Mindfulness: Engaging Frontline Providers in Antimicrobial Stewardship (June 10, 2014)
AHA – Chicago
June National Content Call
June 10, 2014
11:00 AM CT
Operator: The following is a recording of the Paul Tedrick June National Content Call with the American Hospital Association on Tuesday, June 10, 2014 at 11:00 a.m. Central Time. Excuse me, everyone. We now have all of our speakers in conference. Please be aware that each of your lines is in a listen-only mode. At the conclusion of today's presentation, we will open the floor for questions. At that time, instructions will be given as to the procedure to follow if you would like to ask a question. I would now like to turn the conference over to Ms. Ashley Hofmann. Ms. Hofmann, you may begin.
Ashley Hofmann: Hi, everyone, and welcome to the June National Content Call for On the CUSP: Stop CAUTI project. We're so excited you've joined us on today's call which is going to focus on antimicrobial prescribing. Before we begin today's presentation, just a quick reminder that this call is a webinar today, so please be sure to log in to that webinar link that was sent out in the Outlook invite so you'll be able to see the slides. We'll also put a copy of the slides and the recording on the project website later this week. Now I'd like to introduce our speakers for the day. Dr. Arjun Srinivasan is the Associate Director for Healthcare-Associated Infection Prevention Programs in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention, and is board-certified in infectious diseases. We also have with us today Dr. Scott Flanders, who is Professor in the Division of General Internal Medicine at the University of Michigan, where he serves as Associate Division Chief of General Medicine for the Inpatient Programs and Associate Director of Inpatient Programs for the Department of Internal Medicine. He is the Director of the University of Michigan's Hospitalist Program, which has grown to include over 70 faculty members. And without further ado, it is my pleasure to introduce our guest speakers for the day.
Arjun Srinivasan: Great, thank you so much. This is Arjun Srinivasan and I'm going to start things off. You can start with an overview a little bit on antibiotic stewardship. And I want to thank Ashley and the organizers for including this topic. It's a little bit, I think, different from many of the webinars that you guys probably have talking about CAUTI prevention and the specific things that you can do to prevent the development of catheter-associated urinary infections. But I think this is an incredibly important topic for all of you who were so focused on CAUTI prevention, because I think this issue of antibiotic overuse really fits very nicely with the work that you all are doing to prevent catheter-associated urinary tract infections. And I'll apologize to the attendees, I'm going to have to have Ashley advance the slides for me because I'm not able to do that. So, Ashley, if you can move to the next slide.
So just a polling question to get things started. And I wanted to find out from you guys if your hospital currently has in place an antibiotic stewardship program. So, if you guys could go ahead and vote on that, and I assume you click the radio buttons in order to do that. And I think we have about 30 seconds or so. Ashley, do they just click the buttons to vote?
Ashley Hofmann: Yeah, that's right. Just on your screen there, click the radio dial and looks like we've got about half respondents. I'll give you guys just a few more seconds and we'll show the results. (0:03:37 Indiscernible).
Arjun Srinivasan: Great, so looks like most folks do have a stewardship program in place and that's fantastic. So I hope that over the course of this webinar the folks who do have stewardship programs will get some ideas of how we can work with those stewardship programs and maybe enhance them, and try to get them to help us with our UTI work. And for those of you who don't, I hope you'll get some ideas for how you might encourage your facilities to start a stewardship program, or at least look at starting one. Next slide, please, Ashley.
So, we certainly need to work on improving antibiotic use in our hospitals. And one of the main reasons why this is is because antibiotics are different from all of the other drugs that we use. If I don't do a good job of prescribing drugs to treat hypertension, that's a detriment to my patient, but really doesn't impact anyone else's ability to take care of their patients. But if I work in your intensive care unit and I overprescribe and misprescribe antibiotics, and breed resistant bacteria in that intensive care unit, and create cases of C. diff in that intensive care unit, that directly does impact your ability to take care of patients in that ICU. So, we really are all in it together when it comes to antibiotic use. We know that there's a lot of room for improvement of prescribing antibiotic use, and an particular, antibiotics that are used to treat suspected urinary tract infections, or in many cases, (0:05:14 indiscernible) misused to treat asymptomatic bacteriuria. We're fast running out of antibiotics and we're not getting new antibiotics very soon, and we know that antibiotic overuse is a big contributor of adverse effects for the safety of our patients. Next slide, please.
Let me just show you a few of these and I'll start with one of the major ones, and that's, of course, Clostridium difficile. We know that antibiotic exposure is the most important risk factor for the development of C. diff, and we know that giving people antibiotics puts them at increased risk for C. diff for a very long time. For up to about 90 days after a patient gets a course of therapy with antibiotics, they're at an increased risk to develop Clostridium difficile. And we know that in the vast majority of cases, it's the antibiotic exposure that sets the stage for the C. diff infection. Next slide.
