1. On the CUSP: Stop CAUTI in ICU National Content Webinar
Today’s Topic:
Urine Culture Practices in the ICU; Antibiotic Stewardship; Practical ICU Tools; Using Results from the Safety Culture Surveys
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3. Today’s Presenters Mohamad Fakih, MD, MPH
Medical Director, Infection Prevention and Control
St John Hospital and Medical Center
Professor of Medicine,
Wayne State University School of Medicine
Detroit, MI
Pat Posa, RN, BSN, MSA, FAAN
System Performance Improvement Leader
St. Joseph Mercy Hospital

4. Today’s Presenters
William Miles, MD, FACS, FCCM, FAPWCA Director of Surgical Critical Care Clinical Professor of Surgery University of North Carolina, Chapel Hill-Charlotte Campus Carolinas Medical Center Surgical Trauma ICU Misty Wheeler, RN, NE-BC, CCRN Lacey Spangler, RN, BSN, RN, CCRN Neurosurgical ICU Julia Retelski, MSN, RN, CCRN, SCRN, CCNS

5. Improving the Culture of Culturing (aka, Culturing Stewardship)
Mohamad Fakih, MD, MPH
Medical Director, Infection Prevention and Control
St John Hospital and Medical Center
Professor of Medicine,
Wayne State University School of Medicine
Detroit, MI

6. Polling #1
A 45 year old male who is an active intravenous drug user is admitted with fever of 103°F, confusion and respiratory distress. The patient is intubated and admitted to the intensive care unit; the CXR shows multiple pulmonary emboli and the blood cultures grow methicillin resistant Staphylococcus aureus. On day 3, he is still febrile with a temperature of 101.8°F. His blood cultures are still growing gram-positive cocci and the patient has a urinary catheter since intensive care unit admission.
Urine culture
No urine culture
N/A – HRET Staff

7. Polling #2
A 73 year old patient with prostatic hypertrophy was admitted to the hospital with abdominal discomfort. On admission, he was afebrile with normal vital signs and blood white cell count. A bladder scan showed a significantly distended urinary bladder. A urinary catheter was placed and 1200 ml of urine was drained. His abdominal pain improved and he did not complain of any respiratory symptoms. The patient spiked a fever of 102°F the next day. His blood pressure was 100 systolic and heart rate 110.
Urine culture
No urine culture
N/A – HRET Staff

8. Clinical Evaluation
The clinical evaluation of the patient is key to best care, and the optimal use of tests

9. Bacteriuria with Catheter Use (Garibaldi et al, Infect Control 1982; 3: 466-70)
Daily bacteriologic monitoring of 1140 cases:
Bacteriuria at insertion: 99/1,140 (8.7%) catheterizations
1,041 had no colonization at insertion, 433 removed within 24 hours
Of 608 catheterizations >24 hours, 76 (12.5%) developed bacteriuria
Risk of bacteriuria was 3% per catheter-day

10. Picture of Routes of Entry
Maki and Tambyah, Emerg Infect Dis 2001; 7: 1-6

11. Catheter Associated Bacteriuria in ICU (Clec’h et al, Infect Control Hosp Epidemiol 2007; 28: )
12 ICUs: weekly urine cultures or if symptoms in catheterized patients
CAUTI defined as urine culture >103 CFU/ml
CAUTI (bacteriuria) rate= 12.9/ 1000 catheter-days
Median time to CAUTI 11 days (range 6-19 days)
Median ICU LOS longer for those with CAUTI (28 days) vs. those without (7 days)

12. Common Inappropriate Triggers For Urine Culture In Patients With Urinary Catheters
Urine color, consistency and smell
Pyuria

13. Resident Physicians (N=106) and Nurses (N=159): Triggers For Cultures In Catheterized Patients (Sibai et al, ID Week 2013, presentation 205 )
Trigger for Urine Culture
Resident Physicians (Answered Yes)
Nurses
(Answered Yes)
Foul smelling urine
75 (70.8%)
146 (94.8%)
Cloudy urine
84 (79.2%)
Sediments in urine
57 (53.8%)
129 (84.3%)
Darker urine
39 (36.8%)
72 (47.7%)
Chronic UC on admission
46 (43.4%)
115 (74.2%)
All of the above should NOT trigger a urine culture in catheterized patients!

