Urine Culture Practices in the ICU; Antibiotic Stewardship; Practical ICU Tools; Using Results from the Safety Culture Surveys

On the CUSP: Stop CAUTI in ICU
April 8, 2015 ICU Content Call

David: Ladies and gentlemen, thank you for your patience in holding. We now have your presenters in conference. Please be aware that each of your lines is in listen-only mode. At the conclusion of today's presentation, we will open the floor for audio questions. At that time, instructions will be given as to the procedures to follow if you would like to ask an audio question.

Also note that, during today's presentation, we'll be presenting 2 polls. In order for your votes to count during these polls, you'll need to click the appropriate answer within the slide window it appears. It is now my pleasure to introduce today's first presenter, Miss Anna Wojcik.

Anna: Thank you, David, and welcome everyone. Welcome to the April On the CUSP: Stop CAUTI in ICU national content webinar. Today, we'll be talking about urine culture practices in the ICU, antibiotic stewardship, practical ICU tools, and using the results from the safety culture surveys.

Just a few housekeeping items before we get started. A brief overview of the platform, in addition to the announcement David made. You'll notice that we've added back the Attendees section based on some feedback from last month's call. State leads will also be receiving a more comprehensive list of the attendees after the webinar.

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Finally, I know that there's been some issues with the webinar calendar appointment, and the correct information being sent out and included in that appointment. Following today's webinar, Kathy Drury will actually be cancelling that whole webinar series and then she'll be sending out individual calendar appointments for all of the remaining monthly webinars.

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Today's presenters will be Dr. Mohamad Fakih. He's the Medical Director of Infection Prevention and Control at St. John Hospital and Medical Center, and a Professor of Medicine at Wayne State University School of Medicine in Detroit, Michigan. We also have Pat Posa, a resident CUSP Expert, who's also the System Performance Improvement Leader at St. Joseph Mercy Hospital.

Then, we'll have a team from Carolinas Medical Center presenting today. Starting with Dr. William Miles, who is the Director of Surgical Critical Care and a Clinical Professor of Surgery at the University of North Carolina, Chapel Hill-Charlotte Campus. He has a 2 big ICU teams with him today. Misty Wheeler, Lacey Spangler and Julie Retelski. We're really excited to have these great presenters here for you today. Without further ado, we'll get started. Dr. Fakih?

Dr. Fakih: Thank you very much, Anna. Hello, everyone. I'm going to talk a little bit about culturing stewardship or appropriate culturing in the ICU mostly. I'll start with a case. A 45-year-old gentleman who is an active drug user. He's admitted to have a fever of 103. He's confused, he has respiratory distress. He gets intubated and admitted to the ICU. They do a chest x-ray on him and it shows multiple pulmonary emboli. They do blood cultures, its growing MRSA.

He continues to have fever and by day three, because he's febrile, his temperature was 101.8. His blood cultures are still positive for gram-positive cocci. If you are the clinician seeing that patient, would you do a urine culture on that patient at that point? This is 3 days into his admission into the ICU, treated for MRSA. Please, go ahead.

Anna: Okay, Dr. Fakih. I think our votes are slowing down.

Dr. Fakih: It's push and pull. Is that correct? Well, it's about ... We'll, what I can say, we have about 70% who say no urine cultures, and that's the correct answer, so we have a source. We do have a source. It's septoid bacteremia, drug user. This patient is likely to have a right-sided endocarditis with septic emboli to the lung. It will take a few days to clear that bacteremia, and you should know he still has an infection in the blood. There's no reason, in this situation, to have a urine culture done on that patient.

Then, I'll skip to the next slide. I'm not sure I did that very well. Oops, I'll take over, please. A 73-year-old gentleman with prostatic enlargement. Admitted to the hospital with abdominal discomfort. They examined the patient at that point. He had normal vital signs and his white cell count is normal. Bladder scan shows a 1200 ... shows a very large urinary bladder. They catheterized him and he has 1200 milliliters of urine drained.

His abdominal pain improved with the catheterization. He did okay overnight, but then spiked a fever the next day. His blood pressure was a 100 systolic and he was a little bit cardiac with a heart rate of 110. Would you do a urine culture or not. This was a very easy question, I think. The vast majority is doing great.

The reason why I put these 2 cases is that it's extremely important for clinical decision-making to be part of your ordering of any culture. For the first case, you have, very clearly, a patient who have an infection related to drug use. He has endocarditis and there's a source for that infection. The second case, there is also a ... more of a likelihood that the urinary is focused, so the urinary source was the reason for his fever. That would be a pertinent thing to do, to get the urine culture done.