We also know that we're in the midst of a large epidemic of Clostridium difficile. You can see here how there's been this really dramatic rise in the number of cases and the number of deaths from Clostridium difficile infections over the past decade or so. We estimate at CDC that there's about 250,000 cases of C. diff in our hospitalized patients and probably about 14,000 deaths from these infections in 2007. It leads to dramatically increased costs. And, of course, there's the epidemic strain of C. diff which is driving a lot of this increase and a lot of this morbidity and mortality associated with this that very closely linked with fluoroquinolone exposure. And, of course, that has a direct implication in our efforts to try and get people to stop over-treating asymptomatic bacteriuria. Next slide, please.
But there are other issues as well. We also know that antibiotics have side effects and if you give people antibiotics unnecessarily, you're exposing them to side effects from those drugs with no benefit. In 2008, we looked at data on outpatient visits to emergency departments for adverse drug events related to antibiotics and there were 142,000 times that year where people actually presented to an emergency room, and the attending clinician who saw them in the ER thought that they had an adverse drug event attributed to antibiotics. So, even if a small percentage of those were unnecessary, there's opportunities to prevent emergency department visits for adverse drug events because many of these patients were probably getting antibiotics that they maybe didn't need. Next slide, please.
We know that antibiotic exposure also increases risks of antibiotic resistance. This is just a couple of examples, one with carbapenem-resistant Enterobactericeae and the other with ESBL-producing organisms. And this slide simply makes the point that their exposure to these antibiotics puts you at a significantly increased risk to develop and infection with a resistant organism. Next slide.
And when you talk about this type of drug resistance, it's really become a— we're approaching a situation where we're talking about resistance that makes treatment absolutely impossible for some of these infections. This is a susceptibility profile of just one fairly typical isolate of a carbapenem-resistant Enterobactericeae that someone sent to our lab here at CDC. And you can see that this particular strain was only susceptible to tigecycline, which many of you know has a lot of issues when it's used to try to treat infections. And a lot of these strains are frankly also resistant to tigecycline and have very limited, if any, treatment options. Next slide, please.
We also know that there's a huge opportunity to improve the way we use antibiotics. We know that in inpatient settings, that somewhere between 30 and 50 percent of all the antibiotics that we prescribe are either not necessary at all, they're being given to patients who don't need them, or we're making— there is room for improving that type of therapy, we're giving treatment for too long or it's treatment that's unnecessarily broad. And this is just one of those studies which I thought did a nice job of breaking down the unnecessary therapy into three kind of broad categories. Either patients were getting a therapy for longer than they needed it, or in the second two bars, people were getting antibiotics when they didn't need them at all, so they were getting them for non-infectious or for non-bacterial (0:10:07 indiscernible), getting them for viral infections, or they were getting them to treat— they were getting them for bacterial cultures that represented a colonization rather than true infection. And this is, of course, a major issue that we face when we talk about urine cultures, where many, many times we are dealing with colonization of the bladder with bacteria that's getting treated as if the person has an infection. Next slide, please.
We actually looked at this fairly recently in a number of hospitals that were participating in a prevalent survey for healthcare-associated infections that we did. And we did some assessment of how well people did at treating urinary tract infections. And these were community-acquired urinary tract infections, so they were present on admission and there was not an indwelling catheter in place. So these should be fairly classic presentations of urinary tract infections that should be managed in fairly standard ways. But what we found is that there were a lot of errors that were being made in the diagnosis and treatment of these infections. In 16 percent of these cases there was no urine culture that was ordered, even though the patient was being treated for a urinary tract infection. And certainly we would suggest that all of the guidelines would recommend that you get a urine culture in order to diagnose a urinary tract infection. The other very large bucket was, again, this issue of I think treating asymptomatic bacteriuria, where you had a urine culture that was positive, but there was absolutely no documentation of any of the signs and symptoms that we would consider to be diagnostic of a true urinary tract infection. No fever, no dysuria, no flank pain. But yet, these patients were being again treated for a urinary tract infection. And then finally, in a small number of cases the urine culture was actually negative and there were no symptoms present, but yet the patient was still in the chart the antibiotics were still documented as being given for a urinary tract infection. So what we found is, as you can see from the bottom line here, nearly 40 percent of the time there appears to be opportunities to improve the way that we treat these community-acquired urinary tract infections. Next slide.
We also know that antibiotic stewardship programs have a lot of benefits and can really help us address some of these patient safety and other adverse events associated with antibiotic overuse. And this has been, I think, very well demonstrated for Clostridium difficile. This is a nice example of that and I like it because it was done at a community hospital where they implemented a stewardship program to address very high rates of Clostridium difficile. What they did was they began doing kind of what we consider an antibiotic timeout. They were doing a post-prescription review of broad-spectrum antibiotics after two days of therapy. And that resulted in a 25 percent drop in the use of these broad-spectrum antibiotics and a nearly three-fold, or more than three-fold reduction in their rates of Clostridium difficile. Next slide.
And this is something, I think, that's been well demonstrated in the literature. In fact, it's been demonstrated so many times that there are enough publications that there is a meta-analysis that was published earlier this year, a meta-analysis on 16 different studies looking at the impact of antibiotic stewardship on Clostridium difficile, and found that the stewardship programs were significantly protective against Clostridium difficile, the risk ratio over 50 percent reduction. And they found that places that restricted antibiotics had the biggest impact in reducing Clostridium difficile, and also found that protection was especially strong in geriatric settings, which of course is important for what we're talking about, because I think oftentimes these geriatric settings and older patients are also the ones who are frequently over-treated for asymptomatic bacteriuria. Next slide, please.