14. Resident Physicians and Pyuria: Obtain A Urine Culture In Catheterized Patients (Sibai et al, ID Week 2013, presentation 205 )
Trigger for Urine Culture
Answered Yes
Urine WBC 25 cells
71 (67%)
Urine WBC 100 cells
94 (88.7%)
Urine WBC 500 cells
101 (95.3%)
Pyuria in an asymptomatic patient with an indwelling urinary catheter should not be a trigger for culture or antimicrobials

15. Pyuria Is Not Diagnostic Of CAUTI (Hooton, Clin Infect Dis 2010; 50:625–663)
Pyuria does NOT help differentiate asymptomatic bacteriuria from CAUTI
Pyuria + bacteria ≠ CAUTI

16. Pyuria and Bacteriuria (Tambyah, Arch Intern Med. 2000;160:673-677)
761 patients with newly inserted catheters, 10.8% developed bacteriuria or candiduria
Defined bacteriuria as >103 CFUs.
Women had more bacteriuria (21.2%) than men (7.2%)
bacteriuria >103 CFUs.

17. Pyuria and Bacteriuria (Tambyah, Arch Intern Med. 2000;160:673-677)
bacteriuria >103 CFUs.
Pyuria more common with bacteriuria related to gram negatives than gram positives or funguria

18. Pyuria and Bacteriuria (Tambyah, Arch Intern Med. 2000;160:673-677)
Pyuria cannot predict bacteriuria

19. Absence of Pyuria (Hooton, Clin Infect Dis 2010; 50:625–663)
IDSA guidelines: “The absence of pyuria in a symptomatic patient suggests a diagnosis other than CA-UTI”

20. Color or Odor (Hooton, Clin Infect Dis 2010; 50:625–663)
IDSA guidelines:
“In the catheterized patient, the presence or absence of odorous or cloudy urine alone should not be used to differentiate CA-ASB from CA-UTI or as an indication for urine culture or antimicrobial therapy.”

21. Screening Urine Cultures!!
The practice: “screening culture on admission”, “standing orders” or “reflex orders” for urine cultures based on urinalysis results
May not help the hospital avoid non-reimbursement
May increase utilization of additional resources (testing, antibiotics, consults)
May adversely affect patients by exposing them to inappropriate testing and treatments

22. PRE-PRINTED ORDERS FOLEY CATHETER PROTOCOL

23. How to Reduce Unnecessary Urine Cultures
Evaluate current processes for obtaining urine cultures (avoid automatic triggers or screening cultures with no appropriate indications)
Evaluate practice patterns (avoid PAN culturing)
Provide education on when it is appropriate to obtain urine cultures

24. How to Reduce Unnecessary Urine Cultures
Have periodic audits on urine culture use in the intensive care units to look for trends
Promote appropriate urinary catheter use to reduce risk of bacteriuria/ funguria

25. Discourage Urine Culture Use

26. Appropriate Urine Culture Use

27. Key Points Related to Obtaining Urine Cultures

28. Culturing Stewardship and Other Preventative Measures: Large Hospital ICUs
Influenza epidemic (more fever, more cultures)
ICU team only responsible for urine culture ordering

29. Antibiotic Stewardship in the ICU
William Miles, MD, FACS, FCCM, FAPWCA Director of Surgical Critical Care Clinical Professor of Surgery University of North Carolina, Chapel Hill-Charlotte Campus Carolinas Medical Center

30. Disclosures
Nothing to disclose

31. Antibiotic Stewardship in the ICU
Some Points to Consider
Resistance to antibiotics exists in nature before medicine actually discovers or uses them
Antibiotics have societal impacts
Pressure from antibiotic mismanagement forces significant resistance
70% of antibiotics in America go to Food production

32. Antibiotic Stewardship in the ICU
Antimicrobial Treatment Considerations
Must be timely: any delay in starting them increases mortality significantly
Appropriate: must cover spectrum of pathogens
Pharmacokinetics: adequate dose and intervals
Narrowing and Discontinuation: based on clinical data, ICU microbiology data, and clinical response

33. Antibiotic Stewardship

34. Antibiotic Stewardship in the ICU
Novel Antibiotic Development
1980’s: 16 new antibiotics released
1990’s: 10 new antibiotics released
2000’s: 5 new antibiotics released
: ONLY 1 new antibiotic developed!

35. Antibiotic Stewardship in the ICU
What is Antimicrobial Stewardship
Systematic approach to optimize clinical outcomes while minimizing consequence of antibiotic use:
Toxicity
Selection of Resistance
Selection of virulent organisms
C. diff resistance
Combine with infection control practices to limit emergence and transmission of resistance
Reduces healthcare costs without impacting care
Patient safety! 35

36. Antibiotic Stewardship
IDSA
Joint Commission
CMS-California mandate
CDC
Physician Leadership Forum
ATS /ACCP/SCCM

37. Antibiotic Stewardship in the ICU
Goals of Antibiotic Stewardship
Combat the Emergence of resistance
Control Costs
Improve Clinical Outcomes

38. Antibiotic Stewardship in the ICU
Stewardship Strategies
Patient Evaluation Education/Guidelines
Choice of Antimicrobial Formulary Restrictions
Prescription Ordering
Computer assisted strategies
Dispensing Antimicrobial
Review and Feedback-includes all