What I'm going to try to do, within this presentation, is I'm going to describe to you how often bacteriuria happens to a catheterized patient. I'm going to try to talk to you more about, you know, if you have a catheter, and what is the odds to get bacteria at Day 1, Day 2, and so on. Most of these studies were old studies. It seems people can't hear me well. Sorry about that.

Most of these studies are old studies. The main study was by Garibaldi in 1982. At that point, what they did is they looked at patients prospectively and looked at bacteriuria over time. At insertion, they found that about 9% of the patients having bacteriuria. Then they looked at those that had a catheter for more than 24 hours. These patients developed bacteriuria in about 15% of the time. The risk was about 3 to 5% per day.

Bacteriuria happens through 2 different routes. One is in extraluminal ascent, so it's the outside of the catheter. The organisms will ascend through the extraluminal area to go into the bladder, and then bacteria will reach the bladder, or through the urinary system where the urinary system is contaminated. Whether we open the urinary system or break-in techniques happens, what will happen at that time is intraluminal ascent.

Another study, a French study, by Clec'h looked at 12 ICUs where did weekly urine cultures if ... or if the patient had symptoms. They defined CAUTI as more than 1,000 colony-forming units per milliliter. Because of their definition, and because of how often they did these cultures, they had a very high bacteriuria rate. They had about 13 to a 1000 catheters-days. The median time to CAUTI in that study was 11 days.

When they looked at those that had longer lengths of stay in the ICU versus those who had shorter lengths of stay, they found out that those with longer lengths of stay had much more CAUTI than those that had shorter lengths of stay. The mean lengths of stay of those that had a catheter-associated UTI were 28 days versus those without, 7 days. Now, you think even 7 days is a long period of time being in the ICU.

Some of the inappropriate triggers for urine culture in patients with urinary catheters include the urine culture -the urine color, the smell of the urine, or consistency of the urine. Also, the issue with pyuria. You're going to see my next few slide and you're going to be very, probably, surprised about what I'm going to say. I'm going to try, hopefully, to show you some studies that clearly show that pyuria was not very strongly related to infection, and the past predictive study of pyuria not being that great.

This is a ... A study was done at my facility and we looked at resident physicians and nurses, and triggers for cultures in catheterized patients, typically urine cultures. One trigger for urine culture would be foul-smelling urine. We asked the residents, "If you have," ... different scenarios, different case scenarios.

Patient with foul-smelling urine, would you do a urine culture? The resident would say, in 71%, yes. Nurses, in fact, they're 95% of the time, yes. Cloudy urine, pretty much the same thing. Very high percentage saying yes to doing urine culture. Sediments in the urine, half of the residents said yes, to do a urine culture. Nurses said yes in 85% of the time. Darker urine, so let's say someone is dehydrated, more than a third of the residents said yes, and the nurses, half of them said yes.

A chronic urinary catheter on admission, about 40% of the residents said, "Yes, we'll do a urine culture." This is asymptomatically just because of that reason. Nurses, about 75%. Chronic urinary catheters will end up having 100% bacteriuria so there is no benefit of doing a urine culture in them, unless there is symptom.

We look at pyuria and the higher the white cells in the urine, the more likely they will do a urine culture. This is not surprising because when we're taught about UTI, we're taught about urinary tract infection in non-catheterized patients, and I think we extrapolate to the catheterized patients.

This is the IDSA guidelines, the Infectious Disease Society of America guidelines, and it clearly states that pyuria does not help differentiate between asymptomatic bacteriuria and catheter-associated UTI. It also states that pyuria and bacteria in the urine does not equate to CAUTI.

Another study by Tambyah and Maki in 2000, in the Archives of Internal Medicine, they had about 800 patients with newly-inserted catheters. What they did, they did prospective culturing of these patients. Also, they looked at pyuria at the same time. They bacteriuria as more than 1000 colony-forming units per milliliter. They found out that women had more bacteriuria than men. They had about 3 times more bacteriuria than men, which is not surprising because of the urethra and the easier ascent of the organism into the bladder.

The first day of infection, infection means having bacteria in the urine, they looked at how many white cells they had. Those that had the gram-negative organisms in the urine, they had much more white cells than those that had Staph, or Enterococci or yeasts. As you see here, 34 white cells per gram- negative versus 8 for Staph and versus 9 for yeasts.

Those that had the catheter, so this was called the uninfected patients, had an average of 5 white cells in their urine through the U/A. As you see here, the highest value, so looking at all these numbers per patient, the highest value of white cells ... you see there's less than those that are uninfected, but you see there's a huge standard deviation of 100 here. Again, those that have gram-negative bacilli tend to have more white cells in the urine.

What is the positive predictive value of having pyuria? They looked at those that had more than 10 white cells in their urine, and looked at the positive predictive of having bacteria in the urine. It was .36, so about a third. If you have 100 that had a positive U/A, it's going to be 36 of them will have bacteria in the urine. This is ... again, this is not symptomatic. This is just saying that they have bacteria.

