Patient Safety Bulletin
JANUARY 2019
Patient stories and safety improvement updates for providers and staff at UCSF Medical Center
Colleagues,

Happy New Year! In our ongoing efforts to improve patient safety at UCSF, we disseminate a monthly patient safety bulletin. In this issue, we highlight the importance of preventing catheter-associated urinary tract infections (CAUTIs) and our new protocol for removal of foley catheters.

Urinary tract infections (UTIs) account for a significant proportion of hospital-associated infections at UCSF. Although we had some improvement in CAUTI rates after implementation of the reflex urinalysis for urine culture protocol, we still have over 7 CAUTIs per month among adult inpatients—about 20% more than we would expect based on the risk-adjusted, benchmark national data used by the CDC and CMS.

Preventing CAUTIs requires a multidisciplinary, multimodal effort aimed at minimizing unnecessary use of catheters and optimizing insertion technique and catheter maintenance. In late February/early March, we are rolling out a nurse driven protocol (NDP) for urinary catheter removal to empower nurses to remove catheters that are no longer needed using standardized criteria. 

Thank you for your ongoing commitment to patient safety at UCSF. 

Adrienne Green, MD
Chief Medical Officer, Adult Services
Vice President, Patient Safety and Regulatory Affairs
UCSF Health
A Nurse Driven Protocol to Reduce CAUTIs
What happened?
An elderly patient was transferred to the UCSF intensive care unit from another hospital for respiratory failure. An indwelling urinary catheter was placed on admission to UCSF. Three days later, the patient's vital signs were notable for fever and tachycardia and labs showed a new leukocytosis. Concerned for sepsis, the team sent cultures and started broad spectrum antibiotics. Both urine and blood cultures ultimately grew E. coli attributed to a CAUTI. The foley catheter was removed four days after the cultures were initially sent. The patient remained in the hospital for a prolonged course of intravenous antibiotics and was ultimately discharged to a skilled nursing facility. 
What went wrong?
In the case described above, the indwelling urinary catheter was in place for close urine output monitoring in the setting of septic shock. However, there may have been an opportunity to assess the ongoing need for an indwelling catheter in the first day or two after insertion. When the patient initially spiked a fever, the team could have considered CAUTI as a possible source and removed the catheter at that time instead of waiting for cultures to result.
What is the Nurse Driven Protocol for preventing CAUTIs?
  • The goal of the NDP is to reduce the number of days that urinary catheters are unnecessarily in place by empowering nursing staff to remove indwelling urinary catheters (IUCs) that are no longer needed using standardized criteria
  • Workflow for NDP:
  • When providers on the adult services place an order for a urinary catheter, the provider will choose an indication from a dropdown menu
  • The indication that is chosen will determine whether the patient will need a provider order for discontinuation (as in the current state) or whether the patient will enter into the NDP pathway where every shift, the nurse will assess whether the indication is still valid and if not, will remove the IUC
  • The CAUTI Prevention Task Force and Infection Control will be monitoring not only the impact on number of urinary catheter days and CAUTIs, but will also be looking at potential unintended consequences, specifically the need for catheter reinsertion
  • This is part of a multimodal program that includes:
  • Standardized post-catheter management algorithm that will include widespread access to bladder scanners
  • Utilizing new external urine collection devices for men and women as alternatives to IUCs
  • Enhanced training of RNs and PCAs around best practices for IUC insertion and maintenance
  • Encouraging providers to avoid unnecessary insertion
  • Ongoing requirement for an abnormal urinalysis prior to a urine culture
  • For more information please contact:
  • Amy Larsen ([email protected]) or Deborah Yokoe ([email protected])
STOP for Safety
Highly reliable organizations maintain a preoccupation with failure and the capacity to manage complex and unexpected events, prioritizing safety above all else. At UCSF, the STOP for Safety framework has been developed to emphasize how individual actions and behaviors can play a role in preventing harm and promoting safety. The case above is an example of a recent event in which use of the STOP for Safety framework could have prevented patient harm.

Stop the line and speak up:
In this case, any team member could have stopped the line and questioned the need for IUC insertion and ongoing use.
Take the time to review:
When the patient initially became febrile, the team could have taken more time to review possible sources and may have considered removing the IUC earlier.
Patient Safety Week: Video Competition
Patient Safety is sponsoring a competition for participants to submit a short video highlighting the STOP for Safety framework as part of the events during patient safety week (March 11th through 15th). This is a fun opportunity to make a video showcasing how the STOP framework is already being used, or could be used, in your work area to prevent errors and adverse events. Anyone can submit. Interprofessional group submissions are encouraged.

  • There will be prizes!
  • The top videos will be shown during Patient Safety Week
  • You may use your mobile device to film as the use of professional equipment is not required or expected
  • The video should be anywhere from 3-5 minutes in length
  • Please avoid using protected health information
  • The deadline for submission is February 15th
  • For questions and to submit your videos, please email Paige Porter ([email protected])
Prior Patient Safety Bulletins
From the UCSF Patient Safety Committee. Editors: Adrienne Green MD (Professor of Medicine, CMO), Jim Stotts RN (Assistant Clinical Professor, Patient Safety Officer), and Kiran Gupta, MD, MPH (Assistant Clinical Professor of Medicine, Medical Director for Patient Safety). Please contact Kiran Gupta at [email protected] with questions. Disclaimer: Clinical details of cases have been altered to protect patient & provider confidentiality.