How Good Are Medical and Surgical Residents at Addressing ...
1
How Good Are Medical and Surgical Residents at Addressing Urinary Catheter Risk? A Survey of 2 Large Teaching Hospitals 1 St. John Hospital and Medical Center, and 2 Henry Ford Hospital, Detroit, Michigan Mohamad G Fakih, MD, MPH, 1 Ana Cecilia Bardossy, MD, 2 Takiah Williams, RN, 1 Katherine Reyes, MD, MPH, 2 Marcus Zervos, MD, 2 Steven Minnick, MD, MBA, 1 Raymond Hilu, MD, 1 Elango Edhayan, MD, 1 Mina El-Kateb, MD, 1 Susanna Szpunar, PhD, 1 Karen Jones, BSN, RN, 1 Louis Saravolatz, MD. 1 Discussion RPs play a significant role in the prevention of urinary catheter complications. Ensuring adequate knowledge, evaluating competencies, and assessing RP practice are key to efforts geared towards preventing infectious and noninfectious complications of the catheter. Opportunities for improvement in CAUTI prevention include education on the appropriate indications for urinary catheter use, examining the need of training RPs with limited exposures to urinary catheter placement procedures (e.g., considering simulation), and encouraging daily evaluation of further device need. We propose a multistep approach to minimizing the urinary catheter risk at the hospital setting championed by RPs in teaching hospitals: 1.Establishing institutional indications for urinary catheter use, and educating RPs about the indications. 2.Ensuring RP competencies for placement of the catheters (in order to reducing introduction of organisms at insertion). 3.Integrating the assessment for catheter need and discontinuation as part of the RP daily patient care (integrate in progress notes and daily rounds). 4.Promoting device safety as a patient safety imperative that encompasses not only infectious, but also noninfectious harms. Conclusions For hospitals that train RPs, it is important to link the education to competencies and practice. Evaluating RP knowledge and practice are important steps to start improvement efforts. With gaps identified, we plan to address them for each residency program through education and reassess any changes over time. Future efforts may focus on integrating certain areas in the Milestone process that all programs are expected to implement. Abstract Background: Catheter-associated urinary tract infections (CAUTI) are common preventable conditions. Resident physicians (RPs) play an important role in urinary catheter use; improving their knowledge and practice will help reduce the risk to patients. Methods: We administered a web-based survey to Medicine and Surgery RPs at 2 large teaching hospitals (A and B). The questions addressed indications for urinary catheter use, training on placement, and RP views regarding risk mitigation. Results: 149/295 (50.5%) RPs completed the survey. 102/145 (70.3%) of RPs considered themselves knowledgeable of the indications for urinary catheter placement, and a majority answered the questions correctly (Table). More RPs from hospital A reported formal training in placement and maintenance (48/66; 72.7%) compared to hospital B (37/75; 49.3%; p=0.006). Medical RPs rarely placed catheters (43/103; 41.7% never placed), compared to 81.6% (31/38) of surgical RPs reporting placing >14 urinary catheters over last year. RPs reported their preferred method to reduce unnecessary catheter use is by nurse driven evaluation and calling the physician for a discontinuation order (42/141; 29.8%), each physician daily evaluating catheter need (20.6%), and emergency department evaluation and avoiding catheter initial placement (13.5%). Less common was their 1st preference for electronic reminder to physicians (10.6%), evaluation for continued need at transfer from intensive care (10.6%), algorithm based nursing discontinuation without physician order (9.9%), and electronic reminder to nurses (5%). Only 39/138 (28.3%) reported daily evaluating patients for urinary catheter necessity >90% of the time. The majority viewed CAUTI as the most important harm related to the catheter (99/138; 71.7%), while non- infectious harms were uncommonly considered (trauma to urethra 13.8%; immobility 9.4%; patient discomfort 2.9%; risk for falls 2.2%). Conclusion: RPs may benefit from more structured education regarding the indications for urinary catheter use and risk avoidance. Moreover, promoting accountability at the RP level to daily evaluate urinary catheter risk and necessity may lead to a reduction in inappropriate use, thus less complications. Results 102/145 (70.3%) of RPs considered themselves knowledgeable of the indications for urinary catheter placement, with more RPs from hospital A reporting formal training in placement and maintenance (48/66; 72.7%) compared to hospital B (37/75; 49.3%; p=0.006). Medical RPs rarely placed catheters (43/103; 41.7% never