What the Infectious Disease Society of America guidelines state is that the absence of pyuria in an asymptomatic ... in a, sorry, in a symptomatic patient suggests a diagnosis other than catheter-associated UTI. If you do a U/A in the patient you're suspecting a urinary tract infection with a catheter, then if the urinalysis does not have any white cells, it's going to help you. If it has white cells, it's not going to give you the answer whether there's an infection or not.

As far as the odor or the color, there are guidelines that state that in a catheterized patient, the presence of a ... the presence or absence of odorous or cloudy urine alone should not be used to differentiate catheter associated asymptomatic bacteriuria from catheter-associated UTI. It's not an indication for urine culture or antimicrobial therapy.

What about screening urine cultures? This has been something very common after CMS said, "We're not gonna pay for the diagnosis of catheter-associated UTI in the hospital." A lot of hospital started screening on admission and they had it into "standing orders" or "reflex orders." There are certain hospitals that have either fever facts, or fever triggers, and they do urine cultures, or sputum culture or blood cultures without evaluation, just based on a temperature.

These are quite dangerous because what may happen is that we may over-utilizing resources and getting a lot of false positive. When you have a positive culture, whether it's a sputum or your urine, physician is going to stand to treat a number or a culture. This can adversely affect our patients, and one simple bad outcome can happen such as Clostridium difficile.

This is a pre-printed order on ... from a hospital that I have visited. As you see here, they have, for newly-inserted Foley catheters, obtain a urinalysis at the time for a Foley catheter insertion. Do culture and sensitivity if U/A is abnormal. First thing is I would not do a urinalysis unless this urinalysis is going to help me take care of the patient. If a patient is asymptomatic, there's no reason for me to do a urinalysis on that patient.

I think one item that's is very important is to look at your standing orders. Make sure that these are updated, and you don't have these triggers that can give you a major headache as far as global care in your hospital and not one practitioner's care. It becomes a practice throughout the hospital.
How to reduce unnecessary urine cultures? Evaluate the current processes for obtaining urine cultures. As I said, avoid automatic triggers or screening cultures with no appropriate indications. Evaluate practice patterns to avoid PAN culturing. I think there has to be a mindfulness every single time we see a patient. What is the most likely source of that fever? Is it infectious versus non-infectious?

If it is infectious, let's figure out whether the urine is more likely be a source versus, I say, pneumonia, or a line infection or intra-abdominal process. Provide the education on when it is appropriate to do a urine culture and that's, I think, is a tough part.

The fourth item that we suggest is to have periodic audits on urine culture use in the ICU to look for trends. One thing that can be very forgotten is that residents change with time. You have a teaching hospital, you get residents every month and this is going to upset ... some people don't know what is the process regarding working up a fever, and you need to re-educate them and engage them. The last one is to promote appropriate urine catheter use, so reducing on unnecessary urine catheters.

This is a summation of what I talked to you about. Basically, mindfulness as far as when you do culturing. The appropriate urine culture use should be a part of an evaluation of sepsis without a clear source. If you have a clear source, then you don't need to do this urine. CAUTI is often a diagnosis by exclusion. The other thing is it can be based on local finding suggestive of catheter-associated UTI such as pelvic discomfort or flank pain. Unfortunately, this is very uncommon, especially in the ICU patients or patients that still have the catheter.

Prior to urologic surgeries, this is an indication. You do, you're going to culture screening, if you're going for urologic surgery, but other surgeries it's not indicated. Early pregnancy is another indication for urine cultures. Rarely seen in the ICU, however.

Make sure that your physicians are aware of the appropriate indications. Point out the risks of indiscriminate urine culture use. We've seen many cases where you have intra-abdominal catastrophes and Clostridium difficile because of unnecessary antibiotics. Address the local culture in the practice of clinicians and avoid the culture - avoid ordering cultures without clinical assessment.

This is our hospital, and I want to share with you, we had SIR that were very high. This is 50 adult ICU beds, three units. One is a Surgical Intensive Care Unit with Neuro, one is a Medical Intensive Care Unit, and one is a private unit.

As you see here, in 2013, we had SIRs up to 2, and then we worked on ... with the divisors and making sure that insertion is appropriate and maintenance. We also looked at culturing stewardship and has been having great results since then. These results continue, so we have an SIR of less than .5 right now. We're an 800-bed hospital. Thank you very much for your time. Dr. Miles?

Dr. Miles: Yes. Thank you, Dr. Fakih. I hope everyone can hear me. We're going to talk today about antibiotic stewardship. I want to thank Dr. Passaretti, one of our infectious disease preventionists at our institution, in providing me with some of the presentation and slides from her perspective.

