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AHA – Chicago
August National Content Call
August 12, 2014
11:00 AM CT

Operator: The following is a recording of the Paul Tedrick August National Content Call with the American Hospital Association on Tuesday, August 12, 2014 at 11:00 a.m. Central Time. Excuse me, everyone. We now have all of our speakers in conference. Please be aware that each of your lines is in a listen-only mode. At the conclusion of today's presentation, we will open the floor for questions. At that time, instructions will be given as to the procedure to follow if you would like to ask a question. I would now like to turn the conference over to Ms. Ashley Hofmann. Ms. Hoffman, you may begin.

Ashley Hofmann: Hello, everyone, and welcome to our August National Content Call for On the CUSP: Stop CAUTI. So excited to have you with us on today's call, which is going to focus on culture change. Before we begin today's presentation, just a quick reminder that this call is a webinar, so please be sure to log in through that webinar link in order to see the slides today. We'll also post a copy of the slides and the recording to the project website later this week. We have two presenters today. The first is Linda Greene who's the Infection Prevention Manager at Highland Hospital in Rochester, New York. Linda has over 25 years of experience in infection prevention and has authored or coauthored several peer-reviewed publications in nursing and infection prevention journals, textbook chapters, and implementation guides. Linda serves at the national faculty for the CUSP CAUTI Program and was editor for the recently-released APIC CAUTI Implementation Guide. Also with us today is Jenny Tuttle. Jenny has over 25 years in the critical care units at the Tucson Medical Center and Duke University Center, with a focus on neuro and neurosurgical nursing. She was the team lead for On the CUSP: Stop CAUTI project in the Neuromedical and Surgical ICU. As the Clinical Nurse Leader for this unit, she continues to be an active participant in implementing the quality initiative to engage the staff daily and spread success throughout the facility. And now it's my pleasure to turn it over to Linda Greene.

Linda Greene: Thank you so much, Ashley, and it is a pleasure to be here. I'm just going to go through very quickly some of the learning objectives, which is that we're going to describe the way in which improvement in clinical culture can facilitate efforts to reduce urinary catheter use. I just want to pause one second and talk about clinical culture as I go on, but one of the things that we find out, and I'd learned this through some of my participation on other CUSP projects, not necessarily CAUTI projects, is that people don't necessarily get as excited about the cultural issues as they do about the technical ones because sometimes we're just scientific-based and sometimes those cultural issues are what's new or what have you. But what I've learned particularly through this work and some of my other CUSP work is those cultural changes, those adaptive changes are equally if not even more important. So trying to get people to do what they need to do and helping us understand. So I think that's a very important point. We're also going to identify ways in which we can use the HSOPS results and the team checkup tool to identify opportunities for improvement. And I know sometimes it seems like a lot of work. If you're new to the CAUTI CUSP project, you're thinking, “Oh my goodness.” But I can tell you, when you do that cultural assessment, it really does help you identify opportunities for improvement. And then finally, I'm going to utilize some case studies to develop strategies to overcome the barriers. And we do know when it comes to decreasing urinary catheter device utilization, there are many, many barriers. But I'd like to start with just getting some background information, so I'm wondering if you could answer this polling question. Obviously, it's very self-explanatory. Are you a state lead; CUSP facility, fellow, or mentor; unit champion; or other. So, I appreciate that if you'd fill that out, and then we'll have the results.

Ashley Hofmann: So we'll just give everyone about 30 seconds to respond. Alright, there are the results from our poll.

Linda Greene: Alright, so we have a wide variety of people on the phone, which is wonderful. That kind of helps us. The second question, and before we start, just be interested in your answers to this one. What's your greatest challenge with catheter removal? And certainly that helps us kind of understand and direct some of our comments.

Ashley Hofmann: So we still have some responses coming in. I'm going to give you guys 20 more seconds to get your answer in. That's the results.

Linda Greene: There's the results. I could have guessed this result and we'll talk a little bit about that real or perceived. And I see a typo there so our apologies when we loaded the questions. It's not ‘perveived,' it's ‘perceived.' But anyways, real or perceived need for accurate I and O. So, certainly we know that's a challenge and some of the other things are challenges as well, and probably many of you had you been given the choice would have said all of these. So let's just get into the basis of the presentation. When you look at what is the culture, well the culture, as we all well know, it's made up of the values, it's made up of the beliefs, it's made up of underlying assumptions, attitudes, behaviors shared by a group of people. So when you're thinking of culture, culture is the behavioral that results when a group arrives at a set of generally unspoken and unwritten rules for working together.

And I think we talk about culture all the time, but those generally unspoken or unwritten rules really are what makes the difference. And if you go into any unit in a hospital, or even if you go out into the community, or you go to a hotel, or you go to a store, there usually is a culture that's somewhat pervasive. And the more that we can understand that culture, the easier it is certainly to intervene and to make changes. And one of the things that was pointed out, there is such a thing as an organizational culture, but there's also such a thing as a clinical culture. And when I talk about clinical culture, that's that set of attitudes and behaviors in the clinical area or patient care unit, and that clinical culture is strongly influenced by leadership, experience, history, and tradition. And one of the things when we think about the clinical culture, and I think if you're working with hospitals, if you're a state lead or what have you, really think about the clinical culture in the organizations you work with if you're a CUSP unit. But one of the things we know about leadership is it's the direct providers who provide what we'll call the content of care. But it's leadership which establishes that environment in which care is delivered and they set the culture, the behavioral standards, and the organizational values. So we can't underestimate the power of leadership. However, understanding what those values are and what those behavioral standards are for leadership is extremely important.