We also know that improving the use of antibiotics can actually reduce antibiotic resistance. This is a study showing susceptibility profiles of Pseudomonas aeruginosa isolates before and after they implemented an antibiotic restriction program. And as you can see, they had a significant increase in the susceptibility of Pseudomonas across the board following the implementation of an antibiotic stewardship program. And I think these are impressive results, one because they were able to demonstrate this within one year of starting their stewardship program, so they had a fairly rapid rise in susceptibility, and also because they actually improved their susceptibility. They didn't just show that things levelled off, things actually got better. Next slide, please.
And this is also something that's been demonstrated at the individual patient level. This is a study looking at shortened durations of therapy for people who had suspected ventilator-associated pneumonia. And you can see that patients who got what they've called a ‘short-course therapy' for suspected ventilator-associated pneumonia, and a therapy was stopped after three days among patients who didn't have pneumonia, those individual patients were significantly less likely to go on to develop an antibiotic-resistant superinfection. So improving the use of antibiotics actually can protect individual patients from getting resistant superinfections. Next slide, please.
And finally, there's also I think good data showing that if we implement antibiotics stewardship programs we can actually improve clinical outcomes. We can help people take better care of their patients. This is a slide showing a comparison between patients who had their infections managed with input from an antibiotic management program, AMP, they grey bars, compared to usual practice. And you can see that patients who received input from this antibiotic management program were significantly more likely to get appropriate therapy, were significantly— almost twice as likely to have their infections be cured, and were 80 percent less likely to have a treatment failure for their infection. Next slide.
So, what is antibiotic stewardship? Well, very simply, antibiotics stewardship is simply ensuring that every patient gets an antibiotic only when they need it, that they get the right antibiotic, at the right dose, for the right duration. Next slide.
There are three kind of important goals for an antibiotic stewardship program, or I should say three important benefits for an antibiotics stewardship program. They have been shown to optimize patient safety while simultaneously reducing resistance and controlling costs. So I think it's important to note that antibiotic stewardship programs really have kind of a triple benefit, if you will. Next slide.
Now, I would say that the last slide is really kind of mislabelled because reducing costs and reducing antibiotic use really isn't the ultimate goal of a stewardship program. The primary goal of a stewardship program is to improve the treatment of infections and ensure that people get the correct antibiotic therapy. All of these other events, reducing antibiotic use and saving money, really aren't the goals of the program, but happen to be very, very desirable side effects of our efforts to improve antibiotic use. Next slide, please.
I also think that the time has come to really rethink the way that we approach antibiotic stewardship. And this is a lesson I think we've learned from infection control and a lesson that we've learned from the work that many of all of you are doing with the CUSP program. In the past, I think we've viewed a lot of our efforts to improve antibiotic use in the way we used to view our efforts to reduce urinary tract infections, where the job of doing this was on the infection prevention program, or is solely on the antibiotic stewardship program. And I think we now recognize that preventing infections, your CUSP efforts, they work best when there's ownership and accountability for doing this at the front lines with the individual prescribers. And I think antibiotic stewardship needs to become the same way. It needs to be something that all of us are in together, rather than being something that someone else does for you. Next slide.
We don't want to be putting stewardship programs in the position of trying to dictate antibiotic choices, rather, they're there to do what many of you are doing in your CUSP programs, which is to develop a culture of good antibiotic use and to build systems that will help providers use antibiotics the right way and use them optimally in all settings. And in order to do this, I think we need to get more providers and different providers engaged in leadership roles in our stewardship programs. Next slide, please.
We need new groups to take ownership and leadership of efforts to improve antibiotic use. We need hospitalists to be engaged, and Scott's going to talk a lot about this. He's really been one of the national thought leaders in working on efforts to get hospitalists leading antibiotic stewardship efforts. We need intensivists to be engaged in our ICUs and surgeons to help us with improving surgical prophylaxis. And I would argue that stewardship effort work best when they're viewed as a partnership between a stewardship team and frontline clinicians. Next slide.
We also need strong antibiotic stewardship programs in our hospitals that can help us build the systems that will allow providers to prescribe— that will help prescribers prescribe antibiotics optimally. CDC several months ago released a document called the ‘Core Elements for Antibiotic Stewardship Programs.' And what it does is it highlights the factors that have been associated with very successful antibiotic stewardship programs that have been published in the literature. And what we emphasize in the document is that we don't think there's a single structure or a single way that an antibiotic stewardship program needs to look in order to be effective. But we do point out that there are a number of things that the stewardship program needs to do and to have in order to be effective, and these are simply outlined here. Next slide, please.
But ultimately, we know that the most important thing for a stewardship program to do in order to be effective is to implement specific interventions to improve antibiotic use. Next slide.