First of all, I also would like to say, I'll be happy to add any more information to those institutions and ICUs that may not have started an antibiotic stewardship program in your ICU. There are many different ways to begin that process. Obviously, I wanted to add a disclosure slide, there's nothing to disclose. I don't have any consultant contracts with any organization at this time.

Let's talk about antibiotic stewardship in the ICU. The main points ... before we actually get into the actual process of antibiotic stewardship. The appropriate components of understanding why we have gotten to this point is that resistance to antibiotics exists in nature before medicine actually discovers or uses them.

What we are seeing in our society is that with the over-prescription of antibiotics for many small maladies, as well as majority of antibiotics being in our food sources, as well as many antibiotics, when not used, dumped in the sewer system. Bacteria in our society are actually exposed to a lot of antibiotic pressures and therefore have progressed to resistance, many times, even before they have gotten into a hospital system or in the management of patients.

Some of the key points, I feel, that are important for antimicrobial treatment that we all follow, especially if we all can look at the 30,000-foot view at our institutions. You can see, and that's what the key mentioned, many times in a teaching institution, you have residents, you have fellows, you have attendings, all with variable ways they treat an infection and use antibiotics.

In treatment considerations for antibiotics, we really should be timely in starting them. I've provides a slide, that looks at delay in starting them actually increases mortality. We need to be appropriate, meaning cover the broad spectrum of pathogens for the potential infection you have. Understand pharmacokinetics. If you don't have very obese patient versus not, versus a certain organ dysfunction, you need to provide adequate dosing and intervals.

Above all, standardization in narrowing and discontinuation of antibiotics based on clinical data, clinical response of the patient. As well as, I hope, many institutions have their own ICU or hospital-based antibiogram which do show what flora and bacteria in their institutions may be more susceptible versus other institutions for the same infections.

This is a slide looking, from Dr. Kollef and company, that actually looked at the importance of initial and appropriate antibiotic therapy. As you can see, from all-cause mortality versus infection-related mortality, if you have inadequate antimicrobial treatment, which included timing, dose pharmacokinetics, etc., you have a higher mortality versus if you have adequate antimicrobial treatment. This is one of across all critically-ill infections, but it does show the importance of appropriate initial antibiotic therapy.

Another reason why we need to get to this point of appropriate antibiotic stewardship, is that the number of antibiotics being produced by big pharma companies are really being reduced. In the 1980's, there were 16 new antibiotics released. By the early 2000, it's only 5, and in the last 4 years of 2008 to 2012, only one new antibiotic was developed. We have to be better stewards with antibiotics and how we prescribe them because not many of them are going to be produced in the future.

What is antimicrobial stewardship? Most of us know, but it is basically a systematic approach to optimize clinical outcomes while minimizing a consequence of the antibiotic use. Such as toxicity, selection of resistance, selection of virulent organisms, including Clostridium difficile resistance, which we are seeing in this country. You need any antibiotic process, and they are many types of antimicrobial stewardship practices and policies across the country.

Every unit really should have some process for it, but it should be combined with infection control practices to limit emergence and transmission. It is, and does, reduce health care costs without impacting care, and it is all about patient safety.

Just to show you a group of organizations that have mandated, or recommended and suggested hospitals have an antibiotic stewardship program. Infectious Disease Society of America, the Joint Commission has done that. Medicare in California made it a mandate. Centers for Disease Control. Physician Leadership Forum, including other organizations such as American Thoracic Society, American College of Chest Physicians and the Society of Critical Care Medicine. Many organizations have recommended antibiotic stewardship programs at ICUs.

The goals of antibiotic stewardship, on this next slide, really it's a circular component of combating emergent resistance. It is somewhat about controlling costs in this value-based health care that we have, as well as, improving clinical outcomes. We all feel that appropriate treatment of an infection is important but it should be somewhat standardized based on a geographical, institutional location, the flora, the resistance patterns and the type of infection.

As well as the clinical response. If you're treating a urine- a catheter-related urinary tract infection on an elderly patient, who's also a transplant patient, it's going to be different than someone who is a trauma patient who may be younger.

Some of the stewardship strategies that are very important ... whether you have a very basic type of antibiotic stewardship or if you have a more strong antibiotic stewardship, including antibiotic resistance practices or prescription practices. There are several strategies that can be used. From patient evaluation, as well as the education guidelines.

Formulary restrictions with the choice of antimicrobial which ... I don't totally believe in formulary restrictions but I do believe in formulary guidance with the help of our pharmacy departments. Pharm D is very important, which I'll get to in a slide, in our ICUs.

Computer-assisted strategies. In most of the electronic medical records now when we do prescription ordering, if there are shortages, if there are suggestions by the antibiotic stewardship committees, prescription ordering can be altered. Many of us, in busy ICUs, may not realize some of the ordering practices and standards based on the infection, so that's another avenue. Then, the actual dispensing of antimicrobial processes. All of these, with review and feedback, should be utilized for antimicrobial stewardship policy.

