SCCM Resource Library-Catheter-Related Hospital-Acquired Infections in the ICU: Learning From the Past to Shape Our Future

Video Transcription

Good evening, everyone. We're going to have an exciting presentation today as we present a fireside chat on CAUTI and CLABSI with you, the audience.  You will be participating in this fireside chat actively. We have great panelists, all of them experts in their fields to not only emphasize key areas on prevention of hospital-acquired infections, but also on how to prevent use of all catheters, as well as their alternatives.  It will be important for you, the audience, to ask questions as they pertain to areas that concern you and your ICU staff in trying to reduce infections related to catheters.  As you can see from the disclosures, Kathleen Vollman, Linda Green, Pat Poza, and myself are all subject matter experts for the American Hospital Association, HRET, along with SCCM and others for the CAUTI-CLABSI collaboratives over the last several years.  The other disclosures related to the panelists can be seen here. None of them are related to exact topics we are presenting today.  Now, this will be a fireside chat, which is unique with the virtual platform.  As part of the fireside chat, we will have this kind of presentation, and I will be presenting different areas for the next few minutes, and then you will be asking questions on the question and answer box.  We will use some case studies to understand the issues of CAUTI and CLABSI infections as we answer your questions.  This slide shows the life cycle of a catheter. It was created by Jennifer Mettings years ago, and she worked on components of disrupting this life cycle of a catheter.  As you can see from the four different steps, especially the zero step, which is preventing the use of a catheter at all, since there are so many alternatives, the other steps are very important.  From inserting a catheter, making sure it is absolutely sterile, as well as daily discussions about the need for the catheter, as well as timely removal.  I will be presenting where have we been and where do we need to go, using data to drive effective change.  It is so very important to understand how data can remove barriers and impact change in our practices.  Use of public reported data and how it can change practice and bringing it to real time discussions on the ICU wards in related to patient education and patient and family understanding about catheter use.  When we are dealing with data, as well as catheters, it is important to understand some of the history.  Catheters have been around for centuries.  Different cultures, Chinese, Romans, Hindus, Greeks, all use different types of materials from wood or precious metals.  The Syrians actually created catheters from reeds.  In more real time discussions, it is important to understand the history of catheters.  In more real time, the earliest invention of the flexible catheter was actually during the 18th century by Benjamin Franklin when he invented the flexible catheter in 1752 when his brother John suffered from bladder stones.  His was made with metal segments hinged together, wrapped by wire to add some rigidity for insertion.  David Sheridan was the inventor of the modern disposable catheter in the 1940s.  In his lifetime, he started and sold four catheter companies and was dubbed the catheter king by Forbes magazine in 1988.  He also helped save thousands of lives in the early 1900s working with a Dubliner named Walsh and a famous Scottish urinologist at that time, that's what they were called.  His name was Norman Gibbon.  They teamed up together to create the standard catheter used in hospitals today and those currently have been understood to be used in most of the catheters in the ICUs.  The catheter itself has many advantages as we see as different companies have altered them for their improvements of care about patients.  We will be talking about how biomes, the bacterial film that can form in all catheters, can start within as early as 24 hours and using data to understand not only the urobiome but also in understanding removal and infection rates are very important as we progress to prevent these infections.  Kathleen Volman is a clinical nurse specialist consultant and a fellow of the American College of Critical Care Medicine.  She will emphasize the fundamentals of care from protocols to alternatives, challenging strategies and implementing nurse-driven protocols and alternatives.  The inconsistent delivery of these fundamentals of nursing care like bathing and incontinence management have the ability to impact cardiac enclapses.  Reducing the process variation of all these care practices and building robust structures of practice measurement can help address the variation.  Creating a culture like this helps to empower frontline staff to speak up, to carry out protocols and processes, build communication and add infrastructure to improve the care around hospital-acquired infection reduction.  Pat Poza is a quality and patient safety program manager at the University Hospital of Michigan as well as a fellow of American College of Critical Care Medicine.  She will be talking and emphasizing culture eats strategy for breakfast, addressing senior leadership, physician and staff engagement.  Preventing cardiac enclapses is primarily behaviorally focused and culture dependent, requiring engagement, collaboration and communication across all professions, disciplines, including administration.  Engaging all the staff includes making the case for changes to different stakeholders, ensuring support of the leaders of essential groups and identifying champions to lead and be accountable for the work.  As well as having frontline staff as part of the team responsible for that work.  Linda Green will be discussing the inappropriate culturing and learning from the past to shape our future.  Learning from the past to shape our future. The inappropriate culturing and related around infections in ICU have shown that there have been a lot of false negatives over the years without addressing inappropriate culturing.  These urine culturing processes in the intensive care unit remain a cause of concern.  Patients with urinary catheters or central lines have bacteria on the catheters themselves, as we discussed with the biomes.  And these, after colonizing in the bladder or on these catheters, these biofilms quickly add to the potential for a false positive rate if we just look at cultures without looking at the clinical nature of potential infections.  Now we have included several references and these references and articles are really important so that you can review all the items that pertain to your potential issues in the ICU.  