So, let's look a little bit about urinary catheters, and let's examine the culture of safety in our assessment of harm. And one of the things in a previous content call, and I think you— if you don't get a chance to go back and review the slides, but Scott Griffith talked about the fact that culture change is when you move from what we call a rule-based to a value-based culture, when it's because that's what we value. So if you look at safety and harm assessment, first of all, there are three things. People have talked about those three things differently, but I'm going to give you my assessment or my interpretation. First of all, you have to believe that failure to follow guidelines, principles, or what have you, may cause harm. Secondly, there's some type of built-in alert. There's something that really kind of alerts you or prevents you from doing harm. And thirdly, there's got to be consequences for failure to implement those types of things. So here's a familiar picture. I'm sure you're all familiar with this, the case of the catheter, and we know that's an issue. So let's go back, and let's look at Stacy, and let's look at urinary catheters. And let's take something that is pretty apparent. Let's take seatbelts, for example. And if you take the seatbelt example, do people believe in it? Do they believe that if you don't fasten your seatbelt, you could potentially result in harm? And I think we'd say that most of us truly believe that. Now there are a few outliers, people will say, “I never wear a seatbelt,” but I think the majority of us know that it is the right and safe thing to do, and it becomes a value-based thing, it's second nature for most of us. But if I'm pulling out of my driveway and I'm (0:10:18 indiscernible) and I may forget, there's something to remind me. There's that little annoying noise that goes off in my car. And thirdly, and I don't want to emphasize the stick more than the carrot, but there are consequences. For example, you can get a ticket or things like that if you don't fasten your seatbelt. So now let's take the urinary catheter. Do most people believe it causes harm? And I think that's the question that you have to ask yourself when you're doing your organizational assessment. And I would question that. I mean, I think people will talk about preventing catheter-associated urinary tract infections, but do they really believe in the fact that having a urinary catheter can cause harm? It can cause CAUTIs. It can cause non-infectious types of events. Patients certainly can try to get out of bed and pull out their catheter. So there's all types of thing. Do we have built-in safety alerts? And I know in many hospitals that's one thing they're trying to think of, is how can we alert (0:11:25 indiscernible), whether it be automatic stop orders. And finally, are there consequences? And by consequences I don't necessarily mean negative consequences, but do we give feedback to people, “This is an inappropriate insertion,” or, “You didn't follow the nurse-directed protocol,” or those types of things. And are there really some type of sanctions or even just regular feedback related to that.

So if you look at patient safety, I would say most of us feel we have not gotten there yet with urinary catheters. While there are some clear lessons about culture, this is an article from AJIC, “Reducing health care-associated infections: lessons learned from a national collaborative.” And if you look at the findings in the Welsh article here, it's fostering change, overcoming the barriers. So first of all, we've got barriers. I know a lot of you talked about the fact that accurate I and O, whether it's real or perceived. The units that did well had good communication, standardized processes and metrics. They had local focused implementation, so implementation was at the unit level. One of the things I find particularly in large hospitals, and the next speaker, Jenny Tuttle, who will give you some great examples of what she did, is oftentimes when we're studying these projects we want to go organizationally, which is fine in a small hospital. Sometimes in a large hospital we really have to kind of take it one step at a time. Frontline staff engagement. One of the things I've found even in coaching calls and working with a number of hospitals, that although we sometimes say we're engaging the frontline staff, we don't always engage the frontline staff. Oftentimes it's leaders who really don't know the day-to-day issues.

Opportunities for organizational learning, support, resources, and then as I said, feedback and reinforcement. So all of those thing are really, really important. Well, first of all, I think it's really important that we do a stakeholder assessment. And by that I mean if you're in the ICU—and we know urinary catheters are a particular issue in the ICU—and you've been a nurse like myself for many years, it was pretty typical that every ICU patient had a urinary catheter. So when looking at this, ask yourself, who are the key drivers in your unit? Is it the intensivist? Is it the nurse manager? Is it the MD director? Is it the nurses themselves? And I think particularly if you're looking at an intensive care unit, in different clinical cultures there will be different people who are clearly the drivers. I worked in an intensive care unit in my last hospital that the nurse manager was the key driver. She had a good relationship. She was well-respected. If she said something to the intensivist, they certainly would do it. In other hospitals, intensivists rule the bus. So really find out who are the key drivers. There will be a couple tools and we'll post them on the website, there are some stakeholder assessment tools that are available. There are some other areas to determine who are your key drivers and that's really, really important. One of the things to keep in mind when you're doing your organizational assessment, and right now I'm just talking about an ICU culture, but it could be any particularly culture, if I'm trying to reduce urinary catheter utilization, how important is it to each one of these people. And there was another analysis. I know when I was in graduate school it was called the ‘prince analysis,' where you'd take each one of these people and you'd say how much power do they have on a scale from one to three, how strongly do they feel about the issue, which is the salience, and then are they either for or against it. And one of the things that you often find is that we usually, by nature, will go to the highest-ranking person. And oftentimes if it's a new initiative, sometimes that highest-ranking person is definitely going to be for the new initiative and they might have a  great deal of power, but they're not particularly passionate about it. And sometimes that's because their plate is so full that they just really don't have the buy in. They're certainly supportive. So when you're trying to just change that culture for removing urinary catheters, kind of think about that, who are the people.

A good example in the hospital I'm in right now, and I know it takes a long, long time to change culture, but we really did start— are trying to start because we've had a problem with CAUTIs, we tried to start with our surgical arena, at least trying to get to those patients, making sure that obviously patients who had surgery and did not need a catheters didn't have them. And we got a very young, aggressive, passionate orthopedic surgeon, who is not necessarily chief of orthopedics. She's very involved. She's very engaged. She led the initiative. And she came to a meeting last week and she basically said, “I have decided since I'm leading this particular initiative that no one, no orthopedic patients are going to have urinary catheters.” And she said, “I got a lot of pushback from my colleagues, but we decided that's the way we're going to go.” So just an example of trying to find those champions and it's not as obvious as it could be.