placed), compared to 81.6% (31/38) of surgical RPs reporting placing >14 urinary catheters over last year. ID Week 2015 Session 50; Presentation #291 Background Healthcare associated infections result in significant morbidity and mortality. Patients are exposed to multiple risks during hospitalization including invasive devices. Particularly, urinary catheters present infectious and noninfectious risks to patients. Hospitals with training programs are associated with higher catheter associated urinary tract infections, and have been more resistant to improvements in outcomes. Resident physicians (RPs) play an important role in the decision to use, often placement, and continued use of these catheters. A first step to work on reducing risk to patients is evaluating the knowledge and practice of RPs. We evaluated RP’s knowledge, training, and practice related to urinary catheter. Methods We conducted a survey of internal medicine and surgery RPs at 2 large teaching hospitals. The questions addressed indications for urinary catheter use, training on placement, and RP views regarding risk mitigation. Survey was web-based and each resident physician was given a personal code to perform the survey. RP responses were evaluated based on specialty, year of training, and hospital. The surveys included different scenarios with yes and no answers, in addition to multiple choice and Likert scale answers. Table 2: RPs competency training Table 4: RP perception of most concerning patient harm related to the catheter Table 1: Indications for Urinary Catheter Use Medicine vs. Surgery Internal Medicine Surgery P value Were you given any training by your program on the placement and maintenance of indwelling urinary catheters? 57/103 (55.3%) 28/38 (73.7%) 0.048 Do you have to document a number of successful placements under supervision prior to being able to performing the procedure independently? 53/103 (51.5%) 14/38 (36.8%) 0.13 How many times have you placed a urinary catheter over the last year (you performed the procedure)? Never <5 times 59 times 1014 times >14 times 43 (41.7%) 52 (50.5%) 7 (6.8%) 1 (1%) 0 0 0 3 (7.9%) 4 (10.5%) 31 (81.6%) <0.001 Do you use an aseptic technique for urinary catheter placement? I do not place urinary catheters ≤30% of the time 3150% of the time 5170% of the time 7190% of the time >90% of the time 46 (44.7%) 2 (1.9%) 1 (1%) 6 (5.8%) 48 (46.6%) 0 0 0 1 (2.6%) 37 (97.4%) <0.001 Table 3: RPs opinion on reducing unnecessary urinary catheter use (preferred) Internal Medicine Surgery Nurse driven daily evaluation for need (including multidisciplinary rounds) and then calling you for an order to discontinue 33/103 (32%) 9/38 (23.7%) Nurse discontinuation through an algorithm without physician order 10/103 (9.7%) 4/38 (10.5%) Electronic reminder to physicians 12/103 (11.7%) 3/38 (7.9%) Electronic reminder to nurses 4/103 (3.9%) 3/38 (7.9%) Evaluation for urinary catheter need on transfer out of the ICU 10/103 (9.7%) 5/38 (13.2%) Emergency Department evaluation (to prevent initial placement) 17/103 (16.5%) 2/38 (5.3%) Each physician to daily evaluate for catheter need 17/103 (16.5%) 12/38 (31.6%) Internal Medicine Surgery CAUTI 72/100 (72%) 27/38 (71.1%) Trauma to urethra (including hematuria) 13/100 (13%) 6/38 (15.8% Immobility (including pressure ulcers) 10/100 (10%) 3/38 (7.9%) Risk for falls 2/100 (2%) 1/38 (2.6%) Patient’s discomfort 3/100 (3%) 1/38 (2.6%) Resident physician answered correctly Internal Medicine n=106 (%) Surgery n=39 (%) P value 70 year old man with prostate cancer admitted with a creatinine of 4.2 (baseline 1.5mg/dl). Post void bladder scan results =450 cc (Yes) 102/106 (96.2) 36/39 (92.3) 0.33 44 year old morbidly obese patient (400 lbs) with chest pain (No) 103/106 (97.2) 39/39 (100) 0.29 86 year old lady with dementia and urinary incontinence admitted for PEG placement (No) 91/106 (85.8) 32/39 (82.1) 0.58 82 year old lady with UTI and fever of 102°F, Bladder scan shows 80 cc post void. Patient awake, alert and bed ridden (No) 99/105 (94.3) 36/39 (92.3) 0.67 72 year old man with congestive heart failure on 8 L/min O2 admitted to floor (No) 65/106 (61.3) 29/39 (74.4) 0.15 A 60 year old man going for bilateral inguinal hernia repair (No) 60/106 (56.6) 28/38 (73.7) 0.07 A 25 year old woman going for laparoscopic cholecystectomy (No) 77/106 (72.6) 36/39 (92.3) 0.01 Funding Support: Supported by a contract from the Agency for Healthcare Research and Quality HHSA290201000025I/HHSA29032001T, under a subcontract with the Health Research & Educational Trust. Mohamad Fakih, MD, MPH Infection Prevention & Control St John Hospital & Medical Center 19251 Mack Ave., Suite 190 Grosse Pointe Woods, MI 48236 [email protected]
Transcript of How Good Are Medical and Surgical Residents at Addressing ...
