICU 54% of all NV HAP cases spend some time in the ICU 33% transferred to ICU died 42% transferred to ICU survived but were discharged to a higher level of care; 25% home Impact of NV HAP on one year mortality: Any length of time spent in an ICU increases mortality of elderly patients who survive to discharge Slide courtesy of Barb Quinn Quinn & Baker (2016) pend. Pub. Vivek et al. (2016) CC Med,

10 ICU Acquired pneumonia: VAP vs. NV HAP Methods: Prospective study of 135 consecutive episodes over 3 years of adults with ICU acquired pneumonia Compared clinical and microbiological characteristics of VAP and NV HAP Results for VAP & NV HAP were not statistically different: Pathogens Comorbid conditions, Severity parameters, Mortality, and Hospital length of stay Among NV HAP patients, 79 (52%) needed subsequent intubation Slide courtesy of Barb Quinn Esperatti et al (2010) Am J Respir Crit Care Med. Vol 182, p Where is the Highest Risk for NV HAP? 2.5 Rate of Nonventilator Hospital- Acquired Pneumonia Rate Vent Med/Surg NV-ICU NV-HAP per 1000 patient days Slide courtesy of Barb Quinn 10

11 Centers for Disease Control and Prevention Included for the first time in its top TEN public health concerns: Healthcare associated infections Pneumonia new #1 HAI in U.S. Magill, S.S. et.al. (2014) NEJM. 370(13), p CDC (2016) Prevention Status Report Pathogenesis Prevention Germs in Mouth Dental plaque provides microhabitat Bacteria replicate 5X/24 hrs Aspirated into Lungs Most common route 50% of healthy adults micro-aspirate in sleep Weak Defenses Poor cough Immunosuppressed Multiple co-morbidities 11

12 Risk Factors for Oral Bacteria in the Hospital Poor oral health in the U.S. (CDC, 2011) Increased bacteria counts Plaque, gingivitis, tooth decay Reduced salivary flow hours for HAP pathogens in mouth If aspirated =100,000,000 bacteria/ml saliva into lungs Scannapieco FA, Stewart EM, Mylotte JM. Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med. 1992;20: Langmore, S. et.al. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia. 13,

13 Oral Cavity & VAP 89 critically ill patients Examined microbial colonization of the oropharynx through out ICU stay Used pulse field gel electrophoresis to compare chromosomal DNA Results: Diagnosed 31 VAPs 28 of 31 VAP s the causative organism was identical via DNA analysis 49 elderly nursing home residents admitted to the hospital Examined baseline dental plaque scores & microorganism within dental plaque Used pulse field gel electrophoresis to compare chromosomal DNA Results 14/49 adults developed pneumonia 10 of 14 pneumonias, the causative organism was identical via DNA analysis Garrouste-Orgeas et. al. Am J Respir Crit Care Med. 1997;156: El-Solh AA. Chest. 2004;126: Oral Intensity: Reducing NV HAP in Neuro Impaired Patients Method Quasi experimental, comparative study Adults, acute Neuroscience unit Western Canada 51 retrospective patients standard oral care 34 prospective patients enhanced oral care Results Statistically significant decrease in NV HAP (p<0.05) Robertson, T & Carter, D. (2013) Can J Neurosci Nurs, 35(2),

14 Current Evidence for Oral Care Procedure Method: Review of 7 RCTs and 1 meta analysis Results: Toothbrushing removes dental plaque; swabs do not. Chlorhexidine reduces oropharyngeal colonization Chlorhexidine interventions reduce rate of VAP Optimal frequency of basic oral care unknown Halm, A. Amer J Crit Care , Formation of Biofilm Over 13 Hours Loesche, W

15 Phase 2: Could NV HAP be decreased simply brushing the patient s teeth? Impact of Oral Care on HAP Kaneoka A, et al Infect. Control Hosp. Epidemiol, 2015;36(8):

16 SMCS HAP Prevention Plan Phase 2: Oral Care Formation of new quality team: Hospital-Acquired Pneumonia Prevention Initiative (HAPPI) New oral care protocol to include non-ventilated patients New oral care products and equipment for all patients Staff education and in-services on products Ongoing monitoring and measurement Monthly audits Quinn B, et al. J of Nursing Scholarship, 2014, 46(1):11-19 Gap Analysis Best Practice Our Gaps Action To Take Comprehensive oral care for all (CDC, SHEA) Oral CHG (0.12%) periop adult CV surgery and vent pts. (CDC, ATS, IHI). ICU vent patients only Not using CHG on these patients. Develop inclusive oral care protocol Added to preprinted orders, and to protocol Therapeutic oral care tools (ADA) Poor quality oral care tools. Absence of denture care supplies. New tools and supplies. Quinn B, et al. J of Nursing Scholarship, 2014, 46(1):

17 Protocol Plain & Simple Patient Type Tools Procedure Frequency Self Care / Assist Brush, paste, rinse, moisturizer Provide tools Brush 1-2 minutes Rinse 4 X / day Dependent / Aspiration Risk Suction toothbrush kit (4) Package instructions 4 X / day Dependent / Vent ICU Suction toothbrush kit (6) Package instructions 6 X / day Dentures Tools + Cleanser Adhesive Remove dentures & soak Brush gums, mouth Rinse 4X / day Quinn B, et al. J of Nursing Scholarship, 2014, 46(1):11-19 Provide Meaningful Data 4.0 SGH Ortho - Association of Mean Oral Care to HAP Frequency Number HAP Cases Mean Oral Care 3 Ortho Unit had ZERO HAP cases in the last 4 months of 2013!! Great WORK!! 2 HAP Cases Mean Oral Care Remember, the goal is to provide and document oral care after each meal and before bedtime. Quinn B, et al. J of Nursing Scholarship, 2014, 46(1):11-19 Slides Courtesy of Barb Quinn 17