So let's look at organizational culture. Let's look at the levels of organizational culture. And you really want to look at values which reflect desired behavior, but are not reflecting an observed behavior. So if I'm doing an organizational assessment, first of all, my underlying assumption is safety is a system property. But oftentimes, particularly with physicians, and this is really hard to change, and I point this out because as you move forward and you really try to change that culture, they think safety's a result of individual competency. In other words, if I'm a good physician or I'm a good nurse, I promote patient safety. But really, patient safety is a property of the system, and it's only through our working together that we can really have a safe, safe environment. So in terms of beliefs and values, the value is teamwork. But again, particularly in medicine, we value our autonomy. So think about those discrepancies and where those occur, and what you might do to kind of change that. And then finally, in terms of desired behavior, we want people to round to assess catheter appropriateness. But the observed behavior oftentimes is they don't participate in rounds, or the rounds are just kind of another checkbox. So, four components of a safety culture. First of all, you looked at your reporting culture, whether or not you have a just culture, whether there's flexible teamwork, and a learning culture. And that learning culture is so important because that's what really determines high-reliability organizations. And I know you've heard a lot about high-reliability organizations, but it's important to look at those and then to kind of assess your own culture. So, when we look at the cultural assessment, and I know a lot of times people don't get really excited about it, but it is so vitally important. So we want to identify the areas of culture in need of improvement, increase awareness of patient safety concepts and then evaluate those, and then do some internal and external benchmarking. And finally, what we're looking at is meeting regulatory requirements and identifying those gaps between believed and observed behaviors. And what you'll find when you really begin looking at your results that you have a lot of subcultures and micro-cultures, and it sounds like a microbiology thing, but it is quite interesting. So if we're going to apply this to CAUTI, first of all, those core aspects of the safety culture. So there's the culture of safety, it's communication patterns and language. How do we talk about this? When I think of communication I see a few people who were part of the fellow program, and one of the things in one of our (0:20:50 indiscernible) presentations, Jennifer Mettings, who's done a tremendous amount of work, said, “You know, it really boils down to communication. No matter what process you put in place, it's communication at the bedside.” So when you have a culture that there's dialogue about patients, there's dialogue at the bedside about lines, and catheters, and those types of things, the more you begin to hardwire that culture. There's also feedback reward and corrective action practices. And we've heard a lot of examples. I know I heard of one hospital in South Carolina, and a lot of people have done that, it was a small hospital. They put up signs to, quote, exfoliate the patient, and she gave little prizes to people who were— who pulled the catheter in a timely manner and really assessed that. And it may seem complicit, but in that particular culture it really did work. Formal and informal leader actions and expectations. And as I said, when you assess that culture, there's a lot of informal leaders there. And then teamwork processes — what are the processes in place, do we have mutual support, those types of things. Do we have the resources? And I've heard a lot of people on coaching calls talk about the fact that we don't have the right supplies or we are evaluating that. And then finally, how do we do error detection and correction systems. So all of these things come into play.

So if we're looking at our HSOPS, it's supervisor/manager expectations and actions promoting patient safety, it's that organizational learning, it's teamwork within the unit, communication openness, feedback about errors, the non-punitive response to errors, staffing, hospital management support for patient safety, teamwork across hospital units, and hospital handoff and transition. So a number of things there. There is presentation and the national content calls on HSOPS. I would encourage you to look at that. But one of the things that was pointed out in terms of the national database, and that was based on 2012 in an intensive care unit, one of the lowest-scoring areas was non-punitive response to errors. And I found that very interesting and that was in an intensive care unit. On the other hand, what usually scores very, very high is teamwork within units, and the national rate was 84 percent. Now, one of the things that you can predict from looking at this that it's kind of intuitive. We do a great job; it's everybody else who doesn't do a good job. And so when you look at the HSOPS results, it does help you to look at that. Communication and openness, about 61 percent, and organizational learning nationally is fairly in the 70s. So all of those types of things will help you as you begin to look at that and then say, “Okay, now what do I do in terms of my own organization?” So let's take this a step further and let's look at taking those HSOPS results, and let's use those results to leverage change. So here's ‘hospital X,' and as they looked at their greatest opportunity, they found that there was feedback and communication about errors was one of their greatest opportunities, or we can say one of our lowest-scoring errors. Manager and supervisor expectations and actions that promoted patient safety, hospital management support for patient safety, and teamwork across hospital units, and that is not a surprise. So, let's kind of connect the dots now to urinary catheters and say if I had these results, the questions I'd ask myself, is management truly engaged? There is a huge difference between permission or acceptance and engagement. And oftentimes what we find is with all the multiple priorities of management that it's really hard; they support these issues, but they're not truly engaged. Do we give routine feedback on appropriateness? And I know I'll hear (0:25:36 indiscernible) of appropriateness or what have you, and the question I always ask is are we giving the providers or the people who are inserting them for inappropriate reasons, are we really giving them feedback? And it's important to have aggregate rates. But you know what? When I received aggregate rates, it's everybody else who's done it wrong, not me. So ask yourself those questions. Now, are evidence-based guidelines implemented, shared, and incorporated into practice? One of the things, again, that I find particularly— I'm part of the large university system as well. One of the things that I find, and it may or may not be your experience, is the fact that evidence-based guidelines, we look at them. If we're developing bundles or we're developing policies, people have input (0:26:29 indiscernible). People don't like this or that. But then when it comes to incorporating them into practice, oftentimes we don't evaluate the processes. And so part of our challenge is not only whether we're putting into place a nurse-directed protocol, or automatic stop order, or reasons for catheter insertion, do we evaluate whether those processes are work or is it just another checklist or just another piece of paper. And then finally, what strategies can we develop to improve or enhance them. The thing I love and the power, I think, of the CUSP and the work that you're all doing, and the real issue is that we're leveraging the power and the wisdom of the frontline staff. So it's really not about what we think. It's about what the frontline staff are telling us is happening on a day-to-day basis, and the question is what can we do.

