HOW CAN FACILITIES IMPLEMENT A STEWARDSHIP AND
CAUTI REDUCTION PROGRAM?
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How can Facilities Implement a Stewardship and CAUTI Reduction
Program?
Cindy Fronning RN-BC, CDONA, FACDONA, RAC-CT, IP-BC, AS-BC
Director of Education NADONA
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Penicillin
Sulfa
1.0 Contact Hours Participants must complete entire activity. No partial credit will be awarded Participants must submit a post event evaluation form This CNE activity has been jointly provided by Terri Goodman & Associates collaboratively with NADONA
Terri Goodman & Associates is an approved provider of continuing nursing education by the Texas Nurses Association - Approver, an accredited approver by the American Nurses Credentialing Center’s commission
Accreditation
This activity is provided through an unrestricted educational grant from Ocean Spray.
Disclosures
• Cindy has no relationships with commercial entities related to the healthcare industry.
• Cindy is the Director of Education for NADONA
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Objectives
The participant will be able to:
1. Describe how facilities can implement a Stewardship and CAUTI reduction program
2. Explain the need for an interprofessional team to collaborate on a facility Antibiotic Stewardship Program 3. Identify proper communication mechanisms to
breakdown communication barriers
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Penicillin
Sulfa
Bactrim 6
NADONA
Focus on
CAUTI
Reduction
Goal
• Reduce:
– Complications
– CAUTIs (Catheter Associated UTIs) – Unnecessary Catheters
– Costs
– Mortality and Morbidity
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Key Implementation Steps
• Identify Champions and gather a team
• Conduct a readiness assessment
• Plan for implementation
• Introduce new policies and procedure to staff
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Insertion of Catheters
• Eliminate unnecessary insertion
• Provider indication for insertion
• Medically necessary (Survey)
• Urinary retention that cannot be treated or corrected medically or surgically, for which alternative therapy is not feasible, and which is characterized by:
– Documented post void residual (PVR) volumes in a range over 200 milliliters (ml);
– Inability to manage the retention/incontinence with intermittent catheterization;
• Persistent overflow incontinence, symptomatic infections, and/or renal dysfunction.
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Provider Indications cont.
• Medically necessary cont.
• Contamination of Stage III or IV pressure ulcers with urine which has impeded healing, despite appropriate personal care for the incontinence;
• Terminal illness or severe impairment, which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain.
QM = Neuro-genic Bladder Obstructive Uropathy
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Insertion of Catheters cont.
• Consider Alternatives
• External catheter for men
• Programmed toileting
• Intermittent (“in-and-out” or “straight”) catheterization;
• Suprapubic catheter
• Practice Aseptic technique
• Hand Hygiene
• Skin and Site Antisepsis NADONA
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Care and Removal
• Timely discontinuation of unnecessary indwelling catheters
• Regular Assessment
• Automated Reminders
• Adherence to Aseptic Technique
• Nurse-driven protocol
Building a Coalition
Penicillin
Sulfa
Bactrim 13
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Antibiotic Stewardship is a Team Sport
• Administrators
• Medical Directors
• Prescribers
• Consulting Pharmacists
• Director of Nursing
• Infection Preventionists
• Medical Laboratory Leaders
• Resident
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Create an Understanding that Physicians:
• Play a significant role in shaping the care in the facility
• Tend to be fairly autonomous; may not be employed by the facility
• Are primarily interested in treating illness – typically not trained to focus on improving safety and preventing harm
• Are likely unaware of safety efforts in the facility; most have limited time to volunteer for supporting the safety agenda
• May not readily embrace change
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How to Engage Physicians and Providers
1. Develop a common purpose (patient safety, efficiency) show them statistics on their residents
2. View physicians as partners (not barriers) Be prepared – thus earn respect
3. Identify physician champions early
4. Standardize evidence-based processes – This is a part of your ICPC and Antibiotic Stewardship plan
5. Provide support from leadership for the efforts
of the physician champion NADONA
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How to Engage Nurses
1. Develop a common purpose (patient safety) 2. View nurses as partners (not barriers) 3. Identify nurse champions early
4. Standardize evidence-based processes (and make the right thing to do, the easy thing to do)
5. Provide support from leadership for the efforts of the nurse
champion
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Collaboration Yields Success
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Infection Preventionists Case Managers
• Reduce CAUTI
• Reduce antibiotic use
