American Journal of Infection Control 43 (2015) 341-7

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

journal homepage: www.ajicjournal.org

Major article

Provider perspectives on the use of indwelling urinary catheters in

older adults in emergency department settings: Developing a novel
clinical protocol
Mary R. Mulcare MD*, Tony Rosen MD, Sunday Clark ScD, Benjamin A. Scherban BA,
Michael E. Stern MD, Neal E. Flomenbaum MD
Department of Medicine, Division of Emergency Medicine, Weill Cornell Medical College, New York, NY

Key Words: Background: Indwelling urinary catheters (IUCs) are commonly placed in older adult (aged
65 years)
Catheter-associated urinary tract infections patients in emergency department (ED) settings, often for inappropriate indications. The aim of our
Clinical protocol qualitative study was to explore ED provider knowledge, attitudes, and practice patterns surrounding use
Hospital acquired infections
of IUCs in older adult patients in the ED setting, to better guide development of a clinical protocol.
Patient safety
Methods: We conducted 4 focus groups with 38 participants at a large academic medical center. Each
focus group was conducted with a single ED provider type: attending physicians, residents, physician
assistants, or nurses. Focus groups used a semistructured format, ranging in duration from 23-33 mi-
nutes. The sessions were audiorecorded, fully transcribed, and data were coded and analyzed to identify
themes.
Results: Participants reported believing that IUCs are overutilized in ED settings, confirming that IUCs are
infrequently removed once placed and often inserted for staff convenience. Participants reported that
current clinical decision making about IUC placement varies widely; yet all acknowledged the known
risks for patient safety and willingness to adopt a clinical protocol to standardize practice. Focus groups
were a critical component for the development of a user-friendly protocol, identifying 10 key elements
for successful implementation and 11 potential barriers.
Conclusions: An evidence-based clinical protocol guiding ED providers in appropriate placement and
management of IUCs in older adults would be welcomed.
Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

Hospital-acquired infections can be devastating to patients and
are a current source of scrutiny in hospital-based practice. These
infections can be introduced in emergency department (ED) set-
tings,1,2 often in conjunction with the placement of indwelling
urinary catheters (IUCs).2 The risk of developing a catheter-
associated urinary tract infection (CAUTI) is directly related to the
amount of time an IUC is in place, with the risk of infection
increasing by 5% per 24-hour period that the catheter is present.3
One study suggests that 91% of IUCs placed in the first 24 hours
of admission are placed in an ED.4
Although a health and patient safety concern, these infections
are also a financial burden for hospitals, because care associated
* Address correspondence to Mary R. Mulcare, MD, Division of Emergency
Medicine, Weill Cornell Medical Center, 525 E 68th St, Box 179, New York,
NY 10065.
E-mail address: mrm9006@med.cornell.edu (M.R. Mulcare).
Conflicts of interest: None to report.
with the treatment of many hospital-acquired conditions will no
longer be reimbursed.5,6 As of October 1, 2008, The Centers for
Medicare and Medicaid Services no longer reimburses hospitals for
CAUTIs, 1 of 11 hospital-acquired conditions to which this applies.3
Older adults (aged
65 years) represent a growing segment of
the population and an increasing percentage of patient visits to
EDs.7 This demographic is particularly susceptible to infection,
delirium, and falls. This is also a population where urinary catheters
are more frequently placed than is necessary,4,5,8,9 and thus as
might be anticipated, CAUTIs are commonly indentified.10
Further emphasizing the importance of this topic, at the 2013
National Scientific Assembly of American College of Emergency
Physicians (ACEP), the ACEP announced avoidance of IUC place-
ment as part ACEP’s participation in the American Board of Internal
Medicine Foundation’s Choosing Wisely campaign.11 Since that
time, the recently approved Geriatric Emergency Department
Guidelines in 2014 highlight the use of IUCs as 1 of 6 suggested site-
specific protocols for implementation.12

