Defining “Critically Ill” in the ICU; Alternatives to Catheters; Using the

CUSP Staff Safety Assessment and the Learning from Defects Tools to
Improve Safety Culture

Randy Garnett Jr., MD

PCCM Physician, Sentara Medical Group
Chairman, Sentara Norfolk General Critical Care Committee
Medical Director, Sentara Lung Transplant Out Patient Program
Norfolk, Virginia

Sheryl Sheriff, RN, MS

Cardiovascular Clinical Practice Specialist
Greenville Hospital System
Greenville, South Carolina

Emily Pasola MSN, RN, CNL

Clinical Nurse Leader
Surgical Intensive Care Unit
Saint Joseph Mercy Hospital
1 Ann Arbor, Michigan
 Learning Objectives

• Define when “critically ill” is an appropriate

indication for an indwelling urinary catheter in the
ICU
• Describe how to implement an indwelling urinary
catheter removal protocol
• Identify defects in the ICU by using the CUSP tool,
Learn from Defects

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INDWELLING URINARY CATHETER USE IN THE ICU
CRITICALLY ILL PATIENTS

Randy Garnett Jr., MD

PCCM Physician, Sentara Medical Group
Chairman, Sentara Norfolk General Critical Care Committee
Medical Director, Sentara Lung Transplant Out Patient Program
Norfolk, Virginia

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 ICU Characteristics
(Complex Interactions, May Effect indwelling urinary catheter
Utilization)

• Medical vs. Surgical

• Acuity level of patients
• Arena from which patient comes from to the ICU- OR, ED,
floor SNF
• Who put the indwelling urinary catheter in?
• ICU culture
– RN
– MD
– Leadership/admin support
– Other

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Potentially Critical Illness Clinical Observations

• Sweaty, anxious, pale

• Agitated or confused
• Responds to moderate stimulation only – loud voice,
physical prodding
• Accessory muscle use and RR 20-30 or RR < 8
• HR > 100
• SBP < 90
• UO < 0.5 ml/kg/hr

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The Critically Ill Patient Clinical Observations

• Looks ill – poorly perfused

• Unresponsive or poorly responsive neurologically
• Resp Rates < 8 or > 30
• HR < 50 or > 150
• SBP < 60 to 70
• Anuric or oliguric

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 Critically Ill

Surgical Patient Categories who will almost always

need indwelling urinary catheters:
• Post op patients with continued mechanical ventilation and sedation
• CSICU- CVG, Valve surgery, transplant , aortic dissections
• Major abdominal GI surgery- SBO, ischemic bowel, bowel perforations, liver transplant,
abdominal compartment syndrome
• Major Vascular surgery- Ruptured AAA, retroperitoneal bleeds
• Most GU surgeries
• Hemodynamically unstable post op patients where UO guides therapy
• Immobilized patients- trauma , fractures, TBI
• Post operative co-morbid processes where accurate urine output is important to monitor -
acute and chronic renal failure, CHF/CMO or low Cardiac output states, DI
• Post operative delirium, agitation, encephalopathy where incontinence has a detrimental
effect on optimal care – wounds , staff safety

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 Critically Ill

Medical Patient Categories who will almost always

needs indwelling urinary catheters:
• Respiratory failure on mechanical ventilation and significant sedation
• Hemodynamic instability
– Sepsis and septic shock
– Hemorrhagic Shock – GI bleed, trauma, post procedural
– Cardiogenic Shock
• Unstable CHF patients undergoing aggressive diuresis
• Severe neurologic impairment with altered mentation- CVA,ICH,SAH, SDH,TBI
• Acute or chronic renal failure with obstruction/retention
• Critical illness where voiding exacerbates the primary process – COPD or CHF on NIV

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 Types Of Treatments
Requiring Close UO Monitoring
• Bolus fluid resuscitation
• Vasopressors
• Inotropes
• High dose diuretics
• Hourly urine studies to measure life threatening
laboratory abnormalities

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 Case #1
Indwelling urinary catheter – Yes or No?
• 24 yo presents with acute SOB with history of asthma. Acutely ill.
• BP 155/95
• HR 124
• RR 30
• EXAM:
– Oriented x 3
– 2 + accessory muscle use
– Diffuse wheezing bilaterally, prolonged expiratory phase
– Can move from stretcher to bed without significant change in status
• ABG on 2 LNC ---- PaO2 – 87; PCO2 - 46; pH 7.36