39. Antibiotic Stewardship in the ICU
Economic Considerations for Antibiotic Stewardship
Antibiotic use restriction and costs should not be the only focus
Antibiotic costs are a small percentage of treatment costs
Costs from hospital LOS, total Healthcare costs and Infection Prevention should be considered
Patients’ Quality and return to a functional life

40. Antibiotic Stewardship in the ICU
Prescribing Antibiotics
Day 1: Empiric Antibiotics
Based on disease and ICU’s biogram
Day 3: Narrowing/De-escalation
Based on culture results
Infection vs. leukocytosis
What is clinical picture
Base it on Antibiogram of unit

41. Antibiotic Stewardship in the ICU
Antimicrobial Stewardship Principles important
Utilize Pharm D, Infection Preventionist
Prevent MDROs

42. Antibiotics in UTI
• Pyuria either in the setting of negative urine cultures or in patients with asymptomatic bacteriuria usually requires no treatment. If pyuria persists consider other causes (e.g. interstitial nephritis or cystitis, fastidious organisms). • Follow-up urine cultures or U/A are only warranted for ongoing symptoms. They should NOT be acquired routinely to monitor response to therapy. • The prevalence of asymptomatic bacteriuria is high: 1%-5% in premenopausal women, 3%-9% in postmenopausal women, 40%-50% in long-term care residents and 9%-27% in women with diabetes.

43. Duration UTI Treatment
The duration of treatment has not been well studied for CA-UTI and optimal duration is not known.
7 days if prompt resolution of symptoms
10–14 days if delayed response
3 days if catheter removed in female patient </= 65 years with lower tract infection.

44. Treatment Notes UTI • Remove the catheter whenever possible
• Replace catheters that have been in >/= 2 weeks if still indicated
• Prophylactic antibiotics at the time of catheter removal or replacement are NOT recommended due to low incidence of complications and concern for development of resistance.
• Catheter irrigation should not be used routinely

45. Antibiotic Stewardship
Must coincide with Infection Control/Prevention
Prevention
Optimal management of urinary catheters
Control
Hand hygiene
Contact precautions
Active surveillance
Education
Environmental Cleaning Standards
Improved Communication between Facilities

46. Antibiotic Stewardship
As The Wheels Turn
Providers
Pharmacy
Micro Lab
Antibiotic Stewardship
QI/QA
Infection Control
PATIENTS

47. Multi-Drug Resistant Organisms
CRE
MRSA
C Diff Colitis
All possible in ICU management and prolonged urinary catheter and long term antibiotic use
Antibiotic stewardship and Urinary Catheter removal protocols are essential tools for prevention of MDROs

48. Antibiotic Stewardship48

49. Practical Implementation of Antibiotic Stewardship
2 ICUs Work In Implementing Antibiotic Stewardship And Appropriate Urinary Culturing

50. Practical Implementation of Proper Culturing 2 ICUs Experience
Surgical Trauma ICU
Misty Wheeler, RN, NE-BC, CCRN
Lacey Spangler, RN, BSN, RN, CCRN
Neurosurgical ICU
Julia Retelski, MSN, RN, CCRN, SCRN, CCNS

51. Carolinas Medical Center Surgical Trauma ICU
Carolinas Medical Center is part of Carolinas HealthCare System in Charlotte, NC
874 licensed beds, quaternary referral hospital
Level 1 Trauma Center, Largest teaching hospital in NC
Surgical-Trauma ICU
Neurosurgical ICU
29 bed multispecialty trauma and surgical unit including transplant and immunotherapy patients
29 bed multispecialty Neurology and Neurosurgical unit

52. Surgical-Trauma ICU CAUTI Reduction 2014-2015

53. NSICU CAUTI Reduction 2014-2015

54. ICU Urine Culture Initiatives
Oct. 2014
Do not PAN Culture, culture based on patient clinical picture
Nov. 2014
Correct Order Entry for Source by Provider and support for nursing to change order if necessary
Education for correct urine collection
Preservative tube, DO NOT use specimen cup
Send Urinalysis prior to sending culture
Lab and nursing policy rewritten
Feb. 2015
Lab to reject cultures not sent in correct tube
March 2015
Lab to complete Reflex Testing on Urine Specimen

55. Antibiotic Stewardship
Conclusions
Providers need better tools on how to initiate and terminate antibiotics
Stewardship teams are just 1 step to regulate antibiotic prescribing
Start based on national standards and Institutional Antibiograms
De-escalate/narrow agents ASAP
Stop Antimicrobials based on clinical picture and do NOT use Football Scores to decide length of treatment

56. Antibiotic Stewardship and Proper Culturing
They go hand in hand
Synergy with Teamwork
With team effort and following CUSP CAUTI Policies and Guidelines can be achieved