18 Provide Meaningful Data Slides Courtesy of Barb Quinn Frequency of Oral Care: Increased in the ICU By 300% baseline Mar-13 Quinn B, et al. J of Nursing Scholarship, 2014, 46(1):11-19 Slides Courtesy of Barb Quinn 18

19 Open Heart Surgery Patients: NV-HAP Reduced 75% Oral chlorhexidine periop started Slides Courtesy of Barb Quinn NV HAP Incidence 50 % Decrease from Baseline 20 Control chart for NV-HAP January 2010 to December Baseline Oral Care UCL JAN 2010 FEB 2010 MAR 2010 APR 2010 MAY 2010 JUN 2010 JUL 2010 AUG 2010 SEP 2010 OCT 2010 NOV 2010 DEC 2010 MAY 2012 JUN 2012 JUL 2012 AUG 2012 SEP 2012 OCT 2012 NOV 2012 DEC 2012 JAN 2013 FEB 2013 MAR 2013 APR 2013 MAY 2013 JUN 2013 JUL 2013 AUG 2013 SEP 2013 OCT 2013 NOV 2013 DEC 2013 Number of non-ventilator HAP cases Average LCL Month/Year Quinn B, et al. J of Nursing Scholarship, 2014, 46(1):

20 Return on Investment 60 NV HAP avoided Jan 1 Dec $2,400,000 cost avoided 117,600 cost increase for supplies $2,282,400 return on investment 8 lives saved Quinn B, et al. J of Nursing Scholarship, 2014, 46(1):11-19 Mobility The Safe Way to Achieve the Practice 20

21 Safety Culture: Patient & Caregiver Patient Progressive Mobility Safe Patient Handling Prevention of Pressure Ulcers Early Progressive Mobility Progressive Mobility: Planned movement in a sequential manner beginning at a patients current mobility status and returning them to baseline & includes: Head elevation Manual turning Passive & Active ROM Continuous Lateral Rotation Therapy/Prone Positioning Movement against gravity Physiologic adaptation to an upright/leg down position (Tilt table, Bed Egress) Chair position Dangling Ambulation 21

22 Safe Patient Handling Safe patient handling consists of policies and programs that enable nurses and other caregivers to move patients utilizing equipment in a way that does not cause strain or injury to the nurses, other health care providers or the patient while preserving the patient s dignity ANA Safe Patient Handling Guide 2015 Pressure Ulcers Friction Shear MOISTURE A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear Moisture increases the impact of shear and friction coefficient 22

23 Pressure Ulcer (PU) Facts 4 th leading preventable medical error in the United States 2.5 million patients are treated annually in Acute Care NDNQI data base: critical care 7% Med Surg: 1 3.3% Incidence in acute care 4.5% (Hill Rom 2011 Pressure Ulcer Prevalence Study) Acute care: 0 12%, Critical care: 3.3% to 53.4% (International Guidelines) Most severe pressure ulcer: sacrum (44.8%) or the heels (24.2%) 60,000 persons die from pressure ulcer complications each yr National health care cost $ billon dollars for 2010 Dorner, B., Posthauer, M.E., Thomas, D. (2009), Whittington K, Briones R. Advances in Skin & Wound Care. 2004;17: Reddy, M,et al. JAMA, 2006; 296(8): Vanderwee KM, et al., Eval Clin Pract 13(2): Repositioning Injury 50% of nurses required to do repositioning suffered back pain High physical demand tasks 31.3% up in bed or side to side 37.7% transfers in bed 40% of critical care unit caregivers performed repositioning tasks more than six times per shift Number one injury causation activity: Repositioning patients in bed Smedley J, et al. J Occupation & Environmental Med,1995;51: Knibbe J, et al. Ergonomics1996;39: Harber P, et al. J Occupational Medicine, 27; Fragala G. AAOHN, 2011;59:1-6 23

24 Additional Injury Facts Back and other musculoskeletal injuries are the result of repeated exposure to ergonomic risk factors rather than a single, instantaneous event In an eight hour shift, the cumulative weight that nurses lift equal to an average of 1.8 tons per day Tuohy-Main, K. (1997). Geriaction, 15, 10-14) REPOSITIONING THE PATIENT CAREGIVER INJURY 24

25 O3 Number, Incidence Rate, & Median Days Away From Work for Occupational Injuries RN s with Musculoskeletal Disorders in US, Private industry RNs 9, Private industry RN s 10, Private Industry RN 9,820 7 Bureau of Labor Statistics, U.S. Department of Labor, February 14, Numbers for local and state government Unavailable prior to 2008/Nov 2011, Release 10:00 a.m. (EST) Thursday, November 8, 2012, 2013 data International Survey of Early Mobilization Practices: Where Do We Stand Surveyed directors of medical and mixed medical surgical ICUs in 4 countries Institutions selected a random Results Instituting a planned, structured ICU 833 ICUs (US 396; early France mobility 151, UK quality 138, improvement Germany 148) 27% reported project having can a formal result EM in improved protocol outcomes, 21% have adopted and reduced him practices costs without across a healthcare protocol 52% have not adopted EM practices systems EM protocols applied to both Engel ventilated HJ, et al. Crit Care and Med. non ventilated 2013;41:S69-80 upon ICU admission Factors associated with EM protocol presence of multidisciplinary rounds (US) written daily goals (US) Sedation protocol (US) Bakhru RN, et al. Amer J of Respir & Critical Care Medicine. 2014;A