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 Case #2
Indwelling urinary catheter – Yes or No?
• 72 yo male 48 hrs post CVG x 3 and MVR. Still on mechanical
ventilator with moderate levels of sedation and RASS of -2
• Is on moderate doses of norepinephrine and epinephrine that
are being adjusted for MAP of 65-70
• Remains on 55% FiO2 and 8 PEEP
• EXAM:
– Opens eyes and follows simple commands before drifting off
– Lung and cardiac exam are normal
– Abd is benign and extremities feel perfused
• Labs and CXR s are not concerning

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 Case #3
Indwelling urinary catheter – Yes or No?
• 83 yo male with BPH who is post op ruptured AAA returns to ICU for post
op care.
• Is extubated 2 hrs post arrival in the ICU and has moderate abd pain.
• Drips: low dose Neosynephrine
• VS: HR 90, BP 140/85 , RR 17. Temp 95.4
• EXAM:
– Lungs clear
– Heart – RRR without murmer
– Abd – moderately tender
– Extremities perfused
– Urine out put 50 -100 cc /hr since going to the OR

• When can the indwelling urinary catheter come out ?

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 Case #4
Indwelling urinary catheter – Yes or No?
• 65 yo with moderate to severe COPD presents with acute on chronic
respiratory failure to the ICU from the ED and is placed on NIV . No
cardiac history.
• VS: HR 110, RR 21 with 1 + accessory muscle use, BP 125/66 , afebrile
• EXAM:
– Distant breath sounds with rare wheezing and prolonged expiratory phase
– Cardiac exam pertinent only for tachycardia
– Abdomen is benign and extremities are adequately perfused
– He is oriented x 3 , moves around in bed
• He has been supported 3 times with short term NIV in the past year
without needing intubation
• ABG in 40 % and NIV : PaO2 – 72 ; PCO2 - 52 ; pH – 7.35

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Indwelling Urinary Catheter Removal
Protocol

Sheryl Sheriff, RN, MS

Cardiovascular Clinical Practice Specialist
Greenville Hospital System
Greenville, South Carolina

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Indwelling Urinary Catheter Removal Protocol:
Review, Remove, Reduce

Review
Patient no longer meets approved indwelling urinary catheter indications.

Remove
Nurses are empowered to remove the indwelling urinary catheter per protocol.

Reduce
Catheter days are reduced by timely removal of indwelling urinary catheter catheters when no longer indicated

CAUTI rates are reduced.

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 Approved Indwelling Urinary Catheter
Indications
• Ordered or placed peri-operatively for selected surgical procedures (i.e. Unstable Pelvic, Hip/Spine fracture,
Renal/Urologic surgery, Gynecological Surgery, Perineal procedure)
• Accurate measurements of intake and urinary output in critically ill patients:
Hemodynamic instability (requiring Pressors, shock), &/or
Neuromuscular blockade (ventilated), &/or
Deoxygenation with exertion or position changes (i.e. acute respiratory compromise, acute decompensated CHF)
• Epidural catheter in place for pain management and patient is unable to ambulate
• Traumatic bladder and/or ureter
• Acute urinary retention with failure of Urinary Retention Protocol
• Bladder outlet obstruction
• Gross hematuria/irrigation
• Assistance in pressure ulcer healing for incontinent patients with stage 3 or 4 sacral ulcer or perineal wound(s)
• Comfort care (category 4)/hospice at patient/family request
• Pre-existing catheter upon admit and unable to verify indwelling urinary catheter indication
• Pre-existing catheter upon admit with chronic Urological issues
• Catheter tagged with “yellow band” (NOTE: Yellow tag located around Foley tubing or at juncture of tubing
and bag. If Foley is tagged, do not remove without a physician’s order.)

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 Yellow Banded Indwelling Urinary
Catheters
Catheter tagged with “yellow band” (NOTE: Yellow tag located
around catheter tubing or at juncture of tubing and bag. If
indwelling urinary catheter is tagged, do not remove without a
physician’s order.)

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 Fact or Fiction and Indwelling Urinary
Catheters
Fiction: Any patient on Lasix or requiring accurate intake &
output measurement require indwelling urinary catheters – not
true.