And I think one of the big areas where we can implement these interventions is in the treatment, or the overtreatment, improving the treatment of urinary tract infections and reducing the overtreatment of asymptomatic bacteriuria. You can see from the slide there's a number of studies that demonstrate that there is a huge amount of overtreatment for positive urine cultures in hospitals. And this is work that Scott's also done quite a bit of investigation into. But you can see in this slide, 30 to 50 percent of the time in these three different studies, patients who had urinary tract infections who were getting antibiotics for urinary tract infections actually had asymptomatic bacteriuria. Next slide, please.
What's nice is that we've also seen that we can gain significant improvements here. This is a study where a hospital did a simple educational campaign on when to send and not send urine cultures, and then when to treat and not treat those positive urine cultures. And I know that all of us, when we think about interventions, we know that educational interventions are oftentimes fairly limited, they're maybe not as powerful as some of the other interventions that we have at our disposal. But this simple educational intervention resulted in a significant improvement; a decrease in the number of patients who were getting inappropriate care would be down from 31 percent to 13 percent. Just simply by helping people understand (0:22:42 inaudible). —catheter-associated urinary tract infections and antibiotic stewardship, it is an ideal combination here because your efforts at CAUTI prevention often entail things like improving urine culture practices, helping people only send cultures when there's a real suspicion of a UTI, and then sending those cultures the right way. You're working on eliminating the treatment of asymptomatic bacteriuria. And so these are goals that certainly, I think, all of you have in your CUSP: Stop CAUTI efforts, and that also does help very nicely with what your stewardship program is probably working on. Next slide.
And I think that concludes my remarks. Let me turn it over to Scott now to talk a little bit more about some of the work that we've been doing together and that he's been really leading in this arena. Scott?
Scott Flanders: Great. Thank you very much, Arjun, and hello, everyone. Glad to be with you today to talk about this particular issue. I think a lot of my comments are based on certainly our own group's experience here at the University of Michigan, but also, as Arjun alluded to, a lot of the work that we have been partnering on around the country at a variety of different hospitals trying to improve on antibiotic use, and in particular, trying to make providers a bit more mindful of antibiotic use in hospitalized patients. If I could advance my slides, which is working.
So, the first thing I will start with is why should we engage frontline providers. And I think for several reasons. I think stewardship teams working alone have a very limited reach. And Arjun already mentioned that these systems work best when they partner with frontline providers. I also think a lot of what stewardship programs perhaps initially start focusing on I've labeled as top-down initiatives, such as restricting certain antibiotics in the formulary, monitoring the data. I think that is very important, but it's only a first step. And many of the areas where we see probably the most problematic prescribing practices are really hard to spot from behind the frontlines. And examples that have already been mentioned are treatment of asymptomatic bacteriuria is a prime one, and I also think prolonged treatment duration. Many of our patients, when we think about the hospital, leave and finish their antibiotics outside the hospital, and stewardship programs rarely reach beyond the walls of the institution. And so, if patients are being treated may days too long, that may not fall under the purview of the stewardship committee, yet it's a critically important issue. And the last bullet here I think is a big one. I saw your poll and 40 percent of the attendees on this call did not have a robust stewardship program. It's great if you do to help lead some of this work, but if you don't, there still is work to be done and a lot you can do either while you are working on establishing the stewardship program, or starting with some of these early pieces.
The next slide focuses on if we're going to engage frontline providers, who should be engage. And I think there are a lot of options here. The first I identified is perhaps starting with groups where culture tends to drive practice. These are settings where you hear this is the way we do it. This is the way we do it on our service and our unit. Intensive care units are a great example. In our institution, the urology service has very well-established antibiotic use practices that just speaking to one provider is not going to change it; you need to bring the whole along. Orthopedic surgery is another. And if you can change the culture of that group, you can change the practice for all those patients. I think non-physician team members are underutilized: physician assistants, nurse practitioners, nursing. Here at the University of Michigan we use a group of people called ‘clerical assistants' that work along with our doctors and they can be participants in efforts to try and improve antibiotic use, and have been used quite effectively at many institutions. Patients, we are increasingly hearing about the engagement of patients with things such as hand hygiene. You have heard about potential opportunity to engage patients in urinary catheter use, educating them about the downsides of inappropriate urinary catheterization. I think the same holds true for antibiotics. Patients should understand what they're getting, how long they're going to get this antibiotic, and understand some of the risks of antibiotics. And the last bullet here I bolded and it's hospitalists. And I have a particular bias, I am a hospitalist. We've done a lot of work with our hospitals and with hospitals nationally. But I think it's a very important group to engage in your efforts, whether you're working on CAUTI, VTE prevention, or improving antibiotic use, I think you can leverage this group of providers very effectively.