26 Slide 49 O3 Made a correction--previous number for 2013 included private state and local. This number just reflects private like the others Owner, 5/10/2015

27 Post Intensive Care Syndrome Harvey M, Davidson J. Crit Care Med, 2016;44(2): Brain ICU Study Multicenter RCT medical surgical ICU s 821 patients with ARF or Shock Evaluated in hospital delirium and cognitive impact 3 12 months post d/c 1 out of 4 cognitive Impairment at 12 months Results 74% of patients developed delirium during hospital stay 1/3 & 1/4 had cognitive scores at 1 year follow up c/w moderate TBI & mild Alzheimers, respectively Affected both older and younger Pandharipande, PP. et al. N Engl J Med;369:1306:

28 Isn t this a patient & care giver safety issue, not just HAPU, fall, delirium? Care Giver Injury Venous thromboembolism Pressure Shear Moisture Patient Immobility Increased Length of Stay CAUTI Patient discomfort Falls Muscle weakness Delirium 27

29 Identify Patients at High Risk Risk Assessment on Admission, Daily, Change in Patient Condition (B) Use standard EBP risk assessment tool Research has shown Risk Assessment Tools are more accurate than RN assessment alone Braden Scale for Predicting Pressure Sore Risk 6 subscales Rated 1 4 Pressure on tissues Mobility, sensory perception, activity Tissue tolerance for pressure Nutrition, moisture, shear/friction Score 6 23 Clinical judgment of nurses alone achieve inadequate capacity to assess PU risk www,ihi.org; Garcia-Fernandez FP, et al. JWOCN, 2014:41(1):

30 Its About the Sub Scale s Retrospective cohort analysis of 12,566 adults patients in progressive & ICU settings for yr Identifying patients with HAPU Stage 2 4 Data extracted: Demographic, Braden score, Braden subscales on admission, LOS, ICU LOS, presence of Acute respiratory and renal failure Calculated time to event, # of HAPU s Results: 3.3% developed a HAPU Total Braden score predictive (C=.71) Subscales predictive (C=.83) Tescher AN, et al. J WOCN. 2012;39(3): Braden Score Braden Sub- Scales (C=0.83) Friction Score of 1=126 times the risk Multivariate model included 5 Braden subscales, surgery and acute respiratory failure C=0.91 (Mobility, Activity and sensory perception more predictive when combined with moisture or shear and friction) 29

31 Outcomes of Early Mobility Program incidence of skin injury time on the ventilator incidence of VAP days of sedation delirium ambulatory distance Improved function Staudinger t, et al. Crit Care Med, 2010;38. Abroung F, et al. Critical Care, 2011;15:R6 Morris PE, et al. Crit Care Med, 2008;36: Pohlman MC, et al. Crit Care Med, 2010;38: Schweickert WD, et al. Lancet, 373(9678): Thomsen GE, et al. CCM 2008;36; Winkelman C et al, CCN,2010;30:36-60 Dickinson S et al. Crit Care Nurs Q, 2013;36: Bassett RD, et al. Intensive Crit Care Nurs. 2012;28:

32 START HERE Includes complex, intubated, hemodynamically unstable and stable intubated patients; may include non-intubated Progressive Mobility Continuum Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V Perform Initial mobility screen w/in 8 hours of ICU admission Reassess mobility level at least every 24 hours (Recommended at shift Δ) Refer to the following criteria to assist in determining mobility level o PaO2/FiO2 > 250 o Peep <10 o O2 Sat > 90% o RR o No new onset cardiac arrythmias or ischemia o HR >60 <120 o MAP >55 <140 o SBP >90 <180 o No new or increasing vasopressor infusion o RASS > 3 NO Start at level I* YES Start at level II and progress* RASS -5 to - 3 RASS -3 & up RASS -1 & up Goal: clinical stability; passive ROM ACTIVITY: HOB > 30º *Passive ROM 2X/d performed by RN, or UAP CLRT/Pronation initiated if patient meets criteria based on institutional practice OR Q 2 hr turning Tolerates Level I Activities Goal: upright sitting; increased strength and moves arm against gravity PT consultation prn OT consultation prn ACTIVITY: Q 2 hr turning *Passive /Active ROM 3x/d 1. HOB 45º X 15 min. 2. HOB 45º,Legs in dependant position X 15 min. 3. HOB 65º,Legs in dependant position X 15 min. 4. Step (3) & full chair mode X20 min. 3X/d Or Full assist into cardiac chair 2X/day Tolerates Level II Activities Goal: Increased trunk strength, moves leg against gravity and readiness to weight bear PT: Active Resistance Once a day, strength exercises OT consultation prn ACTIVITY: Self or assisted Q 2 hr turning 1.Sitting on edge of bed w/rn, PT, RT assist X 15 min. 2.Progressive bed sitting Position Min.20 min. 3X/d Or Pivot to chair position 2X/d Tolerates Level III Activities RASS 0 & up Goal: stands w/ min. to mod. assist, able to march in place, weight bear and transfer to chair PT x 2 daily OT consult for ADL s ACTIVITY: Self or assisted Q 2 hr turning 1.Bed sitting Position Min.20 min. 3X/d; 2.Sitting on edge of bed; stand w/ RN, PT, RT assist 3.Active Transfer to Chair (OOB) w/ RN/PT/RT assist Min. 3X/d Tolerates Level IV Activities RASS 0 & up Goal: Increase distance in ambulation & ability to perform some ADLs PT x 2 daily & OT x1 daily ACTIVITY: Self or assisted Q 2 hr turning 1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day 2.Meals consumed while dangling on edge of bed or in chair Ambulate progressively longer distances with less assistance x2 or x3/day with RN/PT/RT/UAP For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant ***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level*** *Mobility is the responsibility of the RN, with the assistance from the RT s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment. Determining Readiness Perform Initial mobility screen w/in 8 hours of ICU admission & daily Yes Patient Stable, Start at Level II & progress PaO2/FiO2 > 250 Peep <10 O2 Sat > 90% RR No new onset cardiac arrhythmias or ischemia HR >60 <120 MAP >55 <140 SBP >90 <180 No new or increasing vasopressor infusion RASS > -3 Bassett RD, et al.intensive Crit Care Nurs (2012) 2012 Apr;28(2):88-97 Needham DM, et al. Arch Phys Med Rehabil Apr;91(4): No Patient is unstable, start at Level I & progress 31