And these references, there are many of them, they're not all complete. You are able to send us any requests and comments if you want further references or links that could help you in addressing the problems in your ICU.  And this is important as we talk about the fireside chat and relate to your issues in the ICU, primarily because of the system shocks that most institutions and ICUs have experienced, especially over the last 10 months with the pandemic.  These issues have really caused a lot of competitive forces affecting outpatient safety goals in the ICU.  So now we will begin the fireside chat and discuss the ways to address any of the concerns you have in your ICUs.  Please type your questions in the chat box and we will keep track of them, present them, and answer them during the presentation and emphasize those areas that I mentioned by the key panelist.  As I mentioned, we have included our email addresses so that any member of the audience can send us their questions in addition or request information on specific issues.  Now, thank you and let us begin.  Hello everyone. I'm Will Miles. I'm the moderator and one of the panelists. We have excellent  panelists to answer all your questions today. I wanted to reaffirm that we are not all presenting.  We are here to answer your questions. All the panelists are experts in the field of cardioclapsy reduction and have specialties in those topics that I mentioned on the slides,  but we are here tonight for answering all of your questions for the journey of cardioclapsy reduction. Kathleen Vollman, Pat Poza, Linda Green, Will Miles, please.  Are you going to talk to them about, go ahead and put in your questions about COVID? I wanted to make sure people started putting questions in related to any questions or concerns  you have. I know that the COVID pandemic has hurt a lot of the cardioclapsy and hospital acquired infection reduction programs with all the priorities. One of the questions I  wanted to make sure we did cover and the panelists can start is what problems have you seen facing  in the cardioclapsy reduction due to the stress of the pandemics and the resources?  I'm going to actually open it up to all three of my co-panelists.  Linda, why don't you go ahead? All right, I'll start. Well, let's face it. The COVID pandemic has really put a lot of our initiatives on the back burner despite our best efforts.  There are a number of challenges. I mean, number one is staff shortages. Sometimes as staff are  called to do other types of things, people are really having so many multiple priorities and  trying to deal with the immediate. Certainly, isolation issues and trying to wear full PPE and go in and adjust IV rates and check on patients and all those types of things.  Those are many challenges among others. I'll let the rest of the panelists describe some of their thoughts. Well, guys, we actually have a great  question that applies to this because we're doing a lot more proning in the COVID patient. Amanda asked, does anybody know of a study examining the effect of proning on clapsy?  I'm not aware of a study, but we have a bit of anecdotal information from many of the groups that  we've worked with that feel that proning in and of itself has certainly had an impact on  clapsy. You really think of it from an anatomical perspective that that certainly can be problematic.  Kathleen and Pat, I'll let you go ahead, Pat. I think you're correct in what we've heard from  both on the many collaboratives we're on as well as just in listservs and other chats in our own  experience at the hospital is that it's difficult to care for the patient when they're proned.  Often, the central lines are placed in the subclavian or around in the IJ, and it's difficult to assess the dressing, make sure it's occlusive. If we're proning for 18 hours  and then flipping them back, you have a short span of time to do all that work.  It does become very challenging. Sometimes, you need to have two people in when the patient's  supine so that you can get all the things done that are necessary to care for the patient.  I would say the oral and nasal secretions and the drainage around that area makes it  extremely difficult to maintain the occlusiveness of that dressing. That's definitely a risk factor.  I was going to say there have been several reports, not a full series of publications, but many people are seeing increased CLABSI infections because of all that you all have  mentioned. There's another great question up here that I wanted to ask you guys.  This actually goes towards a couple related to urine cultures. Let's go to those. Bruce asks, should hospitals discourage urine cultures from being checked in critically ill  patients with an unknown fever source to reduce their incidence of reported CAUTI? Great question.  Wow, I'll start. That's a real challenge. One of the things that we certainly have  at the University of Rochester is some of the guidelines, when to culture and when not. Oftentimes, with unknown fever source, if you've done a thorough investigation,  oftentimes, it is important that you do get a culture. It makes it very, very difficult. What we find oftentimes is that there are more obvious sources of infection. The tendency  is to get a urine culture, to pan culture, to do all these types of things. Really taking a  deep dive into what's going on with that patient. Again, the patient has a catheter and you've  really looked at all those other sources. Oftentimes, it is important to get the culture, but also to get it properly. I think that's equally as important. I know I'll turn to  Kathleen and Pat to comment on that as well. Well, one of the things is actually building the  criteria for a culture into the actual urine culture order set on the EMR to help force  function behavior. To make sure that they've done that thorough deep dive that you were talking  about, Linda. Then also alerts for if at the University of Michigan, we recently, probably six  months ago, put in an alert that if I was putting in for a urine culture as an orderer, it would  pop up a question, has your catheter been in greater than seven days? If so, change before  obtaining culture. Again, another reminder that biofilm can collect on the catheter and you want  to really get what bacteria might be growing actually in the bladder and not what's along  the catheter. I know, Linda, you know a lot about the biofilm and if you want to expound on that.  Sure. You know, I always think of biofilm because biofilm loves to adhere to substances. I mean,  we talk about catheters. We certainly think of biofilm with orthopedic surgery or anything when they're on central lines, when there's something in place. I always make the analogy  to my teenagers leaving their dirty dishes overnight and trying to get that residue off.  