Some of the economic considerations for antibiotic stewardship. Obviously, it looks at antibiotic use restriction in costs, but they shouldn't ... that should not be the only focus. Much of what we need to look at isn't just acquisition of antibiotics, it's a small part of the treatment. It's actually the costs from the hospital length-of-stay, total health care costs and, above all, patients' quality and return to a functional life, above all. That quality of life is very important in looking at appropriate management of infections.

This is just an example of how prescribing antibiotics should be standardized from an empiric antibiotic process based on the disease, or infection, and your ICU's antibiogram. The biogram is very important, and most institutions have them for the hospital. If you're lucky enough to be practicing in an institution that actually breaks down the individual ICUs antibiogram, based on the specialty that you may have more in your ICU, I think that is very helpful.

Day 3, it should be considered narrowing, or de-escalation or discontinuing antibiotics based on culture results, whether it's an infection or leukocytosis. What is the actual picture? Is the patient improving, etc. As I mentioned before, base it on an antimi- antibiogram of the individual unit of institution. This is where I think it is important to understand that using your infection preventionist. Using your Pharm D if you're lucky enough to have one in your ICU, is very helpful.

In our institution, we actually utilize our Pharm D as the first step in antibiotic stewardship. Helping us as a multi ... In the multi-professional element of the ICU, the Pharm D is a professional that really guides us in what the antibiogram may be seeing in the last quarter. Knowing what the dosing and, above all, the pharmacokinetics based on the patient size, based on the patients' disease processes. It's been a very big help on the first phase.

Our second phase is when we come in with the infection preventionist and the antibiotic stewards that actually look at 48 hours, to see if certain antibiotics might be tailored, if they're functional, and can give guidance. We don't yet have a truly antibiotic restrictions but it does help having these professions. Above all, it does prevent multi-drug resistant organisms.

This is an example of treating anti- using antibiotics in urinary tract infections. Above all, catheter-associated UTIs. I'm not going to rehash what Dr. Fakih had mentioned, but this came from Johns Hopkins' guidelines from 2015 as an example. Above all, it shows the importance of a culture stewardship, as well as antibiotic stewardship. There are some practices ... and I've seen it in dealing with some surgical colleagues.

They do follow-up urine cultures or another urinalysis for pyurial response to see if the patient's getting better. I don't think, based on all the evidence-based medicine, that that should be done. The follow-up urine cultures or urinalysis should not be acquired routinely to monitor response to therapy. The prevalence of asymptomatic bacteriuria is high, as Dr. Fakih had mentioned, but especially in certain patient populations.

Looking at the duration of treatment. Even though, for catheter-associated UTI, it's not been that well-studied, but there are a lot of standards out there. We really should look at standardizing practice based on antibiograms, your own infections in your ICUs.

As I'll mention this now, the many times I see in my institution, with new residents, and fellows and attendings who have looked at, what I call, "football scores." They want to keep it at 7 days, 14 days, or even had one surgeon treating someone for 21 days with a catheter-associated UTI. Those variable practices need to stop, and that's the advantage of having a process and programs for antibiotic stewardship.

Above all, also for treatment notes of UTI. Remove the catheter whenever possible, as we all are part of this collaborative to look at those policies and processes, because prevention is the key to get to not even need a treatment for UTI. Prophylac- prophylatic ...excuse me. Prophylactic antibiotics at the time of catheter removal or replacement are not recommended due to low incidence of complications, and catheter irrigation should not be used routinely.

As I mentioned, antibiotic stewardship must coincide with infection control and prevention. Optimal management of the urinary catheters, which we've all talked about, as well as prevention control practices. This came from the CDC. I'll list all of these as the wheels turn. Antibiotic stewardship is in the midst, but all of these are key cogs of the wheel. Pharmacy, providers, micro lab, infection control, patients, and then the QA process, all make antibiotic stewardship flow in an institution.

I'm doing the 30,000-foot view of multi-drug resistant organisms. We're all trying to prevent the rise of these. The carbapenem-resistant Enterobacteriaceae, the MRSA, the C. diff colitis, all of these. We've seen a higher incidence of these. Antibiotic stewardship and urinary catheter removal protocols are essential are essential tools for prevention of these MDROs.

As to show antibiotic stewardship and it's practical implementation in an ICU. This came in a study that basically looked at antibiotic stewardship program's impact and looking at one aspect of it, but across the pre-antibiotic stewardship program up to the post period. Looking at the very last line, it is ... it did affect across different departments but, above all, the total hospital costs did improve with no change in hospital mortality. It did … does show a practical implementation of antibiotic stewardship.