0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2014.12.008
342 M.R. Mulcare et al. / American Journal of Infection Control 43 (2015) 341-7
A novel clinical protocol13 guiding appropriate use of IUCs in
EDs, including reassessment, prompt removal as is clinically indi-
cated, and promotion of alternate methods for urine collection, may
be useful in reducing IUC use and the rate of CAUTIs to improve
patient centered care.
METHODS
The aim of our qualitative study is to understand and describe
ED providers’ knowledge, attitudes, and practice patterns related to
use of IUCs in older adult patients in ED settings. The secondary aim
and goal of this analysis is to understand the complexity of the
current clinical environment, including potential barriers to
improving current practice patterns, such that this can be
addressed during development and implementation of an
evidence-based clinical protocol to guide the use of IUCs among
older adult patients in EDs.
Study design
We conducted a qualitative study using focus groups. All par-
ticipants provided written informed consent before the start of the
session. This study was approved by the Weill Cornell Medical
College Institutional Review Board.
Study setting and population
The investigators conducted 4 focus groups at the ED of a large,
urban, academic medical center with a 4-year emergency medicine
residency program over a 2-month period (December 2012-January
2013). This ED has an annual volume of more than 65,000 adult
patients, with 26% aged 65 years and older. Patients are received
from nursing homes, rehabilitation centers, assisted living, and
community-dwelling locations. Each focus group consisted of a
single ED provider type: attending physicians, resident physicians,
physician assistants, or nurses. We recruited participants via e-mail
messages sent to all ED physicians, midlevel providers, and nurses.
The focus groups were conducted during regularly scheduled
provider-specific staff meetings, outside of clinical areas in the
usual meeting location, with all participants relieved from clinical
duties or not scheduled for clinical duties as is customary with
these staff meetings. There was no incentive provided to participate
in this study.
Study protocol
The focus groups were comoderated by 2 of the 3 research in-
vestigators who were trained in qualitative methods and emer-
gency medicine (MM, TR, and MS), using a semistructured format.
For each of the sessions, the moderators utilized the same inter-
view guide, which was developed by the investigators with input
from experts in qualitative research methods and after a review of
the current literature (Fig 1). A member check was completed with
the final 2 questions (ie, 7 and 8) delivered to the focus group to
confirm interpretation and minimize distortion of findings from the
session.14
The focus group sessions were audiorecorded, professionally
transcribed verbatim by an independent party, and reviewed by the
investigators for accuracy. The data were transcribed anonymously
with all voices identified by a participant number, and the confi-
dentiality of the participants was assured. Participant identifiable
information was recorded separately, but not linked to a participant
number, available only to the study team, and destroyed upon
completion of the transcripts.
Fig 1. Interviewer Guide.
Measurements
Each of focus groups was concluded and deemed successful
when saturation of information on the topic was achieved during
the session, as perceived by the moderators.
Data analysis
The coding schema for domains, key themes, and subthemes
was created by the lead investigator (MM) and reviewed by a sec-
ond investigator (TR). The investigators developed codes a priori,
with initial revisions made during debriefing discussions between
the moderators immediately after the focus group sessions. Addi-
tional revisions were made upon reviewing transcripts and during
the coding process according to what emerged from the data de
novo. Data analysis followed the principles of qualitative research15
and emergent content analysis16 to identify concepts using
NVivo10 (QSR International, Doncaster, Victoria, Australia).
The data were captured by referential coding through recording
units,16 so that the investigators were able to make inferences
about attitudes, beliefs, and practice patterns present in the con-
versation without being bound to the physical constructs of text in
the transcripts. This type of coding has been referred to as con-
versation blocks,17 a way of describing the capturing of segments of
conversation around a specific topic. The transcript of each focus
group was reviewed iteratively to identify individual conversation
blocks in which participants were discussing a specific topic.
Quantifying conversation blocks identifies the number of times a
specific topic is introduced or reiterated in the flow of the focus
group to assess the relative importance of different aspects of a key
theme. The transcriptionists utilized voice recognition to identify
and note whether a participant or the moderator was speaking to
ensure that only the participant experiences guided coding.
Discrepancies in coding were discussed and resolved by inves-
tigator consensus so that in the end all coding was reviewed and
confirmed by the study team. Analysis began after the final focus
group concluded, and was completed within 2 months. Descriptive
statistics were generated.
RESULTS
Four focus groups were completed with a total of 38 participants
(approximately 15% of ED providers at this institution), and
 M.R. Mulcare et al. / American Journal of Infection Control 43 (2015) 341-7
Table 1
Factors contributing to use of a convenience catheter
Contributing factor
Lack of supporting resources for patient care (primarily ED
technicians/nurses aides and alternate modes of urine
collection such as commodes)
Ease of monitoring urine output relative to other collection
modalities
Concerns for patient safety if he/she were allowed to get
out of bed independently
Perceived ease for nursing
Patient’s request
Education of providers
