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

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

Mohamad Fakih, MD, MPH
Medical Director, Infection Prevention and Control
St John Hospital and Medical Center
Professor of Medicine,
Wayne State University School of Medicine
Detroit, MI

Pat Posa, RN, BSN, MSA, FAAN
System Performance Improvement Leader
St. Joseph Mercy Hospital

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Additional Presenters

William Miles, MD, FACS, FCCM, FAPWCA
Director of Surgical Critical Care
Clinical Professor of Surgery
University of North Carolina, Chapel Hill-Charlotte Campus
Carolinas Medical Center

Surgical