My next slide shows why I think that. This slide shows the growth of hospitalists and hospital medicine in the United States, such that in 2013, the most recent data suggests there are over 40,000 practicing hospitalists. They're at over two thirds of U.S. hospitals and if you look at some of the largest hospitals, most have hospital medicine programs. And the good news here is at many institutions they care for a decent percentage of the hospitalized patients. So if you could change or improve the way this group utilizes urinary catheters, the way this group prescribes antibiotics, you can impact a large percentage of your hospitalized patients. I think it's important that before we start talking about (0:28:32 indiscernible) a lot of the problems with antibiotic use, I think it's important to understand, perhaps from a physician's or a provider's perspective, why we have so many problems with antibiotic overuse and what is sort of the culture of antibiotic overuse, if you will. The factors are actually quite complex. It's a lot more than just negligent behavior on the part of the prescribers. The first bullet here highlights the fact that hospitalized patients are ill and they're getting sicker. This is more and more comorbid disease that we're seeing. More and more of our patients are being treated with very aggressive immunosuppressive treatments, whether it's organ transplant, or whatever it may, their rheumatologic condition, and that predisposes many patients to very serious infections. And we do know that when someone comes into the hospital with a serious infection, that early appropriate antibiotics are lifesaving and that drives a lot of aggressive antibiotic prescribing. The second bullet is something that I've called the ‘chagrin factor,' and that's that physicians really have this strong desire to avoid the chagrin of not treating an infection. When someone comes into the hospital and often it's not clear whether they're infected or not, I think physicians by and large would rather err on the side of giving that antibiotic, and in that sense, overuse is viewed as better than underuse. And ideally, what we are looking for is appropriate use. And in many situations, it's hard to figure out what the right thing to do is, and I think physicians tend to err on the side of giving the antibiotic. I think part of that related to the next bullet, which is that physicians are very much responsible for the physician right in front of them. They want to do well by their patient. And that's why I think messages such as overprescribing is going to increase resistance in our hospital, as physicians are making individual patient decisions, that tends not to be at their forebrain, if you will. They tend to focus on their patient. If they're on the fence, they're not going to worry about a potential issue with resistance down the road; they're going to give the antibiotic. So those are, I think, some very important points for all of us to understand. That said, there is good news. You can have your cake and you can eat it too. And in fact, a lot of what we're talking about and what we think should focused on are strategies that really benefit both the individual patient, deal with this issue of giving appropriate antibiotics when someone is sick, and yet still using antibiotics appropriately and using them rationally. And those are some of the strategies I'm going to focus on.
The next slide is titled ‘Three Effective Interventions.' And, as Arjun has already mentioned and what he can speak to as well, there have been a lot of groups working on trying to figure out what are some strategies that work in hospitalized patients to improve the way we use antibiotics and the way we treat infections. And after a lot of testing, a lot of experimentation, many groups have found that the three bulleted items listed here are fairly easy strategies to implement and focus on that really facilitate more appropriate antibiotic use in hospitals. The first bullet is what we call documentation or visibility of antibiotics at the point of care. So for every patient, when you go to their chart, go the bedside, you should understand what antibiotic they're on and what is the indication for that antibiotic. You should also know what day of therapy is it. Is it day 1? Is it day 7 of that antibiotic? And what's the expected duration? We have found in many places that that's not easy information to obtain and it's a very important first step in using antibiotics wisely. The second bullet is doing a better job of defining appropriate length of treatment. Urinary tract infection, pneumonia, and skin and soft tissue infections, as I'll show you in a minute, are what we call the ‘Big Three.' And in many institutions if you look at institutional guidelines or ask doctors how long they treat, you'll get treatment durations anywhere from five days to 21 days. And sometimes institutional guidelines facilitate that by highlighting a very long range. And when that occurs, doctors tend to drift toward the longer treatment durations, thinking longer is better, and that's not necessarily the case. So defining appropriate length of treatment is an important step. And finally, this last bullet is what we call the 72 hour antibiotic timeout. Basically, stopping after a patient has been given antibiotics for a period of time. Their disease, hopefully, has improved. They're in a better situation and stopping and having providers routinely ask was it an infectious diagnosis? Do I have the right diagnosis? If so, do I have the right antibiotic? Have the cultures come back? Am I tailoring my antibiotics to the appropriate susceptibility pattern? Do I have the patient on the right dose and do I know what the right duration is for the infection that this patient has? That is a critical step, and doing all of these three things really facilitates much more appropriate antibiotic use than we've seen at many institutions. I'm going to shift now to some of my own experience here at the University of Michigan. And just between all of you on the call and myself, some of this data may be a little bit embarrassing to me and my colleagues, but hopefully we'll reassure you that if you're seeing problems with antibiotic use, you're not alone in your facilities. So, when we first started our journey to try and improve antibiotic use in our hospital, we went to try and see what are the most common infections that result in antibiotics in our institution. And we knew the literature showed that it was urinary tract infections, pneumonia, and skin and soft tissue infections, and like all academic medical centers we were skeptical if that was true at our institution. And lo and behold, that's exactly the way it panned out in our hospital, number one, two, and three were those three conditions. And I suspect at all of your institutions you would find a similar situation. So we started to focus on the top one in the list and that was urinary tract infection. And we decided to first look at testing and treatment for urinary tract infections. And what we found was nothing short of frightening here at our own institution. First of all, when we looked at patients who were having urine sent off for culture, 60 percent of patients lacked an indication for even sending the urine culture in the first place. And we know that if that's the case, that if a patient does grow something, by definition that would be asymptomatic bacteriuria that does not require antibiotic treatment. When