Attending, attending physician; ED, emergency department; IUC, indwelling urinary catheter; PA, physician assistant; RN, registered nurse.
incorporated different health care provider groups involved with
IUC placement in EDs: attending physicians (n ¼ 13), residents (n ¼
8), physician assistants (n ¼ 11), and nurses (n ¼ 8). The focus group
sessions ranged in duration from 23 to 33 minutes. Each of the
focus groups was concluded by the moderator when saturation of
information on the topic was achieved.
Qualitative analysis of the interview transcripts yielded 4 do-
mains with 12 major themes and 34 subthemes, and 393 conver-
sation blocks coded into these categories. The domains included
issues with current IUC practice, barriers to practice standardiza-
tion, suggestions for improvement, and elements to be incorpo-
rated into the new clinical protocol for IUC placement and
management in older adults in the ED.
Participants reported that current clinical decision making
about IUC placement for older adults varies widely, with different
management plans for the same diagnoses often made by the same
level of provider. The diagnoses with the greatest variability in
practice regarding whether an IUC is necessary, unnecessary, or
dependent on the situation were congestive heart failure, immo-
bility, hip fracture, incontinence, patients admitted to the surgical
service but not immediately bound for the operating room, trauma,
and concern for a urinary tract infection (but not urosepsis). Pro-
viders noted the use of “soft indications” and “gestalt” driving the
decision-making process. As 1 attending physician noted: “I think
that the issue is that a lot of these indications are very, very
soft.You can make soft indications for a lot of convenience-type
interventions.” An ED resident physician agreed: “A lot of times
just clinic gestalt..I think a protocol would help sanitize that.”
Participants reported that IUCs were being overutilized in our
ED (5 conversation blocks; 50% of groups mentioning). A physician
assistant said, “I think we tend to over-Foley than under-Foley.” All
provider groups volunteered that IUCs are often placed primarily
for staff convenience (13 conversation blocks; 100% of groups
mentioning). As described by 1 nurse: “You’re asked to straight cath
and [we] just leave the Foley in” (Table 1).
ED providers did recognize the older adult population as being
at higher risk for convenience catheters: “People put [IUCs] in the
elderly when it’s not indicated.” The groups identified several
343
Representative dialogue
Resident 3
Sometimes we’ve had people, usually elderly, with incontinence urinate on the bed several
times and the nurses [say], “We don’t have time or the resources and keep doing that,
can we just put in a Foley?”
RN 5
They don’t want to keep putting them on the bed pan and they’ll [say] let’s just put a Foley in ’em.
PA 6
In terms of measuring output, from a real practical time standpoint, you know when the Foley’s not
indicated for absolute strict [monitoring].and having to take the urinal or bed pan and pour it in
[to a urinal or hat] and measure it as opposed to just you know looking at the Foley bag.
That [is] extra time.
PA 8
If you take the Foley out, you have to walk them more often and now those people who were once
staying still with the Foley in are now at a risk for falls.
Attending 4
It’s easier for nurses.
PA 6
. I think there’s a lot of nursing education and the nurses’, even the nurses aides’ education about
the requirement of getting the samples versus just [placing an IUC] because it’s easy.
PA 6
Patients ask for it. Sometimes patients ask for it and we’re just like, “Oh, okay. You don’t feel like
getting up to pee? Sure.” But it’s not really the best.
PA 9
I think [patients get inappropriate Foleys] if someone doesn’t appropriately order 1 or make sure
[the Foley is] given for the kind of the things we talked about.
Table 2
Eleven potential barriers to indwelling urinary catheter (IUC) practice
standardization
1. Physician variability in practice by diagnosis
2. Physical location of patient in emergency department preventing
placement (ie, hallway bed)
3. Communication with inpatient services that have different pre-established
clinical pathways involving IUC placement
4. Concern that physical location of a patient in hospital should not dictate
whether patient receives an IUC
5. Practicality of alternate modes of urine collection:
a. Lack of space for privacy needed for toileting with commode
b. Lack of supplies, including commodes and measurement hats
c. Lack of patient care support available for walking patients to restroom
6. Nursing variability in placement technique
7. Need for multiple attempts at placement causing increased infection risk
8. Information technology support for orders and pop-up messages
9. Variability in documentation practices
10. Variability in sign-out practices
11. Time management for ongoing reassessments
complications of IUCs in the older adult population. The most
commonly mentioned included infection risk (9 conversation
blocks; 75% of groups mentioning), falls (7 conversation blocks;
75% of groups mentioning), and delirium (5 conversation blocks;
50% of groups mentioning). Additional negative consequences of
IUCs mentioned included accidental traumatic removal, discomfort,
and immobility. Some of the positive considerations in placing an
IUC included skin protection, obtaining a clean urine sample
(although participants immediately noted that this can be accom-
plished with straight catheterization), resource management (ie,
reducing the workload on the nursing staff and ED technicians),
and maintaining a patient’s dignity. The participants reflected that
often a patient may be more uncomfortable sitting in a wet diaper
than having an IUC in place.
Participants confirmed that, historically, IUCs have been
infrequently removed before transfer from the ED (7 conver-
sation blocks; 75% of groups mentioning). For example, “We
usually leave it in and let [the] medicine [team] decide if they
want it.” Yet participants did identify circumstances and
344 M.R. Mulcare et al. / American Journal of Infection Control 43 (2015) 341-7