Think of it that way. It's pretty hard to even put those dishes through a washing machine without  scraping and trying to get the detergent to work. The same thing really holds true. If a patient  does get an infection, that biofilm forms this very dense matrix that antibiotics can't penetrate.  The same types of things hold true. Even when Pat talked about changing the catheter,  I always say rinse the dishes. It is kind of the same type of thing. Just a really quick  explanation for you all. That's a great question. Actually, this sort of hands us over to stays on  the culture theme, but goes over to CLABSI. Would it be beneficial to culture catheter tips on central lines based on the method of Dennis Mackey to help diagnose a true CLABSI?  Wow. We really do not recommend culturing tips. I mean, I know quite a while ago we talked about it.  What you really want to do is the appropriate technique. Obviously, you want a peripheral  culture whenever possible. If you are suspecting a line infection, then you want to get peripheral  and central. Really, it's the time to positivity that will help the physician really diagnose  whether it's a catheter-related infection or not. Right. Thanks, Linda. Actually, I'm going to  stay on the central line. We have a question from Jose. What is your opinion about forming vascular access teams to insert more midline catheters to decrease CLABSIs?  Go ahead. Sure. One of the things quite a while ago, there was discouragement of midlines simply  because of clotting and things like this. Now, with some of the newer materials, midlines are  appropriate, but they are not appropriate for all patients. Most hospitals have guidelines that  will identify when you need a PIC, when a midline is preferred, or when a central line is preferred.  I know, Kathleen, you've worked a lot on that as well as Pat. You can comment on that as well.  Yes. One of the published guidelines that we have used are the MAGIC guidelines, where it really talks about the type of solution that you're using, that you're going to infuse,  and how long you expect this infusion to be needed for. It's a grid to say, then you should use a peripheral IV, a midline, a PIC, or a temporary central line. That's a  great resource to help if you haven't developed a protocol or policy at your facility. There is  good application, but it's important that you do it appropriately using ultrasound to guide putting in the midline. Then you still want to make sure you're infusing the correct type  of solution through it. I would say, and Will, maybe, and Linda, and Pat, what I've seen crisscrossing the country, that would be prior to COVID, is IV teams coming back for a more  structured insertion of peripherals using vein finders or ultrasound, and then having vascular access teams address the midlines, and the PICs, and even some of the central lines.  Yes. Kathleen, I couldn't agree more. We see that more. When we think about it, it's a skill. To have skilled people who that is their primary job, you think of the busy nurse  who's doing so many different things. Bringing those back, I've heard anecdotally, and our  experience as well, is they are very helpful. By the way, there is literature published out there about the affordability, the cost-benefit analysis of vascular access teams,  and also IV teams that you can find in the literature.  We're going to flip over just a little bit to urine. One of the questions that was asked,  what has been your experience with urine collection systems like PURE-WIC, or  PrimaFIT, the two-female, or condom casts for male patients? Any definitive data in this regard?  Since this is one of my areas, I'll take a stab at it initially. Go for it, Kathleen.  There are a couple of publications, not really what I would call strong research. There's before  and after kind of studies, but I will say from on the street, and then you guys can talk about  your individual hospital experiences, is there has been an uptake that has resulted in a reduced  utilization on the female side. I would say on the male side that condom catheters are not really  effective, and that there are two other condom catheters, not condom catheters, but two other male external devices that address for shorter shafts to where you can't get a good  securement with the typical condom cast. I would ask you, especially when we're really moving  towards not putting a catheter in, or taking a catheter out early, to really make sure you have  effective alternatives in your building. Yeah, Kathleen, I think that was a great point.  You know, Will, in his introduction, talked about step zero. Don't put the catheter in in the first  place, and I will tell you, we've gradually introduced the external female catheter. So,  if you haven't introduced it, you will initially get some feedback, or pushback, I should say,  because people are saying, oh my gosh, what's going on? You're hooking this up to some suction  thing, but what I have to tell you over time, as adaption starts, people really do like it.  It has reduced catheter utilization, and we know historically, if you don't have a catheter,  you can't get a CAUTI, but we also know that patients seem to like it, and again, there's  a lot of anecdotal information, but we have seen, almost every one we talked to, a decrease  in catheter utilization. So, it's very interesting. It takes a little while for people to get used to  it, but once they do, they do like it. So, last night, I saw a commercial for home use of the  female external device. So, if you were suffering from incontinence. So, the challenge in the  hospital is, because it costs more, that you have to justify or create that return on investment,  and you want to use it on appropriate people, right? Appropriate patients. You don't want to,  it's not being put on there for convenience. If a patient is able to get up and walk with  assistance to a commode or a bathroom, you don't want to put it on all patients, right? Because  then, you know, the unintended consequence is that person stays in the bed longer and doesn't get  mobile. So, getting up and down to use the restroom gives that patient activity. So, there  should be a good reason that you need to have it, and it's not just for everyone, and I think that  that's one of the key facts as you're attempting to get this new product that, right now, you have  nothing, and now you're bringing something that costs money, and to be able to justify and sell  it to administration to purchase. One of the great areas, I think, that PureWIC and some of the male  external catheters or devices work well is, like, in the specialty ICUs, the neurosurgical ICU that  I'm co-director of, and in the trauma unit, we are seeing a lot more beneficial use of those  devices, especially in the patients with problems with mobility, with neurologic dysfunction,  and the buy-in has been excellent in getting the catheters