So, we have a scenario here, and actually, this is a scenario that some of you may have seen. We have used it. It was developed by ED nurses. But this is a hospital that had a problem with teamwork across hospital units. So Nurse ED gives report to Nurse Med on the medical floor and she says, “Patient A is an 87-year-old woman with cellulitis in her right lower extremity. She arrived from her long-term care facility with fever, inflammation, swelling. She is alert, but confused. We started a peripheral IV and antibiotics. She's also complained of nausea and vomited once. We gave her an antiemetic. You're ready for her now? Wonderful, I'll send her up with the transport tech.” Nurse Med calls back to the ED in 20 minutes later and asks for the nurse. “Patient A arrived with drenched linens after she urinated on herself and then she kept trying to get out of bed, telling us she had to go to the bathroom. Why didn't you put a catheter in her? You told me she was confused. She's going to fall trying to get up.” Now, clearly, this is an example of teamwork across units. It's a unit that is saying to the emergency department, “I can't believe you didn't put in the catheter.” And clearly, what's happening in this particular situation is that both of them do not have a shared mental model. So in the ED we have this initiative, we're trying to decrease urinary catheters, but the nurse on the unit is not fully engaged, and that may be because we haven't done enough work with them, or maybe we sent out a memo and said, “Hey, this is what's going to happen,” or maybe we just haven't done enough work embedding it with stakeholders. So you can see that your HSOPS results certainly can identify issues.

Okay, here's scenario number 2, and this is hospital management support for patient safety. And as it turns out, the surgical unit is not discontinuing urinary catheters, despite the fact that a nurse-driven removal protocol is in place. When discussing the issue with the front line staff, they report that the chief of surgery has created a road block, despite the fact that the protocol was vetted with stakeholders and it was approved by the med exec committee. The nurse manager on this unit does not want to make waves and has not made the nurses accountable for following the new protocol. You approach the chief of surgery but he is non-engaged and somewhat hostile, and he tells you that his department they do not have ‘cookie cutter' medicine. So, you're looking at this culture. You're looking at a culture where people feel managers aren't engaged and you're trying to decide okay, how can I address this. And this is a really, really tough problem. One of the tools I've seen, and when we talk about adaptive or cultural change, I think we have to look at adaptive tools. And we hear about CUSP and we hear about engagement, but I also think there's a lot of literature out there in terms of adaptive strategies. And one of the books, and many of you may have heard it, I know it's been talked about on some calls, but it's ‘Getting to Yes.' Now this book actually was published a number of years ago. It's gone through a few updates to make it more modern with more modern scenarios, but I think it's a great tool. So, the first thing you might do in this particular surgeon's situation is separate the people from the problem. So disentangle the relationship from the substance. So, in other words, yeah, the chief of surgery, he's (0:31:29 indiscernible), he's grumpy, the nurse manager won't support it. But if you're the nurse manager and you're really worried about that, or depending on whether you're a champion or what have you, disentangle the relationship from the substance. Focus on interest, not positions. So what does that mean? What are we here for? We're here for the patients, so let's work together to see how we can help the patients and work together to find creative and fair solutions. And I think that those are really key questions. So, ask yourself, why is the surgeon opposed to the new protocol? Try to find out what he's thinking. Is there a rational reason that this happened? And when it comes to surgeons, just a side story, I was working with a very well-known person in the field of infection prevention who gave me some advice and he said, “You know what? If you're an infection preventionist, you need to make new best friends. We know you see eye to eye with epidemiologists and ID docs, but you've got to try to understand the surgeon and make the surgeon your new best friend.” So I've kept that. Is there a rational reason? How might we engage them? And what is the common interest here, is it patient safety? And then what about the nurse manager, how can we help her to do that? So, just in terms of all of these cultural things and putting them together, and using tools that will help us to drive that culture to begin to see change, I love this particular book too. It's from John P. Kotter, ‘A Sense of Urgency.' So plans and actions should always focus on others hearts as much or more than their minds. And I think that's so important, behaving with passion, conviction, optimism, urgency, and a steely determination with trump and analytically brilliant memo every time.

So as we begin to look at all of these cultural changes, this is a slide that actually came to us, it was presented at a Health and Human Services meeting as they're working at national targets for HAIs. And I thought this really kind of summed it up because I think this is where we need to go when we think of culture. And if you look on the right side of your screen, our traditional journey has what we call the outside in. We define and then we observe. And we observe for compliance, but what we really want to understand is observation for understanding. And so our traditional journey has kind of been based in manufacturing. We think we have all the answers. Solutions are predefined, they're guided by outsiders and those directly involved in buy in. As I said earlier, I came to this hospital about a year and a half ago and it's been a long struggle to change the culture, but when I was meeting with some of the senior leaders as part of my orientation, one of the things that they asked is that we get the frontline staff engaged that we vet it with people, because we think we have the solutions, but we don't.

So the new journey is an inside out one, and we observe and then we define. So observe for understanding. So if you take the issue of getting the catheters out, or you take the issue that people need I and O, let's try to understand what that is. Is it that they're not getting accurate Is and Os? Is it that we're not getting accurate weights? What do we understand about why providers think they need this or do they truly need hourly monitoring? So observe for understand in order to change that culture. And that's our new journey. It's really founded in anthropology. Solutions are uncovered; they're guided by insiders. Remember, the power and the wisdom of those frontline staff and those who are directly involved will create the ownership. So with that and talking about ownership, I'm really pleased to turn the slides over before the last question, excuse me. What strategies for catheter removal have you implemented in your organization? So this will be (0:36:05 inaudible).

Ashley Hofmann: We'll give everyone some time to respond to this question, and just a reminder that we are going to post a recording of today's webinar, the full webinar, along with PowerPoint slides on our project website. We'll have that up probably later Wednesday or early Thursday morning, onthecuspstophai.org. That'll be under our content calls. So I've got 115 responses and give everyone a few more seconds to click that button.

Linda Greene: And so a number of you have nurse-driven protocols and the daily rounding. One of the things that I have found and to be mindful of is that oftentimes, nurses still feel that they need to ask the physician before removing that catheter. So, driving the culture of removal, not just the protocol, and the daily rounding, not making it an exercise in futility, but actually asking the care provider does this patient need a catheter and what is the reason for that. So with that, I'm going to turn this wonderful presentation that Jenny is going to do for us. Jenny Tuttle is— I have heard her before and she's really done a lot of work on an ICU team in terms of catheter removals, so I think you'll enjoy her presentation. Jenny?