57. Safety Culture: Interpreting the Results
Pat Posa, RN, BSN, MSA, FAAN
System Performance Improvement Leader
St. Joseph Mercy Hospital

58. Unspoken, implicit, taken for granted
What is a Culture?
Represents a set of shared attitudes, values, goals, practices and behaviors that makes one until distinct from the next.
Unspoken, implicit, taken for granted
Largely invisible
Measure culture at the unit level

59. Institute of Medicine
“ The biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm”

60. A Positive Culture of Safety
…..recognizes the inevitability of error and proactively seeks to identify latent threats
Nieva, V F Qual Saf Health Care 2003;12(suppl)

61. Chaos, Culture, and Predictability
Improve predictability = less chaos = better safety
Standardized interactions, checklists, familiarity
Reduce predictability = more chaos = worse safety
New Manager, New Location, New Technology

62. Why Measure Unit Culture?
Determine how bedside staff are feeling related to communication and recognizing defects
Diagnose and assess the current status of patient safety culture.
Identify strengths and areas for patient safety culture improvement.
Examine trends in patient safety culture change over time.
Measure/evaluate the cultural impact of patient safety initiatives and interventions.
CUSP is the intervention that will help you improve culture results

63. Survey Action Planning
Assessment data is likely to point to many different area of culture that can be improved
There will be many different ideas regarding potential actions
Incremental changes can be implemented and tested on a small scale, changing one process or practice at a time
Remember—in patient safety this is no one “silver bullet”

64. Safety Culture Drill Down
If low on teamwork – what pulled the score down?
Difficulty Speaking Up
Breakdowns in Interdisciplinary Care Coordination
Difficulty Resolving Conflicts
Difficulty Asking Questions
If low on safety norms – what pulled the score down?
Lack of trust
Lack of feedback
Lack of engagement

65. Changing the Culture Related to CAUTI
Belief that any harm is not acceptable:
If this is present it will show up in categories of ‘non punitive response to error’ and ‘feedback and communication about error’
Mindfully choose interventions:
Don’t do things because “it is always how we have done it here” IE: pan culturing for any fever; indwelling urinary catheter in place because they are in the ICU
Interdisciplinary discussion of risk vs benefit of starting antibiotics --- not just a routine, but thoughtful decisions
This requires good interdisciplinary communication between team where each member of the healthcare team input is heard and valued

66. Teamwork Climate is the Consensus of Frontline Caregiver Assessments Related to Collaboration
Example Teamwork Climate Scale Items:
In this clinical area, it is difficult to speak up if I perceive a problem with patient care
Disagreements in this clinical area are resolved appropriately (i.e. not who is right, but what is best for the patient)
The physicians and nurses here work together as a well-coordinated team

67. Safety Culture Debriefing
Review results with staff
One strategy is to focus on:
5 areas with the most positive results
5 areas with the most opportunities

68. Summarize 5 MOST Positive
Supervisor/manager expectations/actions promoting safety
Considers staff suggestions for improving pt safety-76%
*My supervisor overlooks pt safety problems that happen over and over—76% disagree
Organizational Learning—Continuous Improvement
We are actively doing things to improve patient safety-80%
Teamwork
People support one another in this unit-86%
When a lot of work needs to be done quickly, we
work together as a team-85%
In this unit, people treat each other with respect-78%

69. Summarize 5 LEAST Positive
Communication Openness
Staff feel free to question the decisions or actions of those with more authority-39%
Feedback and Communication about Error
We are given feedback about changes put into place based on event reports—46%
Nonpunitive Response to Error
*Staff feel like their mistakes are held against them—46% disagree
*When an event is reported, it feels like the person is being written up, not the problem—43% disagree
*Staff worry that mistakes they make are kept in their personnel file-33% disagree

70. Summarize 5 least Positive
Hospital Handoffs and transitions
*Things “fall between the cracks” when transferring patients from one unit to another-33% disagree
*Problems often occur in the exchange of information across hospital units-38% disagree
Teamwork Across Hospital Units
*Hospital units do not coordinate well with each other-39% disagree

71. Evidence Based Local Solutions: Teamwork “If-Then”
If staffing levels inadequate/info lost at shift change:
Then Morning/Shift Briefings
If interdisciplinary patient management issues:
Then Daily Goals
If conflicts unresolved/role clarity lacking:
Then Shadowing Exercise
If difficulty speaking up:
Then standardizing with SBAR or Critical Language

72. Evidence Based Local Solutions: Safety “If-Then”
If staff lack consensus about quality and safety issues?
Then educate on the science of safety
If staff feel unengaged in safety and quality?
Then build grassroots with Learning from Defects
If staff feel unengaged, unsafe, & unresourced for quality?
Then build infrastructure & capacity with Psychological Safety and Executive Partnerships

73. Questions?
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