removed, especially in those patients  who cannot get up, cannot move, and that's a targeted population. Well, one of the, and this  is a question I'm going to start with, Will, and then move to the other group. One of the things  that we hear frequently in our collaborative, but also I hear it from nurses all over the country,  is this concept of, I need the catheter for intake and output, or I'm getting pushback from my physician colleague, I'm trying to implement the nurse-driven protocol,  and they don't meet that criteria anymore, but the doc wants it for INO. So, how,  Will, how would you go after that? I'll start off with that. I think the urinary catheter is a hemodynamic device. If you put it in, you need to have, you actually are going to be  truly using it for hourly output, and usually those patients are going to be one on pressors,  have a central line, and you're actively resuscitating them. It is a hemodynamic device,  and as soon as you have someone stable, you ought to start thinking about alternatives and get the  catheter out. Go ahead, Linda. Okay, I think one of the challenges for many people is if you look  at the original Centers for Disease Control guidelines, it talks about urinary, measuring  urinary output, or strict INO, and that had not been well defined, but there's a wonderful article  by Jennifer Mettings and colleagues that was published in Annals, where they really take a  deep dive into what constitutes, and this was a panel of experts who developed consensus statements  about what constitutes an appropriate indication and what does not, and what,  and what indication you might prefer an external catheter, and I think that's really helped people  because this idea of INO, it says INO monitoring in critically ill patients, and then the other  question is what's really the definition of a critically ill patient, particularly as you move  them outside the intensive care unit, so I think that's another issue, and I think Will kind of  described, right, the definition of someone that's critically ill requiring that catheter,  right, is the person that I'm going to respond to that intake and output hourly and change my  treatment strategy based on that. One of the things that as we've added, as we do a analysis  of each CAUTI that we have, one of the things we look at in our ICU, but also in our moderate  care units, is are they documenting, when they have a urinary catheter in, are they documenting  urinary output every hour, and if they're not, then they're really not meeting the compliance  of needing hourly INOs to monitor this patient and to help us, you know, drive home. Now we're  looking at it after the fact, but then that's information that's fed back to the unit, does  that analysis, but that information is then shared at the unit level saying, you know, reinforcing  the appropriate reasons to have a urinary catheter in, in monitoring intake and output.  Have any, so I have a question, have any of you hardwired that in the EMR under indications and  had a drop down that, you know, said acute or critical INO, and in the drop down there was treatment kinds of things to get them to see the difference? How about you, Linda?  Yeah, there are indications in our EMR, I think it's one of the beauties of technology that we  didn't have in the past, because there are questions, and then it leads you to alternatives before you put that in there, which is great.  So one problem about the, having those drop downs on the EMR is, is that it can force people to,  to just put other, or put critically ill, and we really, as we've mentioned, have to define it.  That's where that shared mindfulness of the team on multi-professional rounds and everything, and focusing and saying, okay, we're, the critically ill part is gone,  they have resuscitated, we don't need hourly output anymore, we need to get rid of it. And that's where that shared component of multi-professions all focus on that,  removing the catheter.  So we have a question that sort of goes along with that, a couple of them.  Richard asked, are you doing bladder ultrasounds by nurses at the bedside to decide if the patient requires an indwelling catheter?  And I would say, I know from experience that a lot of the post-removal protocols that have routine bladder scanning after the removal of the catheter  are now being moved to the front end,  and evaluating with a bladder scanner to prevent a catheter from going in. Are you guys seeing that as well?  Particularly, yeah, not all patients, but we do see it in certain circumstances. You know, some patients are critically ill and you want to- And need it. Yes.  And I think with the, because their bladder scanners are readily available and work, right, so initially the bladder scanners, you know, they weren't really that accurate,  now they're a lot better and used to have maybe one bladder scanner for the whole floor, right, and so you wouldn't, you know, I got to run down, you know,  a hundred yards to get a bladder scanner. So now I think that each unit, and the recommendation is that especially each ICU  should have a bladder scanner so that it's easy to be able to assess that. And we've also used the bladder scanner if I'm not getting any urine output.  An old practice was, well, let's just irrigate that fully.  And there, you know, you're breaking the system and you're also injecting stuff, moving around that biofilm and pushing it up into the bladder.  Why not bladder scan to see if, you know, maybe it is a clogged foley.  And if I see urine in the bladder, then it's not, it's the foley that's not working, it's the urinary catheter that's not working.  So for validation, so I think it's being applied in different situations, again, to prevent additional harm to patients.  And one thing I'd like to add is that the protocols for bladder scanning and having them available in every unit is essential.  Having the bladder scanning protocols are essential to have a standard one. But when you go into specialty ICUs, it is okay to amend that protocol for specific patient populations.  Like in our unit, you have a lot of aneurysmal subarachnoid hemorrhage patients or spinal cord injury, high quad patients.  You need to amend that because you don't want to use the same protocol. We have gotten to the point now that even before bladder training is able to be done on patients,  we will get the catheters out and do INO catheters routinely on our spinal cord injured patients within 24 hours. Same with these subarachnoid aneurysmal patients.  Once they have been clipped and you don't have to worry about stimulating blood pressure issues, we'll get the catheters out and have a separate type of protocol  so that we will be doing in and out casts and checking with bladder scanners routinely to keep the catheter out.  