Jenny Tuttle: Thank you, Linda. That was really helpful. And it's taking those principles you talk about and certainly applying them at the beside. And that's where I've obviously done most of my work. It's funny, I look at this, my title, ‘A Success Story.' I really should change it more to ‘An Ongoing Challenge to Reach Success,' because we don't feel we've met— we've made improvement, absolutely, but it's a constant challenge and engagement with the staff. But this is just a little bit of our story for all of you. I know you're about halfway through your program. But my team, when I was the team leader during this process on our unit, I was the unit manager. And I also came from the trenches, having worked at the bedside for over 20 years, nights and days. So I had a very good relationship with my staff and I was kind of the bossy know-it-all, but that's an ICU nurse for you. So we all know the challenges ICU in particular has because there's a real culture there. And a lot of our work was trying to crack a little bit of that culture and getting to think about no, they don't; all have to have a catheter. That's a real big challenge we had. So again, getting over the personality of the ICU nurses too. And if I could change, these people can change. I think we went back one here. I got a little excited on that button, I guess. There we go. Thank you. So just a little bit about our hospital just to give you a reference point because we all typically want to compare ourselves. Well, we're a big hospital. What are they doing comparing those rates to my rates or their challenges? But we're a 611-bed hospital. Before we built our new orthopedic tower, we had the largest single-story hospital in the country. We have eight miles of hallways here at TMC, but we tacked on a little bit to the four-story hospital orthopedic area, so took that notoriety away. But the unit we started our program on was, and this was about almost two years ago, was specifically a single ICU unit. It was a 16-bed unit. It's a, again, neuro/neurosurgical, medical, pulmonary, vascular surgery, and general surgery. We met all of those. We had two primary adult units. Our other unit is all CVICU and cardiac medical ICU. So that's where we're coming from. And a little bit of our journey here is where we went to. And that's, of course, as you guys have already started and have already done and developed your teams, but it is making sure we developed our team from people that had respect from their peers and can actually influence their peers. Because one of the things we learned is a lot of the hospitals as I'd talked to and gone to some of these programs, she was working on our CUSP CAUTI project is a lot of the drivers are infection control people and they're not the bedside nurses. And that's one thing we found that's really helpful is having the nurse as the lead and really pushing the team primarily as nurses, it really made a bigger difference and an impact, because their peers are telling them what to do, not another department telling them what to do. So I picked two night nurses, two day nurses, my educator, and we were able to hit the staff from both sides on both shifts. Now, so very important because a lot got done at night, too, besides just during the day. Again, all shifts represented, we have (0:40:36 indiscernible) on our team. What we did is we also early on embraced the audit process, and that was customizing a tool to evaluate for deficits. I'm going to click forward real quick here. We actually took the audit tool that we took from our CUSP project and we customized it to our needs, and we really were able to identify areas in which we did not have standardization. For example, when we started looking at where were the catheters placed and did we have a seal intact. And we discovered that all of our ER patients that were placed in the ER were coming up without seals intact. So, we were able to make an ER change, a hospital-wide change, actually, and make sure we have all closed systems put in with urometers. It was a little bit more expensive for our ER patients coming to us because they didn't always come to the ICU, but it was a decision our administration had in supporting our whole project, and that it was worth the extra money to make sure that we did those little things to reduce our CAUTI rate. So we really embraced the audit tool, and expanded it, and tried to look for the deficits and areas in which we can improve, and standardize as best we could. And we also looked at our patients vented, as you can see there's one section. We wanted to know many catheters are on our vented patients, and clearly, the standard was that if they didn't have a catheter when they came to the ICU, we put a catheter in. That's just what the rules were in the ICU. But as we started working on our project, we were trying to get these catheters out of our vented patients.

So, I'm going to go back a slide here. So, customizing our tool and identifying barriers, and starting to find areas in which we start working on the ICU mentality of okay, maybe we don't need that catheter in these kind of cases. As we got our CAUTIs through our process, we certainly isolated the root causes, what could we do better, review the  practices of nursing, again, areas we can find for improvement. But we also did was we identified a vented patient population that maybe we can really make our impact, because we're a very busy high-acute ICU. We do CRRT, we have (0:42:33 indiscernible), CABGs. We're one of the top neuro-centers here in Tucson, so we do everything except basically transplants here at our facility. So, we deal with a lot of vented very, very sick patients. So this is the group we were trying to— which ones can we take these out of because we had so many vented patients. The other thing we did as part of our journey was collaborating with the other departments. Linda brought up the emergency department example. One thing we identified was changing that mentality where you better put that catheter in, but as we worked through ER, again, changing our product line and getting it more in line with what our needs were. But we also looked at their utilization and they had a team looking at their foley utilization. And our ER's done a remendous job as well. They went from a 12 percent insertion rate to patients moving to inpatient to a 4 percent insertion rate. And no longer do we question them about putting a foley in. We're like, “Okay, great,” and then we strive not to put a foley in even more. Because the challenge is you put that foley in and then it just gets passed from department to department until finally someone takes it out. So the quicker we get it out, or better yet, not put in at all, then it's even better for the patient to reduce that risk for it sitting in there for days, and days, and days, and people not realizing to take it out. We also work with the operating room. We're trying to identify some single— some short OR patient times that we cannot put catheters in. Working with our transportation as you say the dangling catheter over the top of the stretcher. Working with them, making sure they keep the— following the bundle, keep the foley bags below the bladder, excuse me. We looked at our MRI and our CT scanners. We found that there were hooks to keep the catheter bag below the patient, so we're working on adding those in. But most importantly is that nursing unit and providing them with the tools and supplies in which to meet our goals, and that's reducing our utilization and certainly our CAUTI rates.

