Published in the June 2018 issue of Today’s Hospitalist
AT CHICAGO’S Saint Anthony Hospital, clinicians used to rely on standard interventions to tamp down their number of catheter-associated infections, including bundles. But in 2014, an uptick in catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs) led the infection-control team to try something new.
They started holding a daily huddle to discuss indwelling catheters and devices, pulling hospital leadership into those discussions. Those meetings then snowballed into their current form: a daily interdisciplinary safety huddle (DISH) for the entire hospital.
“It’s basically the state of the hospital meeting every day,” says Alfredo Mena Lora, MD, the hospital’s medical director of infection control, who joined the medical staff in 2015. “As soon as you realize how efficient it is to meet every day, it becomes very important for your daily routine.”
“It’s the best 15 minutes of the day.”
~ Alfredo Mena Lora, MD
Saint Anthony Hospital
The daily huddles have proved to be very effective. Working with the hospital’s quality department, Dr. Mena Lora studied the impact of DISH by comparing hospital-acquired infections and device usage three years before and after the huddles were implemented. They found a 90% reduction in the number of hospital-acquired infections related to catheters and devices. They also found an estimated cost savings to the hospital of $500,000.
Daily safety reports
The daily huddle, which is held seven days a week, starts at 8 a.m. and is usually attended by 15 to 20 people. During the week, one of the hospital’s vice presidents runs the meeting and maintains a standardized list of key events and follow-up actions for the next day.
“We start with a safety report from the nurse manager of the ICU and then hear from the nurse unit managers of all the other departments: psychiatry, pediatrics, med-surg and emergency services,” Dr. Mena Lora explains. Those reports include mention of any indwelling catheters, either urinary or central venous.
Once each clinical department files its safety report, the other managers attending—employee health, telecom, IT, security, nutrition—weigh in with theirs. Each daily huddle takes only between 10 and 20 minutes.
“If it happened once a week, it would take an hour and a half, so this is very efficient,” Dr. Mena Lora points out. “It’s the best 15 minutes of the day.”
While DISH meetings have helped reduce the amount of time patients use catheters, they’ve also influenced hospital culture.
“It really promotes a culture of safety hospital-wide,” Dr. Mena Lora says. “Members of the nutrition or IT department know how many days it’s been since we’ve had a CAUTI and how important it is to remove catheters.” At the same time, his daily attendance means he’s aware of safety concerns throughout the hospital. “The other departments’ priorities become our own.”
A 24-hour removal window
Having a VP in the daily meeting also reinforces how important catheter safety is. “The huddle is both a tool to inform us of what’s happening, but it also keeps the nursing managers in each unit accountable,” Dr. Mena Lora says. When nurse managers report on catheters or devices, “I ask about indications. If I recommend that one be removed within 24 hours, I’m going to ask about that removal at the next day’s huddle.”
Sometimes, for example, a nurse manager may report that a Foley meets an indication because the patient needs strict Is and Os or has urinary retention.
“At the DISH,” he says, “I’ll ask if that’s been proven by a bladder scan. If the answer is ‘no,’ that catheter is going to be removed.”
As for how many catheters and devices are ordered, Dr. Mena Lora says those numbers have remained constant. What has changed dramatically is how long they’re being used.
“We keep devices in place too long either through complacency or by not realizing they’re still in place, so there’s a lot of human error involved,” he says. “That’s what DISH helps correct every 24 hours.” That change in usage duration has been much greater outside the ICU, where critically ill patients often need multiple catheters.
Mitigating physician preference
A big barrier to prompt removal is clinician preference. There are occasions, Dr. Mena Lora says, when “the DISH is not enough” and he’ll need to meet with individual physicians to follow up on why an indwelling catheter or device hasn’t been removed.
“Say there’s a patient with a urinary catheter post-op,” he says. “I’ll talk with the doctor and explain the risks associated with catheters and how we can accurately measure urine output through less invasive means.” Or the chief nursing officer or the chief quality officer (both of whom attend the daily huddles) may get involved.
“Clinician preference is always mitigated,” he points out. “It takes only one conversation.”
Patients with indwelling catheters or devices who are critically ill and febrile are the ones at highest risk. “You have to be careful,” Dr. Mena Lora says. “Promote removal when you can and treat the catheters well when you need them.”
Two months ago, Dr. Mena Lora introduced an online tool to track the indwelling catheters being reported at the daily huddles, as well as the plans for their removal and any removal barriers. That tool, he adds, is supplying data on what barriers infection control runs into, who the high-risk patients are, and which specialties or units may need more education on when and why catheters and devices should be removed.
That tracking tool will come in handy with the next phase of DISH implementation. This January, Dr. Mena Lora and his infection-control team won an innovation challenge award from the Illinois Health and Hospital Association (IHA) for how the daily huddle has improved Saint Anthony’s hospital-acquired, catheter-related infection rates.
As part of that award, Dr. Mena Lora gets to provide oversight on implementing daily interdisciplinary safety huddles at another hospital in the state, one the IHA is now in the process of selecting.
“I’m really curious to see how this works out in another hospital, and this tracking tool will be a big part of that,” says Dr. Mena Lora. “The barriers to catheter and device removal at another facility might be very different from ours.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.