Based on a question, there was a question to the panelists with scheduled bladder scans with intermittent straight casts as a means to reduce CAUTI in the ICU.  That's exactly what I'm talking about. That's what I thought. You have it that way so that everyone focuses. Some of the bladder scanning protocols are doing it every six hours,  but if you have a young trauma patient or young surgical patient with spontaneous diuresis because they're finally recovering, it is okay to go for 24, 48 hours every four hours,  every three hours, so you keep that catheter out. Will, I have a question for you, and maybe it's in the chat already, but in a lot of the nurse-driven protocols,  there are varying what's the volume that I should worry about, and okay, so the volume was 500, and I hit 500, so now I straight cast.  How many times do I do that before I put the urinary catheter back in? I know places that never put it back in. They just put them on a routine in and out.  What are your thoughts on that? I think as a target, 400 or 500 for a standard bladder protocol, a scanning protocol is adequate.  When you're dealing with some specialty ICUs or specialty patients, such as the older neurological patient,  that if you waited to get the 500 CCs, you're going to stretch the detrusor muscle, so you actually may cause more dysfunction. We actually, in the neurosurgical or neurology ICU,  we will actually have it down to 250 to 300, and do more frequent ino catheters. You just have to adjust it based on the patient population.  But it sounds like you're not, if they fail twice, I'm not putting the urinary catheter back in. Try to figure out why they're failing. Okay.  Again, it's not accepting that protocol. It's a great standard starting protocol to capture many of the patients. But then for those individual patients, don't let them fall behind.  Focus on why and that crisis issue to fix the problem, and realize, okay, they're failing because perhaps we gave diuretics,  so we just have to increase the incidence of doing the bladder scans and ino catheters. I see a lot out there where they have a 24 to 48 hours  if they failed the intermittent cath, because we really don't have data on repetitive intermittent cath and UTIs in the hospital. It's really the risk-benefit ratio.  On to that, guys, not putting the catheter in or addressing that issue. We have a question from Richard.  Have you guys asked your respective ERs and ORs to stop placing indwelling catheters on certain patient populations? I can hit that one. Okay, go for it. Absolutely.  Gone are the days at ATLS where we put a urinary catheter in every single patient. We've stopped doing that. It is very important to have and focus on those type of patients  to know when you need to put one in. But consequently, and those are going to be the patients going, again, hemodynamic monitoring, they're unstable.  You know you're going to probably have to use a urinary catheter, same with the central line for a bloodstream catheter. But that's important to put in.  Those patients are going to go to the ICU, most likely. So if you can stop the routine use in the ED for those patients  so you don't need critical ill in the sense of resuscitation, that's great. In the OR, it's really important to have as part of the timeout process.  Those who may not know it, we have a timeout process for, you know, before you start an operation. But we also have one at the end.  And that is the last timeout is really focusing on where the path, any path specimens are documented correctly, any problems happen.  But that's also the time to say they have a central line, an arterial line, and a urinary catheter. Can they come out? If not, when can they come out?  And that way when the patient goes to the ICU, that information is processed in the report so that then you can start the multi-professional rounding.  Dr. Miles said that this can come out tomorrow. Why isn't it out? So that's the best way. Because every time you go, as we all know, from one part of the hospital to the next,  the catheters will stay in two or three days longer. So if you can get it out before they transfer to the ICU, you don't have them in.  Yeah. So, Will, there's a question here. What about using preemptive, I may not pronounce it correctly, temezaline, look in the chat box there,  temezaline in high-risk failure patients? Is that high-risk failure to train the bladder? Is that really us? I don't know. I have to look at that. Okay. We'll get back to that.  Okay. There's also another question. If you could reduce bladder mucosal damage by a better model of urine collection, do you think that would benefit CAUTI?  So the current catheter, my understanding,  with the balloon and the tip can hit the wall and cause mucosal damage. Is that coming to me? Well, that could be coming to you.  It could be coming to, I just know that's an injury point. Yeah. And I would say that anytime you have an injury, again, that's if you don't have to put in a catheter, that's great.  If you don't have to do that, that's great. Now, of course, when you do an in and out, that could be an issue of constant stress to the bladder.  But again, you're putting it in when the bladder is usually full, so you don't have that problem. And, you know, often in our spinal cord patients, we actually,  we may not be able to sit them up, but we can make the bed in reverse Trendelenburg to help drainage. So you're not sitting there manipulating the in and out catheter.  You're not causing that extra damage. So yes, anytime you have a damage to mucosa, it breaks the barrier protection. So it can be an issue for potential infection.  Well, and Will, I think this one's directly to you. I was always taught to leave an indwelling folean until the aneurysm in an  SAH is fixed to avoid any straining or potential re-bleeding. Yes, that is correct. We usually put it in for, again, it depends on the severity of the patient,  but you leave it in until after the clipping. When the aneurysm is clipped and you know that the blood pressure issues aren't as a problem and it's usually around 24 hours,  then that's when you focus on trying to get them out. Now the subarachnoid aneurysm patients are very much a specialty type patient  and we could probably spend two hours talking about it, which we can't. But a lot of those patients who are at high risk for basal spasm, people want to keep the catheters in place.  I understand why, but not all patients need that. Many of the neurosurgical ICUs that are having trouble with high CAUTI rates,  one of the things we ask them to do is to focus on that population or the spinal cord population and really look with the providers at ways you can reduce the catheter use.  Not all of them needed all that time for basal spasm. So work on trying to figure out a way to get adequate INOs.  