So we are quickly moving on here. One of the things we looked at again with our team as we were getting our CAUTIs are trying to— the constant answer was is we were doing our daily rounding. And I'm telling you, it's our daily rounding that's really made the biggest impact. We've had a nurse-driven protocol here, and Epic based is our software foundation here. But we've had a nurse-driven protocol for years, well before we ever started this, but we never saw reduced utilization or CAUTI rates at TMC. So we've had this EMR-based protocol. It's been approved by our medical executive committee. Okay, you can take your catheter out if you meet these criteria, but it never made a difference. So, those daily conversations started happening in the ICU of okay, why do you need it? The (0:45:01 indiscernible) vented. So that's why we decided well, this is what we can work on. So what we did is okay, well let's look at the patients who really, really, really need a catheter, and let's look at the ones that maybe we can take them out. So certainly we acknowledged the sepsis patient. You're doing all your (0:45:15 indiscernible) resuscitation for the first 24 hours. Yes, that's reasonable. Leave them in for the first 24. CRRT patients we want that active measurement, but even then I'm starting to question that. And I have to admit, one of our biggest pushbacks is our nephrologists. They want to leave them in, but a lot of these patients are anuric or so minimal we can bladder scan them. So I'm starting to push back a little bit on our CRRT patients about getting those out because truly, there is a real reduction with some of those patients and their output. Acute renal failure, pressors with titration, therapeutic hypothermia patients, (0:45:45 indiscernible), balloon pumps. If you're not familiar with balloon pumps (0:45:49 indiscernible) the quickest way you can assess that a balloon pump has shifted in the body is it shifts down and blocks renal flow, and then we have (0:45:59 indiscernible) output. So that's really important to keep an eye on them. Then you have your subarachnoid hemorrhages; pardon the acronyms, with cerebral salt wasting or syndrome of syndrome of inappropriate antidiuretic hormone release and diabetes insipidus. Those are all conditions you have to watch urinary output. And then when we do triple H therapy on those patients. And on Lasix drips. So again, we said if that patient meets those criteria, we won't even question why you have a foley in.

But let's talk about the patients we can take them out on, and those are the ones with just maintenance fluid. They're tube feeding, they're already trached and pegged, ready to move to an LTAC. Minor pressors, they could probably maybe get out of bed, use bed pans. So we really started pushing those nurses to take those catheters out and we've seen a lot of success, because what it boiled down to was we never gave these patients an opportunity to be continent because they always had catheters. We're finding that they can use a call bell, we can put them on a bed pan. We can't get them out of the bed, but they're doing pretty well in (0:46:53 indiscernible) mode. So, we never gave them a chance, and by giving them a chance now, we're actually seeing that we can get these catheters out. So it's been a real move for our nurses. Again, providing the tools. What it boils down to is the nurses just want to be able to do their jobs quickly and efficiently, without this hassle. And foleys are convenient. And that's the continual battle we struggle with them is well, it's easier, we don't have the staff to clean the patients. So what we did is we looked at the supplies that we can provide to those nurses. And again, our executive team has been very supportive of this. The one thing, and it was that accurate I and Os certainly came up early on is well we can't measure. What we did is we bought scales. And we literally went on Amazon. We didn't have to buy the thousand dollar scales. We bought infant scales, and we had them (0:47:38 indiscernible) by our biomed department, and they're basically nice little infant scales we can put our (0:47:45 indiscernible) on and we can weigh. And we did some comparisons, where we actually poured water on some of these (0:47:50 indiscernible) we had. And we bought some premium (0:47:52 indiscernible), the higher end absorbent ones. That was, again, a part of our process here, as we let the nurses give their feedback on what was best for them. And we found that it was pretty much within (0:48:02 indiscernible). And nurses were quite creative as they were (0:48:05 indiscernible) linen, they would just bring the whole linen in. They (0:48:08 indiscernible) clean linen and put on the soiled linen. So, it works great, the scales. I will tell you, if you don't have a bladder scanner in your facility that is also a huge benefit too. As we pull these foleys we need to make sure they're not having urinary retention. We use ours all the time. I would certainly advocate that that would help your nurses work through the patients' need for capping or catheters, and if they're removing them in a good time, that they might not perhaps need one back. Because we do pull catheters from patients, we bladder scan them, and we do have an opportunity if they just can't do it, they retain the urine, we'll straight cath sometimes three times. If they're still (0:48:46 indiscernible) we'll leave the catheter in. So, we take these catheters out and sometimes we have to put them back in, but again, we're giving the nurses the tools in which to assess these patients and it makes us feel a little bit more in control of what we're doing. External devices, of course males are always easier; they have external plumbing. Let's not kid ourselves, it is much easier. Women are challenging. Most of our CAUTIs our women. At least that continues to be a challenge for us. But we've had those conversations with the team of what can we do to change it on those patients to get that catheter out but able to measure them. And one of the— another culture change is we never used (0:49:23 indiscernible) in an ICU for God's sake because that's nursing home. That's not what we do in a hospital. But with the improvement in the (0:49:31 indiscernible) we have, really it's become a very viable option for us. Put them in a (0:49:36 indiscernible). We check them every hour or two hours and we can measure that output. So we're actually pushing this a little bit, and like I said, that would have never come up 10-20 years ago. But it really is an alternative that we can have and still contain the patient, keep them somewhat clean, and get those catheters out.

Daily conversations. When we worked on our initial project, those happened every day for six months, daily conversations, daily conversations. And we backed away as we were working on sustainment. And sustainment, let's face it, that's the hardest and that's where we're certainly seeing our challenges. So we're engaging those conversations again because we did go back up a little bit on utilization, and I'll show you that in a second. But it is very important because the nurses, I hate to say it, almost have to be reminded okay, let's stop and think about that. I mean, trust me. They know when I start walking around, oh it's Jenny and she's going to ask about the catheters. But fortunately, it's not just me, but I'm there and they know, and they're thinking about it more, and more, and more, and they know it's a very important goal we have to reduce these CAUTIs and utilization.

Engaging the staff, again, it's back to those conversations of challenging the status quo. It's not oaky to have a cath in every patient. We don't really need a catheter in every ICU patient. But it also has given them an opportunity for feedback because you have to make them a part of the process. You just can't dictate. And I think that some of the challenges I know infection control departments have, ours did years ago when they wanted to start getting our catheters out, it never was bought in by nursing. And it is now since they're more part of the process.

