 Hi, my name is Lori Stromness. I am from Inner Mountain Health Care and today I'm going to be speaking about difficult urinary catheter navigation guidelines. The objective for this is decreasing infectious and non-infectious harm to patients through education enhanced with evidence-based guidelines and rationale to navigate difficult urinary catheter situations and through having a difficult Foley team. In 2017 I was at the 5th annual World Patient Safety Science and Technology Summit, having placed in the top 10 for a Patient Safety Innovation Award for our submission of having a difficult Foley team. At that time, my bio had said, honor student in her first year of graduate studies. I had thought that I would then be starting a difficult Foley team elsewhere external to Inner Mountain Health Care. What we've learned from the Foley team is that we know that failed attempts or improperly performed attempts at urinary catheter placement increases the risk of harm for patients. Our Foley team had profoundly increased the rate and frequency of failed attempts. The difficult Foley team was a collaboration between urologist Dr. Jay Bischoff and Brad Waterman and the manager of one of our acute care floors, Kenna Johnson, who trained staff from our department to be the experts in assisting other departments when they had difficult urinary catheter situations. The success of the difficult Foley team at Inner Mountain Medical Center revealed evidence that and training improved proficiency of nursing urinary catheter placement or navigating difficult situations and decreased calls to urology for consults by over 82% since September of 2013. When urology received a consult, they then knew that meant the patient was likely going to need to go to the OR. And before inception of the Foley team, urology used to receive consults related to urethral injuries from improperly placed catheters one to two times a week. And since the inception of the Foley team, those calls have become very rare. As I approached beginning my doctoral research project and finding an external site to launch a Foley team, while researching through evidence-based databases to find evidence to support my proposal to start a Foley team. In attending meetings with stakeholders at the external site, I began to realize there may be a more productive direction for me to head. The danger with icebergs is all that we can see is a tiny piece that's above the water and we can't ignore what's beneath the water for very long before disaster. Culture trumps strategy. It's the iceberg that sinks organizational change. Not the top. It's the way we say we get things done. But then at the bottom is the way things really get done. Between the two above the water is the strategy, shared values, and goals. Below the water, getting more difficult to see are the structures, policies, beliefs, assumptions, values, traditions, unwritten rules, stories, and the feelings. Initially, I only saw the part of the iceberg that was sticking out of the water, but recognizing what was beneath the water allowed me to see a way to alter my course and realize the point of the Foley team and how to add value to the point. Knowledge, confidence, and proficiency are paramount for patient safety during difficult urinary catheter placement, especially when that placement becomes difficult. Placement is difficult if the first attempt is not successful. When the patient is encountering difficult placements are left to either try again, call urology for a consult, or rely on the variable experience of other nurses around them. A hazardous knowledge gap exists without standardization for addressing difficult urinary catheter situations. Existing education is limited, and it only teaches the basic steps of placement on a mannequin, which lacks correlation for actual placement and consideration for the numerous anatomical variations. My research initially aimed at creating a difficult Foley team at an external site, but it evolved as data revealed a hazardous knowledge gap. Existing procedural education has a failure. It lacks evidence-based rationale addressing difficulties, which really is pretty optimistic, but it sets our staff up for failure. If we don't teach them what to do when things go wrong, then they're left to discover by trial and error on patients. Through the implementation of the difficult Foley team, we saw the benefit of improving and enhancing nursing education beyond the basic steps of placement. Taking it to the next level was the design to evaluate if creating education supplemented with evidence-based best practice guidelines for navigating difficult urinary catheter placements would increase nursing knowledge and comfort. The project began with assessing current knowledge and research and data collection for medical and educational databases, and data collected via feedback during focus groups with senior nursing leadership and nursing educators before creating the initial education with the navigation guidelines. The initial guidelines were shared during focus groups with pre- and post-education surveys with open-ended, short-answer survey questions and ordinal Likert scale questions. The participants were the educators from the acute care floors at the study site. The education was created and enhanced with the data from the evidence-based research, shared, and then enhanced with feedback from the additional focus groups and pre- and post-education surveys. While catheter-associated urinary tract infections or CAUTIs are never events, they're not the only harm occurring with urinary catheters, as both infectious and non-infectious harms can result. Up to 25% of patients in the hospital will need a catheter. One in ten of those patients will get a urinary tract infection. That is beginning to show that non-infectious urethral harm occurs up to four times as often as infectious urethral harm. Rates of harm rise when protocol or guidelines are absent. There is a failure in existing education with a limitation of learning placement steps on a mannequin, which lacks correlation for actual placement in real life in consideration for numerous anatomical variations. Nurses otherwise are left to rely on their experience, the experience of their coworkers or the availability of the on-call physician or resident who might be in surgery or otherwise indisposed. At the study site, the average response team for a urology consult was over 90 minutes. That's the patient waiting in discomfort for over 90 minutes. Knowledge training and standardized protocol or guidelines around urinary catheter placement and troubleshooting when there's difficult insertion increases staff knowledge and proficiency while decreasing patient harm related to catheter placement. The findings from the difficult fully team were that more than 82% of calls of over 1,000 patients since September of 2013 were able to address the urinary catheter needs. So over 820 patients were saved a urology consult over 820 times. A dedicated fully team can disseminate the education system wide. They can teach as they go. This increases mindfulness and mentorship. It's a collaboration and a synergy between nursing staff and urologists. It decreases trauma and harm. It costs nothing to implement, but it has a significant cost savings for the patient. And it elevates the safety culture and reliability. Safety climate can serve as a leading indicator of safety performance in contrast to error and injury rates, which are lagging indicators. The safest way to prevent harm is early detection of the opportunity for harm. The earliest opportunity is addressing harm prevention at the education level by providing evidence based guidelines for navigating difficult urinary catheter situations by increasing the efficiency for urinary catheter placement and other urological bladder catheter related troubleshooting measures. We can state that we not only significantly increase the reliability and safety, which reduces harm, but also identifying a failure in time to intervene before the harm occurs. At the local level, this prevents infectious and non-infectious harm to patients in the hospital, but on a larger scale, health care is impacted by Medicare withholding reimbursement for hospital acquired infections and emerging data indicates non-infectious urethral trauma occurs four times as often as infectious urethral trauma. Proactively mitigating difficult urinary catheter placement before harm will improve the culture of reliability and can prevent non-infectious urethral trauma from reaching the hospital acquired infection status. Thank you.