How Good Are Medical and Surgical Residents at Addressing Urinary Catheter Risk? A Survey of 2 Large Teaching Hospitals
1St. John Hospital and Medical Center, and 2Henry Ford Hospital, Detroit, Michigan
Mohamad G Fakih, MD, MPH,1 Ana Cecilia Bardossy, MD,2 Takiah Williams, RN,1 Katherine Reyes, MD, MPH,2 Marcus Zervos, MD,2 Steven Minnick, MD, MBA,1 Raymond Hilu, MD,1 Elango Edhayan, MD,1 Mina El-Kateb, MD,1 Susanna Szpunar, PhD,1 Karen Jones, BSN, RN,1 Louis Saravolatz, MD.1
Discussion RPs play a significant role in the prevention of urinary catheter complications. Ensuring adequate knowledge, evaluating competencies, and assessing RP practice are key to efforts geared towards preventing infectious and noninfectious complications of the catheter. Opportunities for improvement in CAUTI prevention include education on the appropriate indications for urinary catheter use, examining the need of training RPs with limited exposures to urinary catheter placement procedures (e.g., considering simulation), and encouraging daily evaluation of further device need.
We propose a multistep approach to minimizing the urinary catheter risk at the hospital setting championed by RPs in teaching hospitals:
1. Establishing institutional indications for urinary catheter use, and educating RPs about the indications.
2. Ensuring RP competencies for placement of the catheters (in order to reducing introduction of organisms at insertion).
3. Integrating the assessment for catheter need and discontinuation as part of the RP daily patient care (integrate in progress notes and daily rounds).
4. Promoting device safety as a patient safety imperative that encompasses not only infectious, but also noninfectious harms.
Conclusions For hospitals that train RPs, it is important to link the education to competencies and practice. Evaluating RP knowledge and practice are important steps to start improvement efforts. With gaps identified, we plan to address them for each residency program through education and reassess any changes over time. Future efforts may focus on integrating certain areas in the Milestone process that all programs are expected to implement.
Abstract Background: Catheter-associated urinary tract infections (CAUTI) are common preventable conditions. Resident physicians (RPs) play an important role in urinary catheter use; improving their knowledge and practice will help reduce the risk to patients. Methods: We administered a web-based survey to Medicine and Surgery RPs at 2 large teaching hospitals (A and B). The questions addressed indications for urinary catheter use, training on placement, and RP views regarding risk mitigation.
Results: 149/295 (50.5%) RPs completed the survey. 102/145 (70.3%) of RPs considered themselves knowledgeable of the indications for urinary catheter placement, and a majority answered the questions correctly (Table). More RPs from hospital A reported formal training in placement and maintenance (48/66; 72.7%) compared to hospital B (37/75; 49.3%; p=0.006). Medical RPs rarely placed catheters (43/103; 41.7% never placed), compared to 81.6% (31/38) of surgical RPs reporting placing >14 urinary catheters over last year. RPs reported their preferred method to reduce unnecessary catheter use is by nurse driven evaluation and calling the physician for a discontinuation order (42/141; 29.8%), each physician daily evaluating catheter need (20.6%), and emergency department evaluation and avoiding catheter initial placement (13.5%). Less common was their 1st preference for electronic reminder to physicians (10.6%), evaluation for continued need at transfer from intensive care (10.6%), algorithm based nursing discontinuation without physician order (9.9%), and electronic reminder to nurses (5%). Only 39/138 (28.3%) reported daily evaluating patients for urinary catheter necessity >90% of the time. The majority viewed CAUTI as the most important harm related to the catheter (99/138; 71.7%), while non-infectious harms were uncommonly considered (trauma to urethra 13.8%; immobility 9.4%; patient discomfort 2.9%; risk for falls 2.2%). Conclusion: RPs may benefit from more structured education regarding the indications for urinary catheter use and risk avoidance. Moreover, promoting accountability at the RP level to daily evaluate urinary catheter risk and necessity may lead to a reduction in inappropriate use, thus less complications.
Results Ø 102/145 (70.3%) of RPs considered themselves knowledgeable of the indications for urinary catheter placement, with more RPs from hospital A reporting formal training in placement and maintenance (48/66; 72.7%) compared to hospital B (37/75; 49.3%; p=0.006). Ø Medical RPs rarely placed catheters (43/103; 41.7% never placed), compared to 81.6% (31/38) of surgical RPs reporting placing >14 urinary catheters over last year.