we looked at all of our positive urine culture, we felt that only about 40 percent actually had a urinary tract infection by— what we did was a very robust adjudicated review. Twenty-five percent of patients with UTIs had inappropriate treatment duration. And as Arjun alluded to, this is a big problem with many institutions, 65 percent of our cases that we felt had asymptomatic bacteriuria resulted in antibiotics. And in a very relatively small sample, we found almost a year's worth of excess antibiotic days here at U of M. So we had a lot of opportunity to improve this. I want to ask you right now before I tell you what we did, ask you does your hospital have guidelines that describe the appropriate criteria for ordering urine cultures, so ordering them in the first place. And I'll give you a minute for the polls to tabulate. Alright, so I don't know if you're seeing the numbers tick along like I am. Oh, here's the final result. So, three quarters do not have guidelines for ordering urine cultures, a quarter do. So, we at the University of Michigan did not, when we did some of this work, have guidelines. So, we needed to start working on this problem of improving antibiotic use, in particular for urinary tract infections, but perhaps more broadly. And we decided to do the following things that are shown here on this slide. First thing was to engage our hospitalists. Our hospitalists here at the University of Michigan take care of probably just over a third of all the hospitalized adults in a very large 1,000-bed institution. So we figured if we could change what they were doing that would affect a lot of patients. We've standardized recommendations for testing, which I'll show you in a minute. We've standardized our treatment algorithms, which before we started were all over the map. There were multiple algorithms, different services did different things with variable lengths of treatment. We integrated these algorithms into our systems. And I put ‘systems' in quotes because it's not always computer systems, which is what people tend to immediately jump to when they see that word. Many of our docs carried around a lot of cards in their pockets that they referred to quickly and easily, so we had to create little pocket cards that had some of this information on it. Some carried smartphones and liked the idea of having an app, so we had to create an app that had some of our recommendations on it. We put up poster boards. We tried to implement this into computerized order sets as well. So “systems” is a very broad term, but we tried to make this easy for the doctors. We implemented a 72 hour timeout with our pharmacist to have our hospital stop, review the cultures, the antibiotics, ask if it was appropriate that they should have been on antibiotics in the first place, if not, stop them, and if it was and they had culture results, to tailor the antibiotics, and we decided to measure the impact.
The next slide shows our algorithm for testing for urinary tract infection. And you're all certainly welcome to take this, adapt this to your own institution. We've basically gathered this criteria from multiple different guidelines, as well as some mild alterations based on our own culture and experience. But basically ask does the patient have any of the following symptoms without an alternative explanation. And if the answer was ‘yes,' we recommended urine culture. And if the answer was (0:39:18 inaudible).
The next slide may be a little bit hard to read, it has small print. But basically, it includes key patient categories for urinary tract infections. And we spent a lot of time trying to be fairly rigid with respect to which antibiotic here at our institution, based on our susceptibility patterns, our (0:39:38 indiscernible) physicians opinions, and guidelines, should we be using, how long should patients be treated, and we came up with this particular algorithm here that was disseminated to all of our physicians. As I mentioned before, we did a lot of educational work. We built this into a variety of different systems. We built in the timeout. We did audit and feedback. It was a fairly aggressive intervention. And here's essentially what we found. I have two hospitals listed here because we actually did this at another hospital in addition to our own. And what we found was, overall, we were actually able to decrease the treatment of asymptomatic bacteriuria. One hospital was more successful than the other. But what I'll highlight here is while our results were statically significant, there was still a lot of room for improvement after the fact. Some of this may have to deal with the fact that we were judging asymptomatic bacteriuria based on the medical record, as opposed to talking to doctors, so doctors could not have documented symptoms, for example, which may explain where our numbers are a bit on the high side. But nevertheless, it shows how complex and challenging this problem is, and to me, highlights the need for multimodal interventions that come at this from a lot of different angles and are going to take some time to implement at your institution.
The next slide shows our efforts to improve documentation. So we basically asked our doctors to document the indication for the antibiotic, the day of therapy the patient was on, and how long the patient was supposed to be treated with their antibiotics. And we measured how often this occurred at the outset. And what you see in the blue bars is prior to any interventions, we looked at our discharge summaries, our progress notes, our service sign-outs when one doctor was handing off to another. Rarely did we see all three of those elements. We educated our physicians and we did another interesting thing. We have an incentive program here that affects how our doctors get paid, and every year we have the ability to focus on a particular quality intervention and we focused on antibiotic use. And we rolled this goal into that incentive program. And you can see, when money is at stake, people tend to behave a little bit differently and there were some dramatic improvements we saw on our documentation. Again, it is not perfect across the board, but dramatic improvements. And while I can't say this absolutely led to more appropriate antibiotic use, it's a very important first step. Knowing what someone is getting and what is intended to be done is the first step before you can correct that behavior. We also had some fairly impressive results with our 72-hour timeout that we did with pharmacists. We did this on a Monday, Wednesday, and Friday. The pharmacists were already routinely meeting with our hospitalists to talk about anticoagulation dosing, dosing of antibiotics in renal failure and dialysis patients, and we added this onto that meeting. And it worked quite successfully. You can see in the pie chart to the left, that shows what happened during the antibiotic timeouts. And in 25 percent of cases, the little pink slice, an intervention happens that would not have happened otherwise. And the pie chart to the right shows what the subset of effects were essentially. And interestingly, about a quarter of those interventions were completely stopping all antibiotics at 72 hours. And this was not happening prior to this timeout. So, something as simple as stopping three days after you've started an antibiotic and thinking through it, a forced stop, led to some fairly significant and impressive results at our institution. So, that's what we've been working on here.