In addition, there was another study that just was released today in Sweden, looking at antibiotic stewardship practice, in 5 months, in an institution. It showed improvement in morbidity, mortality and reduction of antibiotic use.

I wanted to bring in two of our intensive care units work in implementing antibiotic stewardship and appropriate urinary culturing. I want to introduce Misty Wheeler and Lacey Spangler, from our Surgical Trauma ICU, and Julia Retelski, who is my co-state lead in North Carolina for our SCCM cohort, and who is the CNS for the Neurosurgical ICU. Lacey?

Lacey: Yes, clicking on to the next slide. We're a 29-bed multispecialty neurological and neurosurgical unit, as well as my unit, the Surgical-Trauma ICU. We're also a 29-bed multispecialty unit that cares for transplant patients, immunotherapy patients, as well as, obviously, the surgical and trauma population. We have 874 licensed beds. We are a Level 1 trauma center. We have the largest teaching hospital in North Carolina. Next slide?

This is a graph showing you where we are with our CAUTI reduction for 2014 and 2015. For time's sake, I'm going to start with our urinary cath- our urine culture initiative, where the arrow is in January, between December and January of 2015. Before that, our highest actual raw number of CAUTIs was in August of 2014, where we instituted our CAUTI bundle much like what we see most of these webinars talking about. We're going to focus on our urine culture initiative.

In November of 2014, we found another spike of CAUTIs after we had started our CAUTI bundle, and that's where we began our proper culturing initiative. We did intense education with both our providers and our nurses, to culture the source versus PAN culture that we've heard spoken about today. Specifically with the nurses, we focused on sending the U/A first. Then, if that came back positive, then send in a urine culture.

A specific challenge that we faced in the Surgical-Trauma ICU is that, since we are a teaching facility, we have residents that rotate monthly in our unit. They weren't aware of our culture of sending a urinalysis before sending a urine culture. We did a lot of work empowering the bedside nurse to help educate the residents on our proper culturing in sending a U/A prior to culture. We did house-side education to send urine cultures in a preservative tubes and not in a specimen cup, and we do audits of that as well.

We also learned that it's very important that the correct collection source was entered into the electronic medical record. For example, if it was a clean catch specimen versus an in-dwelling catheter specimen. We've done a lot of work in auditing around to make sure that that source was correct. As you can see from my graph, especially after our proper culturing initiative, we have had zero CAUTIs for over three months. To be exact, we've gone 104 days without a CAUTI.

Also impressive is our reduction on urine cultures. We compared our Quarter 1, 2014, and our Quarter 1, 2015, urine cultures and we have had a 63% reduction in our urine cultures. In Quarter 1 of 2014, we sent 166 urine cultures, versus Quarter 1 of 2015, we have only sent 61 urine cultures. As far as sustainability, our IPs collaborated with our IS Department, and they created a daily report of urine cultures that were ordered and/or sent.

In our department, we review this report daily and we also complete a chart review of every urine culture that was ordered and/or sent. We acknowledge staff that appropriately cultured or drew U/As and did not culture. We acknowledge them in our daily huddle, and nurses acknowledges them in front of their peers. I'll turn them over to Julia now.

Julia: I would just add, along with STICU, we followed the same initiatives. We also saw a reduction in the amount of cultures and the amount of CAU- compared to the amount of CAUTIs. Going back, real fast, to specimen processing. I think one of our big learns from this was noticing, or realizing, that when the order was put in to the electronic medical record, Sta- Lacey mentioned the source. If the source was a clean catch urine versus from a urinary catheter, it is processed differently in our lab.

The numbers, they look at the numbers a little bit different, so that was an a-ha moment for nursing and for some of our providers. We did not realize that specimens were run at different ways for ... depending on how the source was put in. A lot of our education really focused on that. We also saw huge reductions in our Medical Intensive Care Unit, as well as our ... the distant heart unit. Let's see.

Currently, we are going to work with our lab. This is support with our Infection Prevention Department, and the Medical Director of the lab, to do urinalysis and then reflex testing for urine cultures. Let's see, next slide. Now, I'm going to turn it back over to Dr. Miles.

Dr. Miles: Thank you, Julia. As you can, a use of antibiotic stewardship, as well as culture stewardship, can make a difference in practical implementation in ICU. Some of the tools that were mentioned, the audits, were ... such as Dr. Fakih had mentioned, all these are very important in achieving results in your Intensive Care Unit.

I can tell you, in our Surgical-Trauma and non-surgical ICUs at our institution, we had a very high rate of CAUTIs. This remarkable reduction has been a team effort in ... as well as this collaborative, in order to adopt the principles and policies that are important in antibiotic stewardship and CAUTI reduction.