• Reduce potential of increased resistance and Clostridium difficile disease
Less complication ( mechanical or infectious) = lower costs
Nurse Educator/Unit Manger/DON
Physical Therapists
Leader and supporter to the bedside nurse
Makes appropriate urinary catheter use a priority and a safety issue Helps to address any barriers encountered by the bedside nurse
The urinary catheter reduces mobility in patients: “one-point restraint”
Rapid recovery (Improvement in ambulation) may be hampered by the catheter
Communication
Penicillin
Sulfa
Bactrim 19
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Communication Vehicles
• Suspected Urinary Tract Infection (UTI-
SBAR)
:– Situation – Background – Assessment – Recommendation
• Helps guide communications between nursing home staff and prescribing clinicians -
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Situation
• Who you are and unit
• Resident’s Name
• Reason for contacting the Provider
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Background
• Provide a comprehensive but focused background on the resident’s pertinent medical history
• Mention any key comorbidities
• Share other concerns
• Current catheter
• Dialysis
• Incontinence
• Medication Allergies
• Coumadin usage NADONA
Assessment
• Provide your clinical assessment based on objective facts and clinical observation
• Fever
• New back /flank pain
• Acute pain
• Shaking/ Chills
• Change in Mental status
• Hypotension
• Review the current medication listing
• Assess for potential antibiotic-related adverse events
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Recommendation
• State your recommendation to the provider
• Ask for clarification on any further details
• Document the discussion and repeat back any orders given
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AHRQ SBAR
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AHRQ SBAR
cont.
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McGeer’s
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Table 5. Gastrointestinal Tract Infection (GITI) Surveillance Definitions
Syndrome Criteria Selected Comments*
Gastroenteritis Must fulfill at least 1 criteria.
□ Diarrhea: ≥ 3 liquid or watery stools above what is normal for the resident within 24 h
□ Vomiting: ≥ 2 episodes in 24 h
□ Both of the following sign or symptom
□ Stool specimen positive for a pathogen (e.g., Salmonella, Shigella, E coli O157:H7, Campylobacter species, rotavirus)
□ At least one of the following criteria
□ Nausea
□ Vomiting
□ Abdominal pain or tenderness
□ Diarrhea
• Exclude non-infectious causes of symptoms such as new medications causing diarrhea, nausea, or vomiting or diarrhea resulting from initiation of new enteral feeding
• Presence of new GI symptoms in a single resident may prompt enhanced surveillance for additional cases
• In the presence of an outbreak, stool specimens should be sent to confirm the presence of norovirus or other pathogens (e.g., rotavirus, E coli O157:H7)
Norovirus gastroenteritis
Must fulfill both 1 AND 2.
□ 1. At least one of the following criteria
□ Diarrhea: ≥ 3 liquid or watery stools above what is normal for the resident within 24 h
□ Vomiting: ≥ 2 episodes in 24 h
□ 2. A stool specimen positive for norovirus detected by electron microscopy, enzyme immunoassay, or molecular diagnostic testing
• In the absence of lab confirmation, a norovirus gastroenteritis outbreak (≥ 2 cases in a LTCF) may be assumed if all of the Kaplan Criteria are present
o Vomiting in >50% of affected persons o A mean or median incubation period of 24-48 h o A mean or median duration of illness of 12-60 h, and o No bacterial pathogen is identified in stool culture
Clostridium difficile infection
Must fulfill 1 AND 2.
□ 1. At least one of the following criteria
□ Diarrhea: ≥ 3 liquid or watery stools above what is normal for the resident within 24 h
□ Presence of toxic megacolon (radiologic finding of abnormal large bowel dilatation)
□ 2. At least one of the following diagnostic criteria
□ Stool sample positive for C difficile toxin A or B, or detection of toxin-producing C difficile by culture or PCR in stool sample
□ Pseudomembranous colitis identified in endoscopic exam, surgery, or histopathologic exam of biopsy specimen
• Individual previously infected with C difficile may continue to be colonized even after symptoms resolve
• In the setting of an outbreak of GI infection, individuals could be C difficile toxin positive because of ongoing colonization and also be
co-infected with another pathogen. Other surveillance criteria should be used to differentiate between infections in this scenario
Antibiotic Stewardship
Goals
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Six Goals of Antibiotic Stewardship Programs
1. Reduce antibiotic consumption and inappropriate use
2. Reduce Clostridium difficileinfections 3. Improve patient outcomes
4. Increase adherence/utilization of treatment guidelines
5. Reduce adverse drug events 6. Decrease or limit antibiotic resistance
– Hardest to show
– Best data for health-care associated gram negative organisms
Tamma PD, Cosgrove SE. Infect Dis Clin North Am. 2011 25:245 Ohl CA, Luther VP. J. Hosp. Med. 2011;6:S4
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Nine Factors to Consider When Selecting an Antibiotic
