Case presentation as a core quality improvement strategy

Urethral catheter management provides a good example of a case presentation problem that not only touches on all aspects of Clinical Productivity Waste (CPW), but also that substantially impacts care quality. To give you an idea of the problem’s scale,  according to the Center for Disease Control ( CDC) , between 15-25% of all hospitalized patients end up with an indwelling urethral. From a quality perspective, the related inappropriate care is responsible for up to 380,000 preventable infections, 9,000 preventable deaths, and more than $5B in preventable costs to hospitals. Unfortunately, these urethral catheter management issues are largely due to ineffective case presentation.
 
To illustrate, let’s pretend that there are three clipboards which will hang sequentially on the bed of each catharized patient. The clipboards correspond to 3 different time periods: the time prior to catheterization, the time while the catheter is in place, and the time following removal. Let’s also assume they each have the applicable case presentation template printed on them. And finally, let’s assume there’s a Physician Assistant (PA) whose only job is to keep them in sync with the EHR.
 
There are five persistent barriers to appropriate catheter management:

Lack of agreement on and awareness of standard protocol: Clinicians may have been trained on various catheter management protocols which exacerbates the issue, but most frequently there’s simply a lack of awareness of what the relevant protocol is. Having the case presentation template readily available “on the bedside clipboard” serves as a cognitive aid. For example, if a nurse and physician are discussing the case for removing a catheter, having the clipboard containing the protocol, with the relevant “check boxes checked” makes the presentation and discussion swift, as well as makes the protocol easy follow accurately.

Catheter data is hard to enter and find: The data are difficult to find in the EHR, and often temporarily recorded elsewhere (paper, Excel, online form, etc.). The data is neither consolidated nor readily available when needed. Having all the essential catheter protocol information recorded on the clipboard at the bedside for actionable presentation addresses the issue.

Communication challenges: Communication among clinicians is problematic. Messaging and calls to physicians are problematic because they interrupt the physician and put the onus on physicians to gather the data and figure out the status. Although rounds might be an opportunity to present the catheter management status, it’s often problematic to synch the nurses’ workflow with the physicians’s. Having the case presentation on an easily visible clipboard so any clinician could see it when they’re at the bedside would enable the requisite asynchronous communication (an electronic version would also be required for remote use)

Confusion about authority: Empowering nursing staff to remove the catheter has proven challenging. Physicians are uncomfortable with how well nurses understand the protocol for the situation, so they simply add a “do not remove” and ask the nurses to “call urology.” The case presentation clipboard with a clear protocol, along with specific authorities and the protocol patient data documented to assure adherence (enabling physicians to delegate with confidence) would go a long way to alleviating this issue.

Catheter removal is not a priority: Clinicians don’t think about a catheter unless an issue or complication arises, and physicians are commonly unaware that their patients have one. Moreover, it’s easier for overburdened clinicians simply to leave catheters in. The case presentation clipboard might partially mitigate the issue by being highly visible and by reducing documentation burden substantially.
 
Urethral catheter management quality issues are largely due to ineffective case presentation. The example highlights the need for case presentations that:

  • are readily available and make the protocol / guidelines clear;
  • consolidate essential information for the purpose;
  • may be viewed asynchronously to avoid interruptions;
  • incorporate clear lines of authority; and
  • reduce documentation burden to simplify adherence.

Urethral catheter management also reflects a substantial CPW problem. It includes wasted EHR time; skills-task alignment time; all the time wasted dealing with the consequences of inappropriate care; and the time wasted from interruptions.