Table 3
Themes for suggested improvement of current practice with indwelling urinary catheter (IUC) in older adults

Suggestions for areas of
improvement
Alternate modes of urine
collection
Increased emergency
department technician
support
Technique training
Transitions of care
Other resources
Other supplies needed
Ongoing assessments
Documentation of I&O
Information technology support
Communication with
inpatient teams
Portion of Total
groups conversation
mentioning (%) blocks (n) Representative dialogue
100 16 PA 9
The nurses aide or a tech can monitor or clean patients more often if they have a diaper.
Resident 8
Someone to help them to the bathroom, give them a urinal to use, or a bedside commode
at their bed so you can avoid the Foley.
100 10 Attending 3
Elderly patients with poor mobility.it takes a lot of work to get them to the bathroom.
I mean theoretically [IUCs] may be placed in patients who shouldn’t have them.
Attending 1
But it’s also going to take up more tech time and more nursing time assisting them to the
bathroom.we never really think about that, but then we aren’t dealing with it directly.
75 15 Attending 6
It would be worthwhile to find out how many attempts were made, and I’m sure that’s
not ever recorded. I can imagine that they take that same Foley [after a failed attempt]
rather than using a fresh Foley, and then they try again.
75 8 Attending 5
I don’t think we have a good system or a uniform system about how [IUCs] get removed once
they were placed.
Resident 6
Maybe that’s where the protocol would help. any Foleys in noncritically ill, nonoperative
patients who go up to the floor need to be checked within, I don’t know, 6 hours of getting
to the floor.
50 5 Resident 7
How often in a busy ED does someone flag you (the physician) down and [say], “I need a bed
pan,” and that 1 act.takes up so much time, right?...Someone who can easily get on and off
the bed pan, fine, that’s 1 thing or a patient who can ambulate to the bathroom, but the
patient who wants to use the bathroom and needs assistance to the bathroom or wants to
get on and off the bed pan and there needs to be someone to help them to do so. in an ideal
world if you had enough resources then there wouldn’t be a lot of downsides, I think, to
limiting the number of Foleys that we put in, but potentially [limiting Foleys] increases the
time that you have people just sort of urinating on themselves and just sitting in their urine
.there’s just not enough resources to get over and change that patient.
50 4 RN 5
With the ultrasound, but a bladder scanner would be nice.
50 4 Resident 8
Maybe a doctor has to say, “Oh it’s 3 days, let’s take the Foley out.”.Maybe when the patient
comes upstairs and the nurse is doing the assessment she could say, “I don’t think this patient
still needs a Foley,” page the resident, and ask to take the Foley out.
25 1 RN 5
[The patient] just peed in a hat. The biggest problem in nursing if you ask me with the I&O
argument is the documentation.When it’s in the Foley.no one puts it in the computer.
75 5 Resident 7
I guess if we do end up having a system where you have an expiring Foley order, it could be
like an ED Foley order. That way the ones that we install in the ED are the ones that expire
versus the ones that people put in on the floor.
75 12 Resident 2
I think that we’ve got to really make up this protocol. It should be like an interdisciplinary thing
where people from other departments say, “This is why I think patients with this [diagnosis
need an IUC].” Patients going to orthopedic services probably think they need a Foley for
certain things, [different from] patients going to other services.