33 Consensus on Safe Criteria for Active Mobilization Systematic review performed with 23 international experts to reach consensus Categories Respiratory Cardiovascular Neurological Other Considerations Consensus reach on all criteria. If no other contraindications; vasoactives, endotracheal tube, FIO2 < 60% with SaO2 90% & RR < 30/min were considered safe criteria Hodgson CL, et. al Critical Care, 2014;18:658 START HERE Includes complex, intubated, hemodynamically unstable and stable intubated patients; may include non-intubated Progressive Mobility Continuum Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V Perform Initial mobility screen w/in 8 hours of ICU admission Reassess mobility level at least every 24 hours (Recommended at shift Δ) Refer to the following criteria to assist in determining mobility level o PaO2/FiO2 > 250 o Peep <10 o O2 Sat > 90% o RR o No new onset cardiac arrythmias or ischemia o HR >60 <120 o MAP >55 <140 o SBP >90 <180 o No new or increasing vasopressor infusion o RASS > 3 NO Start at level I* YES Start at level II and progress* RASS -5 to - 3 RASS -3 & up RASS -1 & up Goal: clinical stability; passive ROM ACTIVITY: HOB > 30º *Passive ROM 2X/d performed by RN, or UAP CLRT/Pronation initiated if patient meets criteria based on institutional practice OR Q 2 hr turning Tolerates Level I Activities Goal: upright sitting; increased strength and moves arm against gravity PT consultation prn OT consultation prn ACTIVITY: Q 2 hr turning *Passive /Active ROM 3x/d 1. HOB 45º X 15 min. 2. HOB 45º,Legs in dependant position X 15 min. 3. HOB 65º,Legs in dependant position X 15 min. 4. Step (3) & full chair mode X20 min. 3X/d Or Full assist into cardiac chair 2X/day Tolerates Level II Activities Goal: Increased trunk strength, moves leg against gravity and readiness to weight bear PT: Active Resistance Once a day, strength exercises OT consultation prn ACTIVITY: Self or assisted Q 2 hr turning 1.Sitting on edge of bed w/rn, PT, RT assist X 15 min. 2.Progressive bed sitting Position Min.20 min. 3X/d Or Pivot to chair position 2X/d Tolerates Level III Activities RASS 0 & up Goal: stands w/ min. to mod. assist, able to march in place, weight bear and transfer to chair PT x 2 daily OT consult for ADL s ACTIVITY: Self or assisted Q 2 hr turning 1.Bed sitting Position Min.20 min. 3X/d; 2.Sitting on edge of bed; stand w/ RN, PT, RT assist 3.Active Transfer to Chair (OOB) w/ RN/PT/RT assist Min. 3X/d Tolerates Level IV Activities RASS 0 & up Goal: Increase distance in ambulation & ability to perform some ADLs PT x 2 daily & OT x1 daily ACTIVITY: Self or assisted Q 2 hr turning 1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day 2.Meals consumed while dangling on edge of bed or in chair Ambulate progressively longer distances with less assistance x2 or x3/day with RN/PT/RT/UAP For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant ***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level*** *Mobility is the responsibility of the RN, with the assistance from the RT s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment. 32

34 Do We Even Achieve the Minimum Mobility Standard Q2 Hours? Body Position: Clinical Practice vs. Standard Methodology 74 patients/566 total hours of observation 3 tertiary hospitals Change in body position recorded every 15 minutes Average observation time 7.7 hours Online MD survey Results 49.3% of observed time no body position change 2.7% had a q 2 hour body position change 80 90% believed q 2 hour position change should occur but only 57% believed it happened in their ICU Krishnagopalan S. Crit Care Med 2002;30:

35 Methodology Positioning Prevalence Prospectively recorded, 2 days, 40 ICU s in the UK Analysis on 393 sets of observations Turn defined as supine position to a right or left side lying Results: 5 patients prone at any time, 3.8% (day 1) & 5% (day 2) rotating beds Patients on back 46% of observation Left 28.4% Right 25% Head up 97.4% Average time between turns 4.85 hrs (3.3 SD) No significant association between time and age, wt, ht, resp dx, intubation, sedation score, day of wk, nurse/patient ratio, hospital Goldhill DR et al. Anaesthesia 2008;63:

36 Patient Progressive Mobility Safe Patient Handling Prevention of Pressure Ulcers EBP Recommendations to Achieve Offloading & Reduce Pressure (A) Turn & reposition every (2) hours (avoid positioning patients on a pressure ulcer) Repositioning should be undertaken to reduce the duration & magnitude of pressure over vulnerable areas Consider surface when determining freq Cushioning devices to maintain alignment /30 side lying & prevent pressure on boney prominences Use lifting device or other aids to reposition & make it easy to achieve the turn Assess whether actual offloading has occurred Reger SI et al, OWM, 2007;53(10):50-58, National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of pressure ulcers :clinical practice guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia;