Let's see, moving on. So, it is rewarding the behavior. And Linda mentioned there was a facility that gave out prizes. Well, the first month there was no CAUTIs. And the reason we pick our unit was is we have two to three CAUTIs on average a month. We were the highest CAUTI rate in our hospital, so that's why we were picked. The first month it was no CAUTIs. Infection control gave us a cake. Not very exciting, but it's acknowledging it. We also gave out ‘change,' and it's a little plastic— literally looked like those things. And every time a nurse took a catheter out, I gave them a little coin. And that coin got them potato chips, or a cookie, or a soda in the cafeteria. Now, that didn't meet our living well goal for employees, but we didn't care. It was trying to reinforce, even as small as it was, that hey, you are making a difference. But now we focus primarily on our updates and letting them know, like for example, July we had no CAUTIs. We had a little bit of a bump in the month before that. And I had a big board listing the CAUTIs that we've had and tried to reinforce that these are people and these are— and it does affect those individuals, that that's why we're trying to get these out. Here's our utilization rates during our process. When we started, we were pretty much at 89 to 92 percent utilization rate in the ICU for years. We started our program in April of last year and we dropped immediately, like oh, piece of cake. This is an easy process. It kind of took our eyes off the ball. We used the audit tool. I got a little bit lax with the audit tool, the conversations go down, and boom, we went back up again. So it just shows, you just have to always focus on this and it's a constant challenge. So again, back to the daily conversations and you'll see our utilization. We never expected to hit a utilization of 50 to 60 percent because we have do have sick patients, we do have patients that need catheters. So the fact that we hit 30s and 40s just floored us and we're pretty excited about that. And then we had, as you can see, we had a little bit of a bump up. So, we know what works, so it's getting back to alright, we're seeing it rise again. And it is that constant reevaluation you have to do in looking at your data and say, “Okay, time to refocus again. Little bit of a reminder out there.” So again, this is an ongoing process. I would love to say that, like I said, that we've succeeded and solved this. We haven't In fact, it's funny. The units (0:53:17 indiscernible) the one we started the pilot project on, I told my staff if you can go three months without a CAUTI, which we never ever even got two months without a CAUTI, I'd buy them lunch. And I got them looking at it, and sure enough, we went three months without a CAUTI. But what I got bogged down with is our cardiac ICU, which typically only had two to three CAUTIs a year had suddenly had five CAUTIs this year. So, I was so focused on them I didn't realize how well my other unit was doing. So, it's steps: spread, sustainment, and moving it forward. You're not always going to meet your goal, but it is that continued process and don't give up. So, I would love to say we (0:53:56 indiscernible), but we haven't.

But the lessons we certainly have learned here at TMC was this cannot be just the one department. It has to be bought in by everybody. And nursing, we talked about some of the pushback from physicians, but really nursing owns catheters, 90 percent of it. Yeah, we get some pushback, but we can tell those physicians hey, you know what? We can do accurate Is and Os, or darn close enough truly that you will meet the expectations for the treatment of your patient. So, when we bought in nursing into this program, that's where we really saw a change. One of the early things I know that we could have done a little better was more notification to get the physician buy in, but we certainly, having done this for almost two years now, they know our goal and the buy in has been much improved. Again, our nephrologists however, we still need to work on. But it is bringing all the stakeholders. As we've implemented our products, we realized early on that we (0:54:48 indiscernible) bringing in our inventory management, all of our product people. So, there's been a lot of work in stocking all the urinary catheters, the condom catheters, the change in the foley kits for ER. So it's making sure you identify all of the ancillary departments that you have to work with and it's not just a single or two unit based program. And again, don't give up. This is a continual process. We pull our hair out once every other month it feels like, but we get moved forward. So thank you for your time and there's my contact information. I'm more than happy to talk to anybody I've had the opportunity to share some of our (0:55:22 indiscernible), some of the resources we've had that we've been allowed to get in and help you. So thank you for your time.

Ashley Hofmann: Great, thank you both, Linda and Jenny, for sharing this information. Just kind of a wrap up, I think that you guys have provided this opportunity for hospital teams to think about their own organizational culture and how to improve the culture by utilizing components of this culture of safety model. So we do want to open it up for— we have a few minutes left. And both Linda and Jenny have said that they would stay a little bit late. So we understand if you guys need to drop off the line. Thank you for joining us today, but we are going to do a Q&A session here. So first, I think I'm going to read this question from the chat and then I'll turn it over to the operator to give the instructions. So, we had a question in chat, does anyone have any data on why not to bladder train? Kristin says her physicians won't have buy in without some published material. And then, operator, can you give the instructions for Q&A while Linda and Jenny ponder that question?

Operator: Yes, ma'am. At this time we will open the floor for questions. If you would like to ask a question, please press the ‘star' key followed by the ‘1' key on your touchtone phone now. Questions will be taken in the order in which they are received. If at any time you would like to remove yourself from the questioning queue, just press ‘star 2.' Again, to ask a question, please press ‘star 1.'

Linda Greene: This is Linda. I don't at my hands have any published data. I do think, however, why some physicians are resistant, because, really, a bladder can only be trained to some extent. And oftentimes, it's really influences by the involuntary nervous system. And so physicians feel that it may not be appropriate. So I will find certainly some information, but I think that that's where the discrepancy is, that oftentimes physicians feel that it's just inappropriate, it's the involuntary nervous system, there is no way you're going to train it. However, the literature shows that there are voluntary nerves that also may control it, and I think the problem is evaluating which patients are appropriate for that. So we'll see what other information we have and we will post it in terms of any data that we can find. So, Jenny, I don't know if you have anything to add to that.

Jenny Tuttle: Yeah, actually, that was one of the things we'd talked about early on in probably the first five months of our process is where does bladder training fit in on this. And frankly, we didn't find much literature to support yea or nay. In fact, it really was more like it really isn't effective. So it happened that we looked at that and we didn't go with it because, again, we didn't really find helpful literature to support any benefit to it.

Linda Greene: Yes, and probably for the reasons I mentioned, so thank you.

Operator: Okay, our first question comes from Sarah Gabbard.

Sarah Gabbard: Oh, thank you. This is a side question. We are working on trying to meet all the recommendations by CDC and one of them is keeping a closed system. However, for some of our patient populations, they require intermittent irrigation and using the side port is not effective enough, and we're having to open up the system and using a 60cc Toomey syringe to irrigate intermittently. Is somebody doing something different somewhere and finding success keeping a closed system?