ID Week 2015 Session 50; Presentation #291
Background Healthcare associated infections result in significant morbidity and mortality. Patients are exposed to multiple risks during hospitalization including invasive devices. Particularly, urinary catheters present infectious and noninfectious risks to patients. Hospitals with training programs are associated with higher catheter associated urinary tract infections, and have been more resistant to improvements in outcomes. Resident physicians (RPs) play an important role in the decision to use, often placement, and continued use of these catheters. A first step to work on reducing risk to patients is evaluating the knowledge and practice of RPs. We evaluated RP’s knowledge, training, and practice related to urinary catheter.
Methods We conducted a survey of internal medicine and surgery RPs at 2 large teaching hospitals. The questions addressed indications for urinary catheter use, training on placement, and RP views regarding risk mitigation. Survey was web-based and each resident physician was given a personal code to perform the survey. RP responses were evaluated based on specialty, year of training, and hospital. The surveys included different scenarios with yes and no answers, in addition to multiple choice and Likert scale answers.
Table 2: RPs competency training
Table 4: RP perception of most concerning patient harm related to the catheter
Table 1: Indications for Urinary Catheter Use Medicine vs. Surgery Internal
Medicine Surgery P value
Were you given any training by your program on the placement and maintenance of indwelling urinary catheters?
57/103 (55.3%) 28/38 (73.7%) 0.048
Do you have to document a number of successful placements under supervision prior to being able to performing the procedure independently?
53/103 (51.5%) 14/38 (36.8%) 0.13
How many times have you placed a urinary catheter over the last year (you performed the procedure)?
Never <5 times 5-‐9 times 10-‐14 times >14 times
43 (41.7%) 52 (50.5%) 7 (6.8%) 1 (1%) 0
0 0
3 (7.9%) 4 (10.5%) 31 (81.6%)
<0.001
Do you use an aseptic technique for urinary catheter placement?
I do not place urinary catheters ≤30% of the time 31-‐50% of the time 51-‐70% of the time 71-‐90% of the time >90% of the time
46 (44.7%)
2 (1.9%)
1 (1%) 6 (5.8%) 48 (46.6%)
0 0 0
1 (2.6%) 37 (97.4%)
<0.001
Table 3: RPs opinion on reducing unnecessary urinary catheter use (preferred)
Internal Medicine Surgery Nurse driven daily evaluation for need (including multidisciplinary rounds) and then calling you for an order to discontinue
33/103 (32%) 9/38 (23.7%)
Nurse discontinuation through an algorithm without physician order
10/103 (9.7%) 4/38 (10.5%)
Electronic reminder to physicians 12/103 (11.7%) 3/38 (7.9%) Electronic reminder to nurses 4/103 (3.9%) 3/38 (7.9%) Evaluation for urinary catheter need on transfer out of the ICU
10/103 (9.7%) 5/38 (13.2%)
Emergency Department evaluation (to prevent initial placement)
17/103 (16.5%) 2/38 (5.3%)
Each physician to daily evaluate for catheter need 17/103 (16.5%) 12/38 (31.6%)
Internal Medicine Surgery
CAUTI 72/100 (72%) 27/38 (71.1%)
Trauma to urethra (including hematuria) 13/100 (13%) 6/38 (15.8% Immobility (including pressure ulcers) 10/100 (10%) 3/38 (7.9%) Risk for falls 2/100 (2%) 1/38 (2.6%) Patient’s discomfort 3/100 (3%) 1/38 (2.6%)
Resident physician answered correctly Internal Medicine n=106 (%) Surgery n=39 (%) P value
70 year old man with prostate cancer admitted with a creatinine of 4.2 (baseline 1.5mg/dl). Post void bladder scan results =450 cc (Yes)
102/106 (96.2) 36/39 (92.3) 0.33
44 year old morbidly obese patient (400 lbs) with chest pain (No) 103/106 (97.2) 39/39 (100) 0.29
86 year old lady with dementia and urinary incontinence admitted for PEG placement (No)
91/106 (85.8) 32/39 (82.1) 0.58
82 year old lady with UTI and fever of 102°F, Bladder scan shows 80 cc post-‐void. Patient awake, alert and bed-‐ridden (No)
99/105 (94.3) 36/39 (92.3) 0.67
72 year old man with congestive heart failure on 8 L/min O2 admitted to floor (No)
65/106 (61.3) 29/39 (74.4) 0.15
A 60 year old man going for bilateral inguinal hernia repair (No) 60/106 (56.6) 28/38 (73.7) 0.07
A 25 year old woman going for laparoscopic cholecystectomy (No) 77/106 (72.6) 36/39 (92.3) 0.01
Funding Support: Supported by a contract from the Agency for Healthcare Research and Quality HHSA290201000025I/HHSA29032001T, under a subcontract with the Health Research & Educational Trust.
Mohamad Fakih, MD, MPH Infection Prevention & Control St John Hospital & Medical Center 19251 Mack Ave., Suite 190 Grosse Pointe Woods, MI 48236 [email protected]