37 Prophylactic Dressings: Emerging Therapies Consider applying a polyurethane foam dressing to bony prominences in the areas frequently subjected to friction and share (B) Consider placement prior to prolonged procedures or continuous head elevation (B) Consider ease of application and removal and the ability to reassess the skin. Continue to use all of other preventative measures necessary when using prophylactic dressings (C) Black J, et al. International Wound Journal. 2014;doi:10.111/iwj National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of pressure ulcers :clinical practice guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia;2 EBP Recommendations to Reduce Shear & Friction Loose covers & increased immersion in the support medium increase contact area Use lifting/transfer devices & other aids to reduce shear & friction. Mechanical lifts Transfer sheets 2 4 person lifts Turn & assist features on beds Do not leave moving and handling equip underneath the patient National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of pressure ulcers :clinical practice guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia;

38 The Routine Barriers: Time to turn: 3.5 5min up to 17minutes People resources Current equipment not user friendly Staff perceived barriers 41/49 in bed activities Unstable VS (59%) & low respiratory and energy reserves (46%) most common reasons for restricting activity 34% stated safety issues/falling or tube/catheter integrity 27% reported sedation Draw Sheet/Pillows/People Bates-Jensen et al 2003 Xakellis, et al 1995 Gefen et al 2008 Winkelman C, 2010; Transfer Device Current Practice: Turn & Reposition Specialty Bed Disposable Slide Sheets 70% Draw Sheet/Pillows/Layers of Linen Lift Device 37

39 Achieving the Use of the Evidence For Mobility & Moisture Factors Impacting the ability to Achieve Quality Nursing Outcomes at the Point of Care Resource & System Breathable glide sheet/stays Foam Wedges Microclimate control Reduce layers of linen Wick away moisture body pad Protects the caregiver Value Attitude & Accountability Vollman KM. Intensive Care Nurse.2013;29(5):250-5 Comparative Study of Two Methods of Turning & Positioning Non randomized comparison design 59 neuro/trauma ICU mechanically ventilated patients Compared SOC: pillows/draw sheet vs turn and position system (breathable glide sheet/foam wedges/wick away pad) Measured PU incidence, turning effectiveness & nursing resources Demographic Comparison Powers J, J Wound Ostomy Continence Nur, 2016;43(1):

40 Results: Comparative Study of Two Methods of Turning & Positioning Nurse satisfaction 87% versus 34% 30 turn achieved versus 15.4 in SOC/7.12 degree difference at 1hr (p<.0001) SOC PPS P PU development 6 1 a.04 # of times patients pulled up in bed # of staff required to turn patient < a PU development with 24hrs of admission Powers J, J Wound Ostomy Continence Nur, 2016;43(1):46-50 Safe Patient Handling Initiative: Decreases Staff Musculoskeletal Injuries & Patient Pressure Ulcers 28% 58% $184,720 savings $247,500 savings Way H Presented at the 2014 Safe Patient Handling East Conference on March 27,

41 In Bed Technology Out of Bed Technology 40

42 Current Seating Positioning Challenges Airway & Epiglottis compressed Lack of Body Alignment Frequent repositioning & potential caregiver injury Potential fall risk Shear/Friction Sacral Pressure Repositioning Patients in Chairs: An Improved Method (SPS) Study the exertion required for 3 methods of repositioning patients in chairs 31 care giver volunteers Each one trial of all 3 reposition methods Reported perceived exertion using the Borg tool, a validated scale. Method 1: 2 care givers using old method of repositioning 246% greater exertion than SPS Method 2: 2 caregivers with SPS Method 3: 1 caregiver with SPS 52% greater exertion than method 2 Fragala G, et al. Workplace Health & Safety;61:

43 Moisture Injury: Incontinence Associated Dermatitis Inflammatory response to the injury of the water protein lipid matrix of the skin Caused from prolonged exposure to urinary and fecal incontinence Top down injury Physical signs on the perineum & buttocks Erythema, swelling, oozing, vesiculation, crusting and scaling Strain at which the skin breaks is 4x greater with excess moisture than dry skin Brown DS & Sears M, OWM 1993;39:2-26 Gray M et al OWN 2007;34(1): Doughty D, et al. JWOCN. 2012;39(3): IAD Assessment Tool Junkin J, Selek JL. J WOCN 2007;34(3):

44 IAD: Multisite Epidemiological Study 791 patients in 20 facilities in US One day prevalence To measure the prevalence of IAD in the acute care setting, To describe clinical characteristics of IAD, and To analyze the relationship between IAD and prevalence of sacral/coccygeal pressure ulcers Results: Incontinence 54% 16.3% perineal skin damage, (23.3%) IAD All patients had urinary or fecal incontinence or both 26% was present on admission, 74% was hospital acquired IAD was associated with an increased prevalence of sacral/coccygeal pressure ulcers (p<0.000). Gray M, Presented at the 23rd Annual Meeting of the Wound Healing Society; SAWC Spring/WHS Joint Meeting: Denver, Colorado May 1-5, 2013 Evidence based Components of an IAD Prevention Program Skin care products used for prevention or treatment of IAD should be selected based on consideration of individual ingredients in addition to consideration of broad product categories such as cleanser, moisturizer, or skin protectant. (Grade C) A skin protectant or disposable cloth that combines a ph balance no rinse cleanser, emollient based moisturizer, and skin protectant is recommended for prevention of IAD in persons with urinary or fecal incontinence and for treatment of IAD, especially when the skin is denuded. (Grade B) Commercially available skin protectants vary in their ability to protect the skin from irritants, prevent maceration, and maintain skin health. More research is needed (Grade B) 43