And I think I want to highlight in my last couple of slides the key barriers and facilitators. And I suspect many of these will be relevant and familiar to you in your work with CAUTI, and will resonate with you. This is from our own experience, as well as the experience of a lot of hospitals around the country. As we've tried to do some of this work, I think we run into a lot of real-world barriers that you're going to have to work through. Large groups of doctors either putting in urinary catheters or prescribing antibiotics, multiple groups, make communication very difficult. Even just working with hospitalists, one hospital may have four hospital medicine groups. One or two of those groups may be doing everything you want them to, the others may not. We see a lot of poor continuity in handoffs. So patients get handed off from group of doctors to another, or from doctor to doctor, and often what gets put in place with doctor number one, which may be what you desired, doesn't carry over to doctor number two. Trying to engage nurses is very challenging. Our nurses are overwhelmed. A lot of what is being asked with respect to documentation, quality, fall risk, urinary catheter appropriateness, falls onto nurses. So merely dumping another initiative onto the back of our nursing staff is unlikely to lead to meaningful change. And most institutions that have tried it that way have met resistance. We see very high patient loads for providers, nurses, physicians. That's a barrier. IT systems, many people put this in the plus column in terms of facilitating this work. I would say I've seen just as many institutions struggle because they normally would print out a new order form, but to have it put into their IT system takes 6 to 9 months for someone to get around to prioritizing this. And the last bullet, another darn QI project. If all of this is billed as just another QI intervention, I think a lot of our staff are very much overwhelmed and there are better strategies. How do you get around some of these barriers, the facilitators? Many of you have probably experienced these strategies in dealing with your CAUTI work. My advice is start small and build. We often emphasize start working with one provider, one patient, on one day. Maybe it's a little bit broader than that, it's one unit, one small group of providers. But work with these individuals before you go big, create a process that works, and importantly, integrate it into the existing systems. Don't build a new system, don't add it on. Find out how people work, what their workflow is, and work with them to say how can we integrate this into this so this is not an additional task you have to do. If you focus that way, you're able to do this relatively seamlessly and without a lot of resistance. And I think you spent a lot of time working on CUSP, learning about CUSP and trying to work on improving your safety culture. Changing culture is not an easy thing to do. When we talk about antibiotic use, and stewardship programs, and trying to facilitate more appropriate use, it is not uncommon to have physicians say I really don't want to be told what to do with my antibiotics. That may be true with respect to the urinary catheter; I want you to tell me that the patient needs this urinary catheter out. It's a common issue. And as I am sure some of you are aware, there are ways around this. And I think we are having some success changing the culture in our hospitals as we work on CAUTI and some of these other problems. With respect to antibiotic use, we've been very successful by finding a champion. In our institution we work very closely with our infectious disease doctors. Many groups don't necessarily have infectious disease doctors in their hospitals and they work with chief medical officers, chief quality officers, a variety of different people. Partnering those individuals with a frontline provider has been very successful. I think having an institutional leader that supports your work, whether that's CAUTI or improving antibiotic use, you have to have someone that says, “I support that work and I think it's important,” to go to to help you work through some barriers you're going to encounter. I'm a big fan of winning your first battle, all the more reason to start small and focus in something that's winnable, because people will follow a winner. They tend not to follow someone who has an initial failure. So think about what you want to try to tackle first and do your best to win it. Then celebrate your successes, sell it, highlight what you're doing, because your goal is to make your new process the new norm. We have been somewhat successful by trying to do that through incentives. We highlight people with awards we give out for good work with this. Creating competition amongst different units, different groups of providers, sometimes that can be fun competition. That's been a successful strategy as well. So all of these things are potential tools you could use that many of you may have used some of these in your CAUTI work, that can be leveraged for antimicrobial use work as well. So that is all the formal comments I have and I think that Arjun has. I think we have our ten minutes left, and maybe, Ashley, I'll turn it over to you to facilitate the questions.
Ashley Hofmann: Yeah, great. Thank you so much for sharing this information about antibiotic stewardship, both at the national level, and then also the journey you've had at the University of Michigan. So now we're just going to open up the call to questions from the audience. Operator, can you begin the Q&A session, please?
Operator: Yes, ma'am. At this time we will open the floor for questions. If you would like to ask a question, please press the ‘star' key followed by the ‘1' key on your touchtone phone now. Questions will be taken in the order in which they are received. If at any time you would like to remove yourself from the questioning queue, just press ‘star 2.' Please try to limit your questions to one at a time. Again, to ask a question, please press ‘star 1.' We're currently holding for questions at this time. Oh, actually, okay. Our first question comes from Barbara Lucas.