Fact: Lasix and I/O measurement are not approved indications

for indwelling urinary catheters.

• Follow the hospital approved indwelling urinary catheter

indications.
• Use alternatives to indwelling urinary catheter for
measurement of output.
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 Fact or Fiction and Indwelling Urinary
Catheters in Critical Care
Fiction: All patients in critical care require a indwelling urinary catheters for accurate
measurement of intake and output – not true.

Fact: Patients do not need indwelling urinary catheters just because they are in a
critical care bed.

Approved indications defines “Accurate measurements of intake and urinary output in

critically ill patients” as:
• Hemodynamic instability (requiring pressors, shock)
• Neuromuscular blockade (ventilated)
• Deoxygenation with exertion or position changes
(i.e. acute respiratory compromise and/or acute
decompensated CHF)

Critical care patients admitted from the OR/PACU

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do not automatically need a urinary catheter.
 Identifying Defects and
Using the Learn From a Defect Tool

Emily Pasola MSN, RN, CNL

Clinical Nurse Leader
Surgical Intensive Care Unit
Saint Joseph Mercy Hospital
Ann Arbor, Michigan

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 Objectives

• Discuss strategies to identify defects

• Review steps of Learn From a Defect Tool (LFD)
• Discuss example using LFD

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 What is a defect?
HAPU
Self Extubation
Infection Control
CLABSI/CAUTI/VAE
Medication Error
RN Shift Handoff
Missed Documentation
Knowledge Gap
Environmental Safety
 Finding the Defects

• Staff feedback
– Shift huddles, staff meetings
• Event reporting
– Root Cause Analysis, hospital reporting system
• Quality and safety measures
– Monthly data reports
– Recurring gaps
• Staff Safety Assessment survey

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 Appendix C

STAFF SAFETY ASSESSMENT – CUSP

Purpose of this form: The purpose of this form is to tap into your knowledge and
experiences at the frontlines of patient care to find out what risks are present on
your unit that have or could jeopardize patient safety.

Who should complete this form: All health care providers.

How to complete this form: Provide as much detail as possible when answering
the 2 questions. Drop off your completed safety assessment form in the location
designated by the CUSP improvement team with your job category, date and unit
in the top box (name is optional).

When to complete this form: Assessing safety should be considered an iterative

process with no defined end (like a moving bicycle wheel). Thus, it can be filled out
by any health care provider at any time. At the very least, all health care providers
should complete this form semiannually.

Name (optional):
Job Category:
Date:
Unit:

Please describe how you think the next patient in your unit/clinical area will
be harmed.

Please describe what you think can be done to prevent or minimize this
harm.

Thank you for helping improve safety in your workplace!

 Staff Safety Assessment
• What is it?
Two questions for bedside staff:
– Please describe how you think the next patient in your unit/clinical area will
be harmed.
– Please describe what you think can be done to prevent or minimize this
harm.
• Why is it important?
– Staff engagement-driving change
– Staff understanding their role in patient safety
• What should you do with the information?
– Be transparent
– Identify theme
– LEARN FROM IT

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 Learn From a Defect

Supporting a culture of safety

• Easy to use
– efficient
• Structured Method
• Continuity
• Non-punitive
• Ownership
– collaborative, multidisciplinary
• Improve Quality

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 Conclusion

• Easy, efficient & organized

• Supports staff engagement
– Multidisciplinary approach to quality care
• Provides transparency
– Staff want to know what we do.
– Staff want to know that we listen.
• Provides structure & accountability
• Tracks progress

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 Summary/Next Steps

• Understand the HICPAC indications for urinary

catheter use, especially in the critically ill population
• Understand when catheters may be discontinued in
critically ill patients
• Know what alternatives to indwelling urinary
catheters are available in your organization
• Implement the Learning From Defects tool and staff
safety assessment with your ICU team

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 Thank you!

Questions?

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 Funding

Prepared by the Health Research & Educational Trust of the

American Hospital Association with contract funding
provided by the Agency for Healthcare Research and
Quality through the contract, “National Implementation of
Comprehensive Unit-based Safety Program (CUSP) to
Reduce Catheter-Associated Urinary Tract Infection
(CAUTI), project number
HHSA290201000025I/HHSA29032001T, Task Order #1.”