Friday, February 27, 2015

Choosing wisely - the saga continues

Today, the ABIM Foundation published a nice blog post on the choosing Wisely campaign - which they launched several years ago. It can be read here
This week, this was the topic of my institution Department of Hospital Medicine Grand Rounds. We reviewed the current state of healthcare in USA - and the disproportionate ratio between healthcare expenditure and outcomes. Then we discussed the 5 SHM recommendations. 1) Don't use routine antacid prophylaxis out of ICU, 2) Don't place routinely urinary catheters, 3) Don't get daily labs in the setting of clinical stability, 4) Don't routinely transfuse unless clinically unstable and Hb < 7 (and we emphasized the word "consider" transfusion instead of "just go ahead and transfuse"), 5) Don't use telemetry routinely.
Interestingly, there was a lot of controversy around each topics - why so far, we still have gaps in performance? - why so far is so difficult to hardwire change?.
Let's just focus on the urine catheter use.
Regarding urinary catheters, we have an overall low DUR (Device Utilization Ratio) - meaning the number of "Foley-days" divided by the total number of patient days. We have a low rate of CA-UTI - still it is not zero. Why? 
In most cases, the CA-UTI was linked to urine cultures obtained by trainees at the middle of the night in patients with fever as part of a pan-culture approach. Yet, these patients were: 1) not neutropenic, 2) didn't have urinary malformations, 3) didn't have a renal transplant, 4) did not have any clinical evidence of cystitis or pyelonephritis, 5) were not hemodynamically stable. Still - it is very difficult for a trainee to simply withhold a urine culture in a patient with a Foley catheter. In addition, these positive cultures had no translation whatsoever into any kind of clinical meaning. They become a statistic without clinical relevance, yet with impact in the overall institutional quality metrics.
The question needs to go further and beyond - does the patient still needs the Foley catheter? 
My question to my trainees is - instead of just performing a urine culture in this patient, which most likely will have no real clinical meaning, why don't we just consider having the urine catheter removed?
We reviewed the other organizations Choosing Wisely recommendations - and the ACEP also recommends against routine placement of urinary catheters - therefore, hopefully, the story of "the patient already came with a Foley when admitted from the ED" will be a goner.
We had implemented in 2013-2014 an enterprise-wide Nursing driven protocol for Foley removal - which has impacted in a 30% decrease in CA-UTI rate. The current utilization of the protocol ranges in the 80%. Interestingly is that in quality improvement, it is not only the implementation of a new protocol or change which creates impact, but also the adherence and compliance with it. 
Nowadays an interesting phenomenon, is the engagement of patients in the decision making process, which by the way is a principle objective of Choosing Wisely. When a catheter is placed - for instance to "monitor diuresis in a patient who is getting IV diuretics" - I have now patients asking if the catheter is strictly necessary, as they can use a urinal for quantification of urinary output. Still, I've witnessed resistance from providers regarding the "need for an accurate output measurement" and accepting not placing the catheter in a "lost battle mood". And this is because we were hardwired to use catheters in an indiscriminate way - and now are swinging the balance to the opposite side.
The times are changing and we all need to ensure there is engagement, especially from our young trainees. We need to hardwire best practices early enough. Teach them the words of Henry Ford "Quality is doing the right thing when nobody is watching".

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