Barbara Lucas: Hi, I had a question for Scott in regard to your algorithm with the indications for a urine culture. Can you tell me if, when you presented that algorithm, if you recommended doing a stepwise approach starting with looking at the UA first, and then follow up with a culture if the UA is suggestive of an infection?
Scott Flanders: Yeah, that's a great question. We are moving toward that now, but at the time we put this algorithm in place, we did not. It was recommended for both the UA and urine culture for us to take a look at that in greater detail. But now, our current algorithm does include looking at the UA first, and if abnormal, ordering a culture, if not, stopping there.
Barbara Lucas: Great, thank you.
Operator: Okay, again, to ask a question, please press the ‘star 1.' We're currently holding for questions.
Ashley Hofmann: This is Ashley. While we're waiting for questions, I do have a question for Dr. Flanders as well. Have you heard of any other hospitals in the area that are also implementing this and have they had the same kind of successes that you have had? Or what are their barriers? Are they different by geography, or what are some of the other issues?
Scott Flanders: Yeah, good questions. Yeah, I only showed you data, for the most part, from our institution. But Arjun was involved with a project as well where we worked with five different hospital medicine groups around the country. And most of those groups were able to achieve results that were not dissimilar to our results that I've showed you here. The barriers at each institution are unique and I largely used that experience to compile the barriers that I showed you on my slide. So those barriers were not all unique to my own institution here. Those were the types of barriers we saw at the five hospitals where we did this work. So yes, there are many other institutions that have been able to implement these things. And largely, we tested this out to make sure it wasn't just unique to one institution that was able to do this, but that some of these strategies were generalizable to very diverse institutions. And this was everything from the large academic medical center like ours to the small community hospital. And were able to do this to a variable degree.
Operator: Okay, we have a question in the queue from Robin McElligott.
Robin McElligott: Just wondering what phone application you used.
Scott Flanders: Yeah, it wasn't a phone application. We have one of our physicians that's very savvy at producing apps for smartphones and created his own app that our faculty was able to download. You could not ask me how it works, how to do it, because I have no idea. And you can't have him because he is ours.
Robin McElligott: Thank you.
Operator: Our next question comes from Tammy Crawford.
Tammy Crawford: Yes, I was wondering if in your algorithms anywhere, or if these play into how long or if you start an antibiotic, the lab lactate and your procalcitonin, if you ever run those levels.
Scott Flanders: Yeah, well specific to urinary tract infections, I don't think there's good data on procalcitonin and whether it's elevated, and how to use it in urinary tract infections. We just started using procalcitonin within the last year here at the University of Michigan, largely for respiratory tract infections. And we're a bit early in our experience, so I can't tell you. Yes, we are taking a look to see how it impacts our antibiotic use, but from the information I showed you today, none of that involved procalcitonin in our algorithm. I don't know, Arjun, if you have any additional comments on procalcitonin.
Arjun Srinivasan: Just to reiterate what you said, I'm not aware of any data looking at procalcitonin in urinary tract infections. And also to mention that a lot of the experience with procalcitonin has suggested that the research studies make it look very good, like for respiratory infections and for ICU infections. But when people just bring the tests online in their hospital, what they find is that it's actually not very helpful, it doesn't really lead to reductions in antibiotic use. And I think the take-home message is that the procalcitonin is a useful tool if it's in the hands of a stewardship program and a stewardship effort where they're really working collaboratively to use the procalcitonin as an additional piece of information to try and stop antibiotics. But if you just bring the lab test on and let people order it, what you'll find is that people order the procalcitonin and then basically ignore the procalcitonin.
Tammy Crawford: Okay, thank you.
Operator: Again, if you'd like to ask a question, please press ‘star 1.' We're currently holding for questions.
Ashley Hofmann: While we're waiting here I do want to make a little plug for our evaluation. At the end of today's call if you could all take a moment to fill out an evaluation of today's webinar. We do appreciate your feedback about the content and the speakers. I'm going to put that web link in the chat on the left side of your screen. You'll be able to click the web link and open it up. (0:56:29 Inaudible) after the webinar today. We'll also have a recording and slides posted to the website so you can access some of those algorithms that Dr. Flanders talked about as well.
Operator: We currently have no questions in the queue at this time.
Ashley Hofmann: Okay. Any last comments about the presentation today, Dr. Flanders or Dr. Srinivasan?
Arjun Srinivasan: None from me. I'll just mention that we're certainly eager to help folks in any way we can with efforts both on antibiotic use and on your CAUTI prevention effort. Please don't hesitate to contact me if there's anything we can do to help or any questions you might have.
Scott Flanders: Yeah, I'd second that. I think this is important work, very complementary to your CAUTI work, and worth trying to tackle and get your hands around. So thank you for joining the call.
Ashley Hofmann: And this is just a quick preview of upcoming calls that we have. Next month, the content call is on June 10 at noon Eastern Time and it will feature Dr. David (0:57:52 indiscernible) from the University of Pennsylvania Health System and Dr. Greg Kennedy from the University of Wisconsin School of Medicine and Public Health. And they will be presenting on procedural-related catheter use. So we hope to see you then on that call. And we will give you one minute back of your day. Thank you, everyone, for joining us.
# # # #
Page originally created November 2015