45 EBP Recommendations to Reduce Injury From Incontinence & Other Forms of Moisture Clean the skin as soon as it becomes soiled. Use an incontinence pad and/or briefs that wick away Use a protective cream or ointment Disposable barrier cloth recommend by IHI & IAD consensus group Ensure an appropriate microclimate & breathability < 4 layers of linen Barrier & wick away material under adipose and breast tissue Support or retraction of the adipose tissue (i.e. KanguruWeb) Pouching device or a bowel management system National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; Williamson, R, et al (2008) Linen Usage Impact on Pressure and Microclimate Management. Hill-Rom Doughty D, et al. JWOCN. 2012;39(3): Reusable Incontinence pads Current Practice: Moisture Management Adult diaper Disposable Incontinence Pads Airflow pads for Specialty Beds 44

46 EBP Recommendations to Reduce Injury From Incontinence & Other Forms of Moisture Clean the skin as soon as it becomes soiled. Use an incontinence pad and/or briefs that wick away Use a protective cream or ointment Disposable barrier cloth recommend by IHI & IAD consensus group Ensure an appropriate microclimate & breathability < 4 layers of linen Barrier & wick away material under adipose and breast tissue Support or retraction of the adipose tissue (i.e. KanguruWeb) Pouching device or a bowel management system National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; Williamson, R, et al (2008) Linen Usage Impact on Pressure and Microclimate Management. Hill-Rom Doughty D, et al. JWOCN. 2012;39(3): IAD/HAPU Reduction Study Prospective, descriptive study 2 Neuro units Phase 1: prevalence of incontinence & incidence of IAD & HAPU Phase 2: Intervention Use of a 1 step cleanser/barrier product Education on IAD/HAPU Results: Phase 1: incontinent 42.5%, IAD 29.4%, HAPU 29.4%, LOS 7.3 (2 14 days), Braden 14.4 Phase 2: incontinent 54.3%, IAD & HAPU 0, LOS 7.4 (2 14), Braden Hall K, et al. Ostomy Wound Management, 2015;61(7):

47 EBP Recommendations to Reduce Injury From Incontinence & Other Forms of Moisture Clean the skin as soon as it becomes soiled. Use an incontinence pad and/or briefs that wick away Use a protective cream or ointment Disposable barrier cloth recommend by IHI & IAD consensus group Ensure an appropriate microclimate & breathability < 4 layers of linen Barrier & wick away material under adipose and breast tissue Support or retraction of the adipose tissue (i.e. KanguruWeb) Pouching device or a bowel management system National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure ulcer prevention & treatment :clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; Williamson, R, et al (2008) Linen Usage Impact on Pressure and Microclimate Management. Hill-Rom Doughty D, et al. JWOCN. 2012;39(3): Optimal Hygiene ph balanced (4 6.8) Stable ph discourages colonization of bacteria & risk of infection Bar soaps may harbor pathogenic bacteria Excessive washing/use of soap compromises the water holding capacity of the skin Non drying, lotion applied Multiple steps can lead to large process variation Voegel D. J WOCN, 2008;35(1):84-90 Byers P, et al. WOCN. 1995; 22: Hill M. Skin Disorders. St Louis: Mosby; Fiers SA. Ostomy Wound Managment.1996; 42: Kabara JJ. et. al. J Environ Pathol Toxicol Oncol. 1984;5:

48 Stool Containment Options If the rectum is intact Patient is neutropenic Stool culture negative If the rectum is not intact Stool culture positive Fecal Containment Device STOOL MANAGEMENT SYSTEM

49 Early Mobility: Can We Do It? Is it Safe? Patient Safety > 1 % adverse events during 1449 sitting, standing and walking sessions with patients on ventilators. Underwent daily sedation interruption followed by PT & OT daily until achieving physical function independence Safety events occurred in 16% of all sessions Loss of 1 arterial line, 1 nasogastric tube, 1 rectal tube Therapy was stopped on 4% of all sessions for vent asynchrony, agitation, or both Delirium present 53% of the time during therapy sessions Bailey P, et al. Crit care Med, 2007;35: Pohlman MC, et al. Crit Care Med, 2010;38:

50 Hemodynamic Instability??? Is it a Barrier to Positioning? The Role of Hemodynamic Instability in Positioning 1,2 Lateral turn results in a 3% 9% decrease in SVO 2, which takes 5 10 minutes to return to baseline Appears the act of turning has the greatest impact on any instability seen Minimize factors that contribute to imbalances in oxygen supply and demand Factors that put patients at risk for intolerance to positioning: 3 Elderly Diabetes with neuropathy Prolonged bed rest Low hemoglobin and cardiovascular reserve Prolonged gravitational equilibrium 4,5 1.Winslow EH, et al. Heart Lung. 1990;19: Price P. Dynamics. 2006;17: Vollman KM. Crit Care Nurs Q. 2013;36: Vollman KM. Crit Care Nurs Clin of North Amer, 2004;16(3): Vollman KM. Crit Care Nurs Q Jan;36(1):