Most patients with risk for basal spasm or mild basal spasm do not need an indwelling catheter. Okay. But that's post clipping. Okay.  So one of the questions that we refer to is the patient that is a potential high failure on when we remove the catheter that may have an enlarged prostate.  Do you preemptively treat them with Flomax? Yes. Okay. It's easy. That answers that. Well, I have a question.  I've seen some literature out there about having algorithms for when to use CUDE catheters and not always calling a urological consult.  What are you guys seeing out there in the practice world?  I have seen where there are some nurses, not all, that are credentialed to put in CUDE catheters. So it's a credentialing process. Yeah. Competency. Yes. Got it.  And would that be routine use on all males over 50? No, no. It would meet certain criteria. So you have very specific criteria for it. Okay. That makes sense.  Go ahead, Dan. I've seen where if you've attempted twice, you know, is one of the criterias because you don't want to create another passage.  You don't want to cause the urethral trauma. But institutions that have done that have a specialized team. I was going to go back to that question about tensilucin and high risk  for failure. I try to understand and figure out exactly what the high risk for failure means. But obviously it's going, just like we mentioned about the prostate  patients, absolutely we, I feel in those type of high risk patients, and high risk isn't just prostate. Any time you have a high risk patient, you identify them and then bring  a team by the bedside and work at ways to try to remove a catheter, work at ways to try to, you know, fix the alternatives.  Anything that works along those lines to ameliorate the problem for that high risk patient. So if you can have a patient, if you have a patient with high risk because  of prostatic issues or with bladder muscle dysfunction, absolutely start Flomax. Yes, there's some mild side effects with dizziness, other things like that.  And you should continue it for, urologists tend to say two weeks, but you don't always have to keep them for two weeks if the swelling goes down or if the problem is resolved.  So now we're going to the other part of the body in terms of central line catheters. And this one I think may be a slam dunk for the group.  What is your practice regarding routine central vascular catheter exchange to decrease CLABSI? Yeah, no, I know, guys, but I think it's important to reaffirm what the science.  Yes, yes, you don't routinely change catheters. I mean, that's been in the guidelines for some time. You might, you would want to change them for particular clinical criteria,  but not a routine change. And it's really a risk benefit because the trauma, the going through the skin, the potential for contamination in inserting a new catheter often  outweighs any benefit of changing it. The one that I totally agree with that, and like you said, you need to have for certain clinical situations.  I absolutely, if you, with the audits of dressings for central lines, if you find a break in sterility, if you know that a line was not swiped clean  before a new med was put in, if there's any potential for that, you really have to label as a high risk. And if there's a dressing problem that you know that is contaminated the  line, you really ought to consider changing it or switch to an alternative like a midline. And that being said, you know, we have a protocol for emergency lines placed  or from outside hospitals that you know or don't know that sterility was maintained to have a policy to change those as quickly as possible. Within 24 hours.  So as a standard, Will, then all central lines coming from, because we're a large transfer center, if you're getting someone that has had a central line  for seven days at a different hospital and then they come to you, are you automatically changing it or are you looking for signs and symptoms?  Again, if they've had it for seven days, that's a little different. Because usually sterility should have been maintained if you know from the original procedure note.  Unfortunately, in surgery trauma world with smaller outside hospitals, if they were put in the emergency room for an emergency procedure and they do  not know in the note and you can call them and ask them, without trauma program, we can go back and, you know, have things set up at the outside  referral hospital so they can make sure the documentation is there, placed early, blah, blah, blah. We don't have a routine for that.  But if you know it wasn't placed early, it was an emergency line, or you keep track of infections and your CLABSI rates and you know that every line  coming from that one place, we tend to have infections, well, you need to adjust it and say we're going to change it every time.  Linda, do you have a comment on that? No, I agree with Will. I think particularly, and we see lines maybe even started in the field. Obviously, you really want to change those.  There was a place I was consulting that a nurse had come from another organization where they had to figure out, because there wasn't always good  communication between the ED and the ICU, what was put in sterilely and what wasn't. So the nurses in the ED and the ICU talked with each other and literally, if  a gauze dressing was placed on the line in the ED, the ICU nurses knew to push for a change in the line. That it wasn't put in sterilely. And I thought that was quite creative.  So we have a question, and actually I'd be interested to hear Linda on this. Richard asks, what happened to the science of impregnated or coded urinary catheters?  You know, I remember, as a matter of fact, it was a number of years ago when they were recommended. However, the studies actually have shown over time that there really was no  impact with the coded catheters. And, you know, when you talk about cost, they were more expensive. So basically, it's certainly, it's been one of those things that has been  thoroughly studied. And they do not recommend them routinely. You know, we learn over time. It's just like everything else.  You know, it sounded great, and I even remember it being recommended for a while until there were some really good robust studies that showed there was no benefit.  I've got a question for the group here. Ian, in what ways can you use data to help drive improvement? The visibility of it, the use of it, who to deliver it to?  Will, you want to start on that? I'll start on that. Again, we could spend an hour talking about this.  I think data has to be collected and visually given to all providers as well as posting in the ICU of your infection rates of the last time you had an  infection, catheter utilization. You know, for physicians and APPs, they need to see that data on a real-time basis.  