In conclusion, for my portion, providers do need better tools on how to initiate and terminate antibiotics. I think, the stewardship teams are just 1 step to regulate antibiotic prescribing. The importance of standardizing your practice of antibiotic use and the use of institutional antibiograms are important.

Really, to stop antimicrobial treatment based on clinical picture and obviously don't use variable football scores to decide length of treatment.

Antibiotic stewardship and proper culture, and they do go hand-in-hand and in synergy with the teamwork. That, team effort in following the CUSP CAUTI policies and guidelines, good results can be achieved, as we've mentioned, in ICUs. Pat? I'm turning it over to Pat Posa.

Pat: Hi. Great work, and I echo the results. We instituted, at my organization, the mapping culturing, PAN culturing, and we're seeing significant drops in our rate as well. I'm going to turn it over and talk to you about the Comprehensive Unit Safety Program or CUSP. We're going to talk about safety culture, interpreting the result, and the importance of culture.

We're talking a lot about culture today, I'm going to talk a little bit about changing that culture to support the technical interventions that you heard today. What is culture? It represents the set of shared attitudes, values, goals, practices and behaviors that make one unit distinct from the next. In our program here, aren't we truly trying to influence behaviors and practices, and so we're trying to influence the culture of the unit.

Culture issues- the unspoken, implicit, taken for granted and often largely invisible. It's important, when you think of culture, that you measure it, and think of it, in trying to impact it at the unit level. Culture can be different in different units. Our Surgical ICU culture is different than our Medical ICU culture.

As well as, even within a unit, the day-shift culture is often different than the night-shift culture. It's because of the people and the attitudes, values, goals and practices that they bring. The Institute of Medicine shares with us the biggest challenge to moving toward a safer health system is changing that culture.

One important change that needs to happen is to change from a culture 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. That doesn't negate holding people accountable to performing established practices and guidelines, so there's a fine balance between that.

We strive for, and the Comprehensive Unit Safety Program will help us get to a positive culture of safety. That's really a culture where we recognize that errors will happen, and we proactively seek to identify latent threats and do something about them. We don't wait for the errors. We're always constantly vigilant to finding errors. People talk about errors, and potential errors, near misses so that we can view them as opportunities to make things better, to establish better- a more standardized practices, etc.

We know that chaos and less predictability results in worse safety. If we can improve the predictability, resulting in less chaos, we will have better safety. How we do that is through standardization, checklists, familiarity, good orientations, etc. As part of the patients' safety movement, and as part of the CUSP program, as you're putting this in place in your unit ... I know a lot of hospitals measure their safety culture.

We are actually not administering a safety culture survey during this collaborative because of the short time, but it's still important to, as an organization, you should be measuring your safety culture annually or every 18 months. Then, when you measure that safety culture, you need to then do something about the result. Why should you measure unit culture? You need to determine how the bedside staff are feeling related to communication, errors, teamwork and safety.

It helps you diagnose and assess your current state of culture, identify your strengths, and then also your areas for opportunity to improve. It allows you to examine trends, over time, and measure and evaluate the impact of different strategies that you're implementing to improve the culture. CUSP is one of those interventions and we'll talk about it more specifically in how it relates to improving safety culture.

It's important that, when you administer the survey, that you get a good response rate. You want to get, at least, 60% of your staff to respond in order to really ... those results could be generalizable and really reflective of your staff. Once you get those results, you need to organize and share them with your staff, and begin to problem-solve and create action plans with the staff to ... where there are areas of opportunity where you can improve.

This assessment data is likely to point to many different areas of culture that can be improved, and there are many different potential actions. You want to start small, through incremental change, change one practice at a time. Remember, you're not going to be able to solve and improve your safety culture with just doing one thing. You'll need to do multiple things. There isn't really one “silver bullet.”

When you get your survey back, you need to drill down to understanding what it says. One of the domains that you'll be looking at are questions related to teamwork. Often, what pulls your scores down, where people don't feel like there's good teamwork, is questions related to difficulty speaking up when I'm concerned about an error, breakdown in interdisciplinary care coordination. How conflicts get resolved related to patients, etc., and I don't feel comfortable asking questions.

Also, you might find that your sc- the overall ... the safety related questions get pulled down because there's lack of trust, that if I report an error, that it's not going to go into my personnel file, and lack of engagement.

We need to change the unit culture. As we heard earlier today, that work on changing the entire safety culture will assist you as you're working on changing the culture related to CAUTI. By improving the overall culture in your unit, one of the first step is ensuring that everyone believes that any harm is not acceptable. We know that CAUTI is a harm to a patient and that should be considered unacceptable.

If this is present, if this belief is present, you're going to see that on your ... some of the categories from the culture survey. Non-punitive response to errors, if people believe and feel comfortable talking about errors. That they don't feel they're going to get a punitive response, then your culture is changing to allow those kind of discussions to be able to problem-solve and make things safer.