51 O4 Decision-Making Tree for Patients Who Are Hemodynamically Unstable With Movement 1,2 Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible Is the patient hemodynamically unstable with manual turning? O 2 saturation < 90% New onset cardiac arrhythmias or ischemia HR < 60 <120 MAP < 55 >140 SPB < 90 >180 New or increasing vasopressor infusion Yes Is the patient still hemodynamically unstable after allowing 5-10 minutes adaption post-position change before determining tolerance? Yes Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate inbed mobility strategies as soon as possible Yes Has the manual position turn or HOB elevation been performed slowly? Yes Initiate continuous lateral rotation therapy via a protocol to train the patient to tolerate turning No No No No Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates Allow the patient a minimum of 10 minutes of rest between activities, then try again to determine tolerance Try the position turn or HOB maneuver slowly to allow adaption of cardiovascular response to the inner ear position change HOB=head of bed; HR=heart rate; MAP=mean arterial pressure; SPB=systolic blood pressure. Vollman KM. Crit Care Nurse. 2012;32: Vollman KM. Crit Care Nurs Q. 2013;36:17-27 Hamlin SK, et al. Amer J of Crit Care, 2015;24: Brindle CT, et al. J WOCN, 2013;40(3): Safety Culture: Patient & Caregiver Hospital LOS ICU LOS Skin Injury CAUTI Delirium Time on the vent Patient Progressive Mobility Safe Patient Handling repetitive motion injury Musculoskeletal injury Days away from work Staffing challenges Loss of experienced staff Nursing shortage Prevention of Pressure Ulcers Skin Injury Costs pain and suffering Hospital LOS ICU LOS 50

52 Slide 99 O4 Added a referernce Owner, 5/10/2015

53 It is not enough to do your best, you have to know what to do and then do your best. E Deming 51

54 The Why Urinary tract infection (UTI) are one of the most common hospitalacquired infections Along with other device associated infections (CLABSI and VAP) account for 25% of all hospital acquired infections 70 80% of CAUTI are due to urinary catheters 12 16% of inpatients are catheterized Leads to increased morbidity and costs Medicare no longer reimburses U.S. hospitals for the additional costs of certain infections CAUTI prevention is part of the 2012 National Patient Safety Goal Double hit with VBP, Readmission Magill et al NEJM 2014; APIC Guide to Prevention of CAUTI, 2014; Lo et al SHEA/IDSA Practice Recommendations Inf Control and Hosp Epid 2014 CUSP & CAUTI Interventions Adaptive /Cultural CUSP 1. Educate on the Science of Safety 2. Identify Defects (Staff Safety Assessment) 3. Senior Executive Partnership 4. Learn from Defects 5. Implement Teamwork & Communication Tools Technical CAUTI 1. Insertion Limiting use Using aseptic technique for site prep, equip & supplies 2. Maintenance Securing the catheter for unobstructed flow Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples 52

55 Pathogenesis of CAUTI Source: colonic or perineal flora on hands of personnel Microbes enter the bladder via extraluminal {around the external surface} (proportion = 2/3) or intraluminal {inside the catheter} (1/3) Daily risk of bacteriuria with catheterization is 3% to 10%; by day 30 = 100% APIC Guide to Preventing CAUT Disrupting the Lifecycle of the Urinary Catheter 1. Preventing Unnecessary and Improper Placement 1 4. Preventing Catheter Replacement Maintaining Awareness & Proper Care of Catheters 3 3. Prompting Catheter Removal (Meddings. Clin Infect Dis 2011) 53

56 CDC, SHEA, IDSA and NHS: Indications for Placement Perioperative use for selected surgical procedures Urine output in critically ill patients Management of acute urinary retention and urinary obstruction Assistance in pressure ulcer healing for incontinent patients At a patient request to improve comfort(shea) or for comfort during end of life care (CDC) How-to Guide: Prevent Catheter-Associated Urinary Tract Infections. Cambridge, MA: Institute for Healthcare Improvement; (Available at Ann Arbor Criteria for Appropriate Use Meddings J, et al. Ann of Intern Med, 2015;162:S

57 Core Recommendations Insert catheters only for appropriate indications (1B) Leave catheters in only as long as needed (1B) Ensure that only properly trained persons insert and maintain catheters (1B) Insert catheters using aseptic technique and sterile equipment (acute care settings) (1C) Consider use of alternatives (II) Maintain a close drainage system (1B) Secure the system (1B) Maintain unobstructed urine flow (1B) Key the collecting bag below the level of the bladder at all times (1B) Lo E, et al. Infect Contr & Hosp Epidemiol. 2014;35(5): Simplified Insertion Checklist for Urinary Catheter

58 Core Recommendations Insert catheters only for appropriate indications (1B) Leave catheters in only as long as needed (1B) Ensure that only properly trained persons insert and maintain catheters (1B) Insert catheters using aseptic technique and sterile equipment (acute care settings) (1C) Consider use of alternatives (II) Maintain a close drainage system (1B) Secure the system (1B) Maintain unobstructed urine flow (1B) Key the collecting bag below the level of the bladder at all times (1B) Lo E, et al. Infect Contr & Hosp Epidemiol. 2014;35(5): Challenges with Current Appropriate Alternatives: External Male Catheters 1 out of every 200 men is born with what s medically known as micro-penis 56

59 Buried Penis Condom Catheter 57

60 Common Problems Most common problems are: Skin irritation and maceration Difficult to keep the condom from falling off/retraction of the penis or decrease size Ischemia and penile obstruction/tightness Adherence: requires to secure on the shaft & adhesive mechanisms are challenging Reference: Newman, DK. Managing and Treating Urinary Incontinence. Health Professions Pr Before & After QI Project 60 day comparison Use of a novel EMC device vs. indwelling catheter Inclusion criteria: No restraints No BPH No neurogenic bladder Cooperative Hospitalize 2 wks or greater Monitored wear time and evaluated the skin Average Wear Time = 24hrs Fitzwater M, IP Kindred Albuquerque,

61 Core Recommendations Insert catheters only for appropriate indications (1B) Leave catheters in only as long as needed (1B) Ensure that only properly trained persons insert and maintain catheters (1B) Insert catheters using aseptic technique and sterile equipment (acute care settings) (1C) Consider use of alternatives (II) Maintain a close drainage system (1B) Secure the system (1B) Maintain unobstructed urine flow (1B) Key the collecting bag below the level of the bladder at all times (1B) Lo E, et al. Infect Contr & Hosp Epidemiol. 2014;35(5): Securement Devices 59