Linda Greene: Are you using a three-way catheter? This is Linda.

Sarah Gabbard: No. These are patients that come in and we just put the regular foley in, and for some reason they end up with little clots, and sediments, and things like that, and needing some irrigation.

Linda Greene: Well, I was— this is Linda again. I was at an AMA conference and we had representatives from the Center for Disease Control there as well who were part of our panel, and they were very clear that if you have to open it up, and you anticipate that there might be more irrigation, you should insert a three-way. If it's a onetime type of thing, then ideally, you want to replace that catheter to maintain that closed system. And I know hospitals struggle with that, but doing intermittent irrigation is really certainly not something that you would want to do. So if you're going to have to irrigate on numerous occasions, then really the catheter should be replaced with a three-way.

Sarah Gabbard: Yeah, I mean (1:00:15 inaudible) sometimes we had issues with clotting some of our transplant (1:00:22 indiscernible) patients.

Jenny Tuttle: Yeah, this is Jenny here. I mean, there is one— again, we sometimes have to think outside of the box and be creative, and that's what we do sometimes. I know when we do bladder scans or when we do bladder pressures— do you guys do bladder pressures there?

Sarah Gabbard: Yeah, we need to open up the system too for that sometimes, yes.

Jenny Tuttle: Yeah, so, I mean, you can actually— because what we do is we actually hook up an IV system to that Luer lock port on that foley, and you can actually maintain a closed system because we instill 50ccs to do a bladder pressure. So you could actually adapt that process. Again, ideally follow the recommendation and put a three-way in, but if it's been maybe two or three times, you could just put an IV bag on that one, put a three-way in, hook it to that side port, and you can leave it closed system and just put a 60cc syringe on that. And that's one way to kind of work around it, but we certainly— that's a (1:01:17 indiscernible) we've used to maintain a closed system for when we do bladder pressures.

Sarah Gabbard: Okay, thank you.

Operator: Our next question comes from Debra Cioffi.

Debra Cioffi: Hi, it's Debbie from New Jersey. I just had a question. We have been very successful in engaging our physicians and our chairs of our department, also the director of surgery, and they are really supportive of us removing the foley so we can move forward with our protocol. However, one thing came up with urology and there were some concerns that surgery may have any patients that have— like men that have prostate issues, that they'd want to check before they remove a foley on a patient that may have some difficulty if it had had to be reinserted. Has anyone had any challenges with that population?

Linda Greene: This is Linda and Jenny may have it as well. But what I can tell you is with the urology population, oftentimes it can be very unique and they can have some issues in terms of difficult insertions or what have you. What we've done with our nurse-drive protocol is allow an opt-out of the protocol for patients with particularly difficult insertions or difficult urological problems so that the physician can opt out of that for that very reason.

Debra Cioffi: Yeah, we tried to keep it very simple and only a few reasons, long anesthesia or something, maybe a spine case that takes very long, but this is the one. They were okay with everything but the urology, so I was wondering.

Linda Greene: Yeah, I would probably add something, patients with difficult or urological issues, or something like that to cover that, because I know that is a challenge. I don't know, Jenny, have you had any of those issues in your neurosurgery ICU?

Jenny Tuttle: Yeah, definitely. In fact, it's kind of like a caveat on our protocol is if it's a urology-placed catheter, you don't take it out until you've cleared it with urology. So yeah, we've given them kind of that free pass on those patients because of the challenges. But on the flipside, we've also found when reminding our nurses, if you've got that patient who does have a history of prostate, you're better off not putting a foley in because you can actually cause trauma. And that's where you run into trouble is because of the trauma from the foley placement and that's a non-surgical patient, let's say an ER patient coming in, we've caused trauma, which (1:03:43 indiscernible) lying on a catheter and the urology has to come in and put in the catheter. So yes, from a surgery perspective, yes, we require (1:03:50 inaudible).

Debra Cioffi: Thank you.

Operator: Okay, our next question comes from Barbara Keller.

Barbara Keller: Yes, this is Barbara Keller from California. I have a question from the last speaker. What devices or hooks did they find for the MRI and CAT scan?

Jenny Tuttle: (1:04:12 indiscernible) MRI in a while. CAT scan, when you're working with our infection control manager, they're working on the hooks, we have what— a simple fix is we just have an IV pole in the room and we have a little hook that can be adapted to the IV pole. So we could just put a pole next to the side of the bed and then— obviously you can't put a pole in the MRI room. I haven't been there in a while. But yes, and the CT scan we just hook it on the IV pole that's below the patient.

Barbara Keller: (1:04:41 Indiscernible) creative.

Operator: Again, to ask a question please press ‘star 1.'

Ashley Hofmann: I just want to take a moment, make sure that you guys complete the evaluation from today's webinar. There's a link over in the left side of the discussion area. Go ahead and click it. We appreciate your feedback and we use it to— not only for our presenters, but also for the content of the presentations as well. And then I want to highlight some upcoming content webinars that we'll be having over the next few months. Our September, October, and November topics are listed there on the right side. And then, (1:05:23 indiscernible) for September is going to feature Doctors Mohamad Fakih and Nasia Safdar, as well as Ms. Kathlyn Fletcher, and they're going to be talking about infectious complications that are related to the catheter other than CAUTI. So tune in for that on September 9 at noon.

Operator: And we currently have no further questions in the queue.

Ashley Hofmann: Alright. Well I think we're going to call it a day. We're eight minutes over. I appreciate everyone staying with us during the presentation today. If you do have other questions, you can always email us. I'm going to put our email also in the discussion area. Feel free to reach out with any questions you have later this afternoon or throughout the week. We can send those to Linda and Jenny for follow up. And again, thank you, Linda and Jenny, for presenting today and thank you to all of our attendees for joining us. And we hope that everyone has a wonderful afternoon.

Operator: Thank you. Ladies and gentlemen, this concludes today's teleconference. You may now disconnect.