We want to ensure, and as you heard today, we don't ... we want to avoid the practices of PAN culturing, and to focus on a positive safety culture is to also ensure that we're mindfully choosing intervention. Don't do things because that's how we've always done it. Do things mindfully that you have a reason. I'm not going to PAN culture, but I'm going to, as Dr. Mile presented early or Dr. Fakih presented early on, the patients that clearly did not have a urinary source for that infection, you don't need to get urine culture.

Having interdisciplinary discussions of the risk versus benefit of starting antibiotics through ... as part of your antibiotic stewardship program. Again, having interdisciplinary discussion means that you have to have a culture where everyone can speak up and their input is valued. By working on your culture, you'll be able to support these types of conversation.

What do you do with the results? I know we only have a couple of minutes. Teamwork climate is usually the consensus of the frontline caregivers related to collaboration. These are common questions that get answered, and they get answered not as positively. In a clinical area, it's difficult to speak up. Disagreements are not resolved appropriately , and physicians and nurses work well together. If you don't have high positive scores on these, then you have a teamwork problem.

As you get your culture results, and this is your safety culture … and most people are using AHRQ HSOPSC, you want to review the results with your staff, and there's a zillion questions. I think there's 65 or something, so we're not going to be able to focus on everything.

One way to do it is to pick areas where you saw good- really positive results and celebrate those. Ask the staff, "Why did you score that positively?" Get some thoughts behind it, but really recognize that you're ... has some good pockets of excellence. Then, pick 5 areas where you have the most opportunities.

I'm going to walk through an example. For example, here's a positive. Under the section of supervisor and manager expectations. On this particular survey, they got a 76% had strongly agreed, that considered staff suggestion for improving patient safety. In teamwork, people support each other in this unit. When lots of work needs to get done quickly, we work together as a team. People treated each other with respect. Highlighting these good things that are happening.

Then, you can focus on the least positive, and you can look at the domains or the specific question. Here, there was a low response to staff feel free to question the decision or actions of others, and so there has to be some work to help with that. Interdisciplinary rounds, so one of the Comprehensive Unit Safety Program's communication and teamwork tools, and interdisciplinary rounds will assist you in improving with that.

Feedback and communication about errors, doing learning from defects is going to help improve that. Non-repunitive ... Non-punitive response to errors. Again, using ... asking the ... using the CUSP safety assessment tool, as well as using the learning from defect tool, is going to help the staff realize that we want to hear what are the issues, and the problems and safety concerns so that we can solve them.

If you have a teamwork problem, then here are some tools to use to help improve that teamwork. We'll be talking ... at the next content call, we'll talk about some teamwork tools. If you have poor staffing levels, or you feel information is lost at change of shift, then do a morning or shift briefing. Interdisciplinary patient management issues, then institute interdisciplinary rounds a daily goal. Role clarity conflict, shadowing exercises. Difficulty speaking up, institute some standard language, SBAR or other critical language.

If it's safety, then ensure that you're educating people on the science of safety. If their staff isn't feeling engaged in safety and quality, doing the learning from defects will be very helpful. Executive partnerships will help them feel engaged and get the appropriate resources.

I know that was a quick brief overview, but it's just ... what I want you to walk away from is that it's important to change your culture if you're ... to a positive safety culture. Where people talk about errors, and you can have good conversation, in order for all of these technical interventions to stop CAUTI to work. You have to also be promoting and working on creating a positive safety culture.

Anna: Terrific. Thank you so much, Pat. Again, thank you to all of our presenters. I am, we're almost at the top of the hour, going to send the evaluation to everyone. Now, if you have to leave right at 3 'o clock, please be sure to fill out that evaluation. I think, we'll take 1 or 2 questions in an Q&A, but I do encourage everyone.

If you have questions, we will probably not be able to get to all of them, so I would ask that you post your questions in the chat box. We'll ask our presenters to answer any of questions we can't get to in the Q&A. We want to take 1 or 2 questions. David, can you start that process for us?

David: Absolutely. Ladies and gentlemen, if you'd like to ask an audio question, please press star 1 on your touch tone phones now. Again, if you'd like to ask an audio question, please press star 1. Ms. Wojcik, at this time, we have no audio questions.

Anna: If there are no question now, I again encourage questions there. You can email any questions you have directly to me as well. Thank you, everyone, for participating in today's webinar. We'll see you again next month, on May 13th, for our next content webinar. The recording, and all of the details on this webinar, will be posted on our website by early next week. Thank you, again, to everyone.

David: Ladies and gentlemen, that concludes today's presentation. You may disconnect your phone lines, log off your webinars, and thank you for joining us today.

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