62 Core Recommendations Insert catheters only for appropriate indications (1B) Leave catheters in only as long as needed (1B) Ensure that only properly trained persons insert and maintain catheters (1B) Insert catheters using aseptic technique and sterile equipment (acute care settings) (1C) Consider use of alternatives (II) Maintain a close drainage system (1B) Secure the system (1B) Maintain unobstructed urine flow (1B) Key the collecting bag below the level of the bladder at all times (1B) Lo E, et al. Infect Contr & Hosp Epidemiol. 2014;35(5): Traditional Bathing Why are there so nurwse! many bugs in here? Soap and water basin bath was an independent predictor for the development of a CLABSI Bleasdale SC, e tal. Arch Intern Med. 2007;167(19):

63 Bath Basins Potential Source of Infection Large multi-center study evaluates presence of multi-drug resistant organisms Total hospitals: 88 Total basins: % Marchaim D, et al. Am J of Infect Control. 2012;40(6): Contaminated 686 basins/88 Hospital 35% Colonized w/ VRE 385 basins/80 hospitals Gram negative bacilli 495 basins/86 hospitals MRSA 36 basins/28 hospitals 3% Impact on UTI with Basin Bathing UTI Rate- Removal of Prepackaged Bath Product QTR 3 FY Rate/1000 Device Days th percentile 0 QTR 1 FY05 QTR 2 FY05 QTR 3 FY05 QTR 4 FY05 QTR 1 FY06 QTR 2 FY06 QTR 3 FY06 McGuckin M, et al. AJIC, 2008;36:59-62, 61

64 Impact on UTI with Basin Bathing UTI Rate- Removal of Prepackaged Bath Product QTR 3 FY Rate/1000 Device Days th percentile 0 QTR 1 FY05 QTR 2 FY05 QTR 3 FY05 QTR 4 FY05 QTR 1 FY06 QTR 2 FY06 QTR 3 FY06 McGuckin M, et al. AJIC, 2008;36:59-62, Mechanisms of Contamination Skin flora Multiple-use basins Incontinence cleansing Emesis Product storage Bacterial biofilm from tap water Shannon RJ, et al. J Health Care Safety Compliance Infect Control. 1999;3: Larson EL, et al. J Clin Microbiol. 1986;23(3): Johnson D, et al. Am J Crit Care, 2009;18(1):31-38, 41. Marchaim D, et al. Am J Infect Control. 2012;40(6):

65 Waterborne Infection Cervia JS, et al. Arch Intern Med, 2007;167:92-93 Trautmann M, et al. Am J of Infect Control, 2005;33(5):S41-S49, Cleansing of Patients with Indwelling Catheter Indwelling catheter care should occur with the daily bath (basinless bathing)*, as a separate procedure using clean technique There is no evidence to support 2x a day indwelling catheter care If a large liquid stool occurs, bathe the patient with basin less bathing Use separate cloths to clean front to back in the perineal area and 6 inches of the catheter** Apply barrier cloth to area of skin requiring protection **Universal ICU Decolonization: An Enhanced Protocol. (Prepared by The REDUCE MRSA Trial Working Group, under contract HHSA i). AHRQ Publication No EF. Rockville, MD: Agency for Healthcare Research and Quality; September *Sage recommends following hospital policy 63

66 Additional Recommendations: SHEA Compendium Update 2014 Replace the catheter and the collecting system using aseptic technique when breaks in aseptic technique, disconnection, or leakage occur (quality of evidence: III). For examination of fresh urine, collect a small sample by aspirating urine from the needleless sampling port with a sterile syringe/cannula adaptor after cleansing the port with disinfectant (quality of evidence: III). Unresolved Antiseptic or sterile saline for meatal cleaning before insertion Lo E, et al. Infect Contr & Hosp Epidemiol. 2014;35(5): Additional Recommendations: SHEA Compendium Update 2014 Develop a protocol for management of post op urinary retention Bladder scanner Intermittent catheterization Do not routinely use antimicrobial/antiseptic impregnated catheters Do not screen for asymptomatic bacteriuria in catheterized patients Lo E, et al. Infect Contr & Hosp Epidemiol. 2014;35(5):

67 65

68 Cost Benefit Ratio CA-UTI vs. IAD & Pressure Ulcer Nurse Directed Catheter Removal 300 bed community teaching hospital Implementation of a nurse directed urinary catheter removal protocol Protocol linked to physician catheter order Physician documentation of catheter insertion criteria & device specific charting in progress notes Bi weekly unit specific feedback Results: 50% in catheter use & 70% in CAUTI Parry MF, et al. AM J Of Infect Control, 2013;41:

69 How Do We Make It Happen? Driving Change Gap analysis Build the Will Protocol Development Structure Make it Prescriptive Overcoming barriers Daily Integration Process Outcomes 67

70 Sustaining Your Initiative Advocacy Braden subscales/mobility Readiness Assessment Skin and Mobility rounds/time frequency Hand off communication The right products and processes for patient and caregiver Quarterly prevalence/incidence of PU & IAD Champion nurses Creative strategies to reinforce protocol use Visual cues in the room or medical record Rewards for increase compliance Yearly competencies on beds, in bed positioning aids and out of bed lift equipment and chair to ensure correct and maximum utilization 68

71 Be Courageous We all are responsible for the safety of our patients & ourselves Own the Issues If not this, then what?? If not now, then when? If not me, then who?? Contact Kathleen Vollman at 69