215 A Novel Clinical Protocol for Placement and Management of Indwelling Urinary Catheters in Older Adults in the Emergency Department: Implementation and Impact Assessment

Abstract

Indwelling urinary catheters (IUCs) are placed frequently in older adults (age ≥65) in the emergency department (ED) and carry significant risks. As highlighted by the Choosing Wisely campaign, this is an intervention that should be considered judiciously. To implement and assess the impact of a novel clinical protocol to assist ED providers with appropriate indications for placement, reassessment, and removal of IUCs in older adults in the ED. We developed a comprehensive, evidence-based clinical protocol and implemented it at a large, urban, academic medical center with over 67,000 adult patient visits annually. We introduced the protocol to multiple EM providers, including attendings, residents, mid-levels, and nurses with a 20-minute scripted slide presentation. Pocket cards were distributed and the protocol was displayed in the ED. Written surveys were administered before the intervention, immediately after, and at 6-months to assess providers’ baseline knowledge, attitudes, and practices, as well as the protocol’s long-term impact. Surveys included asking providers for IUC management decisions for 25 unique clinical scenarios. To objectively assess the clinical impact of the protocol, we retrospectively compared rates of IUC placement in this ED in patients aged ≥65 in the 6 months before (January 1, 2013 to June 30, 2013) and 6 months after (September 1, 2013 to February 28, 2014) implementation of the protocol. Of the 125 EM providers participating in the implementation phase of this study, 112 (90%) completed 6-month follow-up. Immediately after protocol introduction, 98% of the participants reported that the intervention made them more comfortable with the appropriate indications for IUC placement; 87% reported anticipating that this intervention would reduce rates of IUC use and increase patient safety. At 6-month follow-up, 80% felt that the protocol had changed their practice and 38% reported frequently referencing the protocol. In the clinical vignettes, ED providers correctly identified the appropriate approach for IUC placement in 33% of cases pre-intervention compared to 54% immediately post-intervention and 44% at 6 months (P<.001). Four thousand nine hundred sixty-seven (61%) of the 8,147 older adults evaluated in the ED during the 6 months prior to implementation were admitted. Of those admitted, 935 (18.8%) received an IUC in the ED. In the 6 months after implementation, 4,781 (59%) of the 8,119 older adults evaluated in the ED were admitted, with 731 (15.3%) having received an IUC in the ED. This represents a relative risk reduction of 18.6% (P<.001) for ED use of IUCs in this population. Introduction of this comprehensive, evidence-based clinical protocol has been well received by ED providers. It has led to sustained self-reported practice change and significant reduction in overall IUC placement in older adults in our ED who were admitted to the hospital. Our next steps include evaluating whether this reduction has concomitantly increased the proportion of IUCs placed in the ED for appropriate indications, and to assess whether it has led to fewer catheter-associated urinary tract infections during hospital admission and improved patient-centered outcomes.