For staff and everyone in the multiple professions in the ICU, they need to see that data. And routinely, the public reporting of data, it's out there anyway as part of  the value-based purchasing for Medicare. Why not have it out in public in the halls of the ICU? Often hospitals don't want to do that.  But until you actually do that and put it so all patients can discuss it and families can see it, that's when it really becomes real for everyone.  When it starts to change the culture. The culture. Because I know in places I've gone to where they put it's been this many days  since and they were at 240 and then it went down to zero, the staff are all going, what happened? Which patient? Where did it go?  I think that is a great way to display that data and how many days since. Or number of infections per month.  When is it appropriate to utilize rates and ratios to be able to, I think  that's important to utilize those when sharing the data with the physician staff and leadership so that you can get an understanding of how you rate along with someone else.  And Linda or Will, what are your thoughts on that? Well, I think it's really important, Pat. You brought up a good point.  I think one of the things about data is that you have different ways of displaying and communicating data to different stakeholders. Right.  But one of the things about the rates and particularly now with value-based purchasing and HAC data and things, they depend on the SIR or the standardized infection ratio.  One of the beautiful things about NHSN, the National Healthcare Safety Institute, is that when you not only can you get your SIR data, but it will  tell you what percentile you are in. And that's very, very helpful to physicians. So I can get my SIR is such, and that means I'm in the 35th percentile.  And we know in infections, low is good. And so that's something that you can really tell. Look at how well we've done.  There are 65% of the hospitals reporting in that are worse than us. So those types of data speak volumes. And it matches you, right, Linda, to like ICUs, correct? Right.  It is risk-adjusted. So that really, I think that type of data will drive. And it also, the other thing I think is important, and we forget about the  fact that we also need to get the attention of administration because we're talking about resources. We're also talking about patient safety.  But being good stewards of the organization, we don't want to get with a hack penalty or something like that. So that's a language using data that really speaks volumes.  I think, I totally agree. I think every institution needs to have gradations of data presentation and what your institution needs, what your provider needs.  Maybe it needs, they need to have the data presented on a weekly basis at their faculty meetings or, you know, on rounds.  Every Monday, multiple professional rounds, just go over that data before you start. Whatever works to drive that change and change that culture, that's the kind of data you need.  So I've got a question, a comment and a question. Angela says, I am frequently called the guardian of the groin and try to keep providers from placing groin lines. I love that.  That's what I'm going to take away. We're going to steal that, Angela. Yeah, I know. I have some surgeons who feel strongly that dialysis catheters should go in the groin.  I have nephrologists who are totally fine with placing these in the jugular. Do you have any suggestion on changing the culture of the surgeons, Mr. Surgeon? Yes. Thank you, Angela.  I've got to borrow that term to use it on a few of my colleagues. That being said, I totally agree and understand that the groin is the last  place you want to put a longer term catheter, especially like a dialysis catheter. It is important to understand that you can put one at any of the other catheters.  You can put one in the right catheter, jugular veins, subclavian. The key that most people who don't put in a lot of those catheters, they need  to understand that there are different lengths. If you put one in the right IJ, you might want it a little shorter than the  one you have to put in the groin or the one you put in the subclavian. You have to match it to the area you're putting it in.  That's the first step, to make sure you have adequate resources for those so you don't put it in the wrong catheter.  There's a lot of information related to the larger type catheter. There's also overwhelming data that femoral lines have a higher CLABSI rate.  Sometimes on a very critically ill patient that needs emergency dialysis. Right. You may do it. Again, you put it in. It's an emergency line.  You keep it on for 24, 48 hours while you get the patient going and then you keep changing it. Again, they can be used occasionally, but it should not be and really needs  to be stopped. That's where you have to show the data to the surgeons and say, especially if you can capture at your institution, you've had a couple of CLABSIs related  to the dialysis catheter in the groin. Use that data to make that change. Yeah. Well, keeping on the theme of big catheters, I think this may be our last question.  And that is, do you have any recommendations for prevention of bloodstream infections in patients with long-term VV ECMO support? That's a tough one. That is a tough one.  Dressing dislodgement, dressing securement, consistent bathing, chlorhexidine bathing with the best, latest science.  Those kinds of functional maintenance practice is pretty much the bread and butter of trying to prevent any infection.  Well, and also in addition to that is to minimize accessing the line. So it's going to be in there a long time.  Every time you access it for a blood draw or something else, you know, like the urinary catheters, we keep a closed system and we don't open it for any reason.  Well, we need to think of that in the central line, too. Minimize the blood draws from it so that we can prevent, you know, infection  that way, especially if it's in for a long time. And I was going to say, especially for ECMO patients, if you know you're  going to have the catheter in for, the cannula's in for a long period of time, you need to take those policies and procedures and really focus and do  it more often and more strict for that population. Right. Because that's the only way to make a difference. Because once they get infected and all the problems that are so much more  different than another type of patient without ECMO. Well, guys, we are out of time. And that went so quick. We had awesome participation by the attendees.  And lots of great questions. Yeah. Audience, I wish we could go on for a couple more hours. But we really appreciate your questions.  And the ones we did not address, we will answer in text. So thank you very much. Thanks, everyone. Thank you. Enjoy your evening.