Attending, attending physician; I&O, ins and outs; PA, physician assistant; Resident, resident physician; RN, registered nurse.

reasons why removal is important to consider: when the IUC is
no longer needed (9 conversation blocks; 100% of groups
mentioning); if the IUC was placed for an inappropriate indi-
cation initially (4 conversation blocks; 75% of groups
mentioning); and other reasons such as patient request and
discharge (5 conversation blocks; 50% of groups mentioning).
Likewise, participants expressed concern regarding the man-
agement of IUCs by the medical team on the floor, including
the duration the IUC is left in place and the quality of daily
care, heightening the importance of removing IUCs in the ED
before transfer if possible.
When discussing the implications of CAUTIs, attending and
resident physicians discussed reimbursement implications for the
hospital: “Eventually, there’s going to be reimbursement consid-
erations because reimbursement is [going to] be tied to the number
of hospital-acquired infections and we think that infections from
Foley catheters is going to be high on the list.”
Eleven potential barriers to practice standardization were
identified (Table 2). Participants discussed the importance of
communication with the different inpatient hospital services,
noting varying established clinical protocols involving IUC place-
ment, especially on the surgical services. The practical nature of
alternatives for urine collection was mentioned most frequently by
nurses (38% of conversation blocks) and midlevel providers (31% of
conversation blocks). In contrast, the attending physicians
comprised only 6% of conversation blocks on this topic.
Ten subthemes for improvement to our current practice
were identified. The most frequently mentioned topics included
alternate methods of urine collection, such as increasing the use of
bedside commodes with collection hats and condom catheters (16
conversation blocks; 100% of groups mentioning) and the need for
more ED technicians or nursing aides with a teamwork approach to
patient care (10 conversation blocks; 100% of groups mentioning)
(Table 3).
 M.R. Mulcare et al. / American Journal of Infection Control 43 (2015) 341-7
Table 4
Ten key items to include in the protocol for placement and management of
indwelling urinary catheters (IUCs) in older adults in emergency department (ED)
settings
1. Adaptability to specific patient situations
2. Flow sheet style
3. Diagnoses appropriate for insertion
4. Diagnoses where insertion is contraindicated
5. How to differentiate between ambiguous diagnoses, giving weight to
clinical judgment
6. Communication with other departments, especially those most
frequently admitting from the ED
7. Suggestions for alternate modes of urine collection
8. Tips for placement of IUCs; for example, sterile technique and pain
control
9. Reassessment guidelines indicating appropriate intervals and
situations to re-evaluation of the IUC necessity
10. Access to literature/research informing the protocol and establishing
the purpose of having such a protocol
Participants identified 10 key elements needed for a successful
clinical protocol (Table 4). All ED provider groups expressed a desire
for and a willingness to adopt a clinical protocol to standardize IUC
use in older adult patients in EDs. As described by 1 resident
physician: “Having a protocol would help [such that the decision to
place an IUC] doesn’t [only] fall under the purview of whoever is
taking care of the patient [at that time].” Participants emphasized
that these focus groups were a critical component for the devel-
opment of a protocol.
Limitations
We used counting in this qualitative study as a proxy for
importance of a given theme or subtheme, which may not be the
case were participants asked to explicitly delineate the relative
importance of the highlighted subjects.
This study was conducted at a single, urban ED with an aca-
demic focus on the older adult population. Eliciting the views and
experiences of patients and their families would have added useful
insights, but gathering this information was beyond the scope of
this study.
A potential limitation of this study is in participant recruitment.
Physicians, nurses, and midlevel providers were recruited based on
their attendance at regularly scheduled meetings and willingness to
participate in the focus groups. Participants who volunteered to take
part in the study may be a group with a more favorable view toward
changing practice surrounding IUC use than those who did not.
There may be significant reporting bias during the sessions,
especially because the moderators were clinicians working in the
same ED. To elicit honest commentary, the moderators of the focus
groups, who were trained in qualitative research methods, were
very deliberate in their attempt to create a safe, nonjudgmental
environment. For the resident physician group, the moderators
were a fellow (MM) and coresident (TR), thus not directly respon-
sible for evaluating the resident physicians. For the ED attending
physicians, the moderators (MM and MS) were colleagues, and
supervising physicians to the physician assistants and nurses. The
moderators had frequent contact with the participants clinically
during the time of the study but were not directly responsible for
evaluation of these individuals. The moderators made every effort