1. Spectrum of coverage 2. Patterns of resistance
3. Evidence or track record for the specified infection 4. Achievable serum, tissue, or body fluid
concentration (e.g. cerebrospinal fluid, urine) 5. Allergy
6. Toxicity
7. Formulation (IV vs. PO); if PO assess bioavailability
8. Adherence/convenience (e.g. 2x/day vs.
6x/day)
9. Cost NADONA
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Principles of Antibiotic Therapy
• Empiric Therapy (85%) Directed Therapy (15%)
• Infection not well defined Infection well defined
(“best guess”) Narrow spectrum
• Broad spectrum One, seldom two drugs
• Multiple drugs Evidence usually stronger
• Evidence usually only 2 randomized Less adverse reactions controlled trials Less expensive
• More adverse reactions
• More expensive
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Why So Much Empiric Therapy?
• Need for prompt therapy with certain infections
– Life or limb threatening infection – Mortality increases with delay in these cases
• Cultures difficult to do to provide microbiologic definition (i.e. pneumonia, sinusitis, cellulitis)
• Negative cultures
• Provider Beliefs
– Fear of error or missing something – Not believing culture data available
– “Patient is really sick, they should have ‘more’ antibiotics”
– Myth of “double coverage” for gram-negatives e.g.
pseudomonas
– “They got better on drug X, Y, and Z so I will just continue those”
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To Increase use of Directed Therapy for Outpatients:
• Define the infection 3 ways
– Anatomically, microbiologically, pathophysiologically
• Obtain cultures before starting antibiotics – Often difficult in outpatients (acute otitis media,
sinusitis, community-acquired pneumonia)
• Narrow therapy often with good supporting evidence – Amoxicillin or amoxicillin/clavulanate for AOM,
sinusitis and CAP
– Penicillin for Group A Streptococcal pharyngitis
– 1st generation cephalosporin or clindamycin for simple cellulitis
– Trimethoprim/sulfamethoxazole or
cipro/levofloxacin for cystitis NADONA
Tenets of Proper Stewardship
Tenet = Principle or belief
Tenet 1: Treat bacterial infection, not colonization
Tenet 2: Do not treat sterile inflammation or abnormal imaging without infection
Tenet 3: Do not treat viral infections with antibiotics
Tenet 4: Limit duration of antibiotic therapy to the appropriate length
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Tenet 1: Treat Bacterial Infection, not Colonization
• Many patients become colonized with potentially pathogenic bacteria but are not infected
– Asymptomatic bacteriuria or Foley catheter colonization – Tracheostomy colonization in chronic respiratory failure – Chronic wounds and decubiti
– Lower extremity stasis ulcers – Chronic bronchitis
• Can be difficult to differentiate
– Presence of WBCs not always indicative of infection
– Fever may be due to another reason, not the positive culture
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Other Tenets of Antibiotic Stewardship
• Limit duration of surgical prophylaxis to <24 hours perioperatively
• Use rapid diagnostics if available (e.g. respiratory viral PCR)
• Solicit expert opinion if needed
• Prevent infection
– Use good hand hygiene and infection control practices
– Remove catheters
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Conclusions
• Antibiotic Resistance is one of the largest threats to public health of our time
• It takes ongoing and transparent collaboration to reduce risk and improve prescribing practices
• You don’t have to have a prescription pad to influence change and practice
• Engage the RESIDENT
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Key References
• Centers for Medicare and Medicaid Services (CMS). Catheter Associated Urinary Tract Infection Prevention tracker.
• Centers for Disease Control and Prevention.
CAUTI Prevention. Electronically accessed from www.cdc.gov/hai2017.
• Gould, CV, et al. Guideline for the Prevention of Catheter-Associated Urinary Tract Infections.
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Contact Hours
• You will receive an email within 2 weeks that will have the eval link.
• Please fill out the eval and when completed the certificate of attendance and contact hour will be sent to you.