Video Summary

In this fireside chat on CAUTI (Catheter-Associated Urinary Tract Infection) and CLABSI (Central Line-Associated Bloodstream Infection), the panelists discuss key areas on the prevention of hospital-acquired infections. They emphasize the importance of preventing the use of all catheters, as well as their alternatives. The panelists are experts in their fields and have worked on various collaborative initiatives to reduce infections related to catheters.<br /><br />The panelists discuss the life cycle of a catheter and the steps involved in preventing infections, such as ensuring sterile insertion and timely removal. They also highlight the use of data to drive effective change in practices. They discuss the importance of using public reported data and communicating it to ICU staff for real-time discussions on patient education and understanding about catheter use.<br /><br />The history of catheters is also discussed, from ancient cultures using various materials to the invention of modern disposable catheters in the 1940s. The panelists emphasize the need for proper care and maintenance of catheters to prevent infections.<br /><br />The panelists address questions from the audience, covering topics such as the use of bladder ultrasounds, the role of data in driving improvement, the use of impregnated or coated urinary catheters, and the prevention of infections in patients on long-term VV ECMO (veno-venous extracorporeal membrane oxygenation) support.<br /><br />Overall, the fireside chat provides valuable insights and recommendations for preventing hospital-acquired infections related to catheters, highlighting the importance of data-driven practices and continuous improvement efforts.

Asset Subtitle

Infection, Procedures, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives:

Demonstrate challenges in data definitions and reveal how data presentation may impact and effect change
Elucidate the biggest cultural challenges that impact infection safety in critical care as well as compare and contrast approaches that overcome cultural barriers
Explain the multiple issues with inappropriate culturing, antibiotic stewardship, and the Urobiome and outline evidence based tactics for Electronic Medical Records to successfully reduced inappropriate culturing in Intensive Care Units
Differentiate which routine care practices contribute to increased catheter associated infections and describe the science and process practices to improve catheter related outcomes

Interactive Panel Discussion Linda R. Greene, William S. Miles, Patricia J. Posa, Kathleen M. Vollman

Meta Tag

Content Type Presentation

Knowledge Area Procedures

Knowledge Area Infection

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Catheters

Year 2021

Keywords

CAUTI

CLABSI

hospital-acquired infections

catheters

alternatives

sterile insertion

timely removal

data-driven practices

patient education

bladder ultrasounds

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.