at continuous reflexivity; however, it cannot be assured that there
was no influence on the participants.
Finally, our participants believed additional resources in the ED,
such as more ED technicians, are important to successfully chang-
ing culture. This is a staffing and financial issue for the department
that was outside the scope of our clinical protocol, and thus was not
345
included in the final version. We brought this finding to the
attention of the administration for their use going forward.
DISCUSSION
Consistent with recent literature,18 we confirmed that unnec-
essary IUCs are commonly placed in older adult patients in our ED
and significant variation exists between providers in the clinical
decision making about IUC placement. Throughout the focus
groups, participants often made conflicting arguments for and
against the same indication for IUC placement, emphasizing the
complexity of this issue in clinical situations and the need for a
protocol to help guide practice. Much of the conundrum around
whether or not to place an IUC is related to the anticipated risk-to-
benefit ratio when considering an individual patient’s scenario.
All groups acknowledged the known risks for patient safety
and deleterious outcomes,10,19,20 including infection, delirium,
falls, patient discomfort, traumatic removal, and promotion of
immobility.
Interestingly, the nurse participants agreed with the other 3
groups that the nursing staff does frequently place “convenience
catheters,” despite the knowledge of associated risks. EDs can be
challenging environments where the nurses are balancing high
patient volumes with limited resources and time per patient,
making the most practical choice (ie, an IUC) common. Based on the
focus group participant input, it appears that nurses are eager for
alternatives and hope that a clinical protocol will help drive a cul-
tural change.21
In addition to gaining insight as to which types of ED patients
clinically require an IUC, we uncovered several barriers to changing
practice. Communication was a consistent theme. The nurses, in
particular, voiced frustration that their perspective on patient care
was not included in the decision-making process. For example, they
reported that many patients with mild congestive heart failure
have IUCs ordered even after a nurse suggests that urine can be
successfully measured use a measuring hat or bedpan. Thus, we
incorporated a second step into the protocol, such that after initial
identification of the clinical condition requiring an IUC there needs
to be agreement among the team members that placement is
necessary, with the ED attending physician mediating the final
decision.
Placement of an IUC is a decision that is infrequently reversed
once a patient is transferred out of the ED to the floor. In fact, per a
study done in 2000, 28% of the time an inpatient provider did not
know that a patient under his or her care had an IUC.22 Thus,
preventing initial placement or considering removal upon transfer
out of the ED may have a large influence on the length of catheter
use and subsequent infection. As a result, a third step was included
in the protocol to remind providers to reassess the need for an IUC
at regular intervals: shift change, admission to the hospital, transfer
to the floor, or upon discharge from the ED. The focus group par-
ticipants also independently recommended the need for visible
reminders about alternate modes of urine collection, techniques
employed during placement, and management of the IUC.
Despite existing barriers, a comprehensive, evidence-based
clinical protocol to guide ED providers in appropriate placement,
reassessment, and removal of IUCs in older adult ED patients was
deemed necessary. The implications of this study and development
of a protocol potentially extend beyond the ED in improving care
and safety for older adult patients.2
CONCLUSIONS
The knowledge gained through these focus groups was instru-
mental in the development of our protocol for placement and
346 M.R. Mulcare et al. / American Journal of Infection Control 43 (2015) 341-7

Fig 2. Protocol for emergency department placement and management of indwelling urinary catheters (IUCs) in older adults. ATLS, Advanced Trauma Life Support; CHF, congestive
heart failure; ED, emergency department; I&O, ins and outs; NIPPV, Non-Invasive Positive Pressure Ventilation; NYP, New York-Presbyterian.

management of IUCs in older adults in ED settings (Fig 2). The focus
groups contributed new ideas and directions that made the pro-
tocol novel, comprehensive, and clinically viable in our ED setting.
The protocol design included not only evidence-based research, but
also the concepts of teamwork, communication, and reassessment.
We anticipate that the involvement of all members of our health
care team, including nurses and midlevel providers, will create
buy-in for the implementation and ongoing application of the
protocol.
Acknowledgments
The authors thank Jaime Lynn Hayes, RN, Division of Emergency
Medicine, Weill Cornell Medical College, New York, NY; Regina
 M.R. Mulcare et al. / American Journal of Infection Control 43 (2015) 341-7
Mysliwiec, MD, Division of Emergency Medicine, Weill Cornell
Medical College, New York, NY, and the Emergency Medicine Res-
idency, New York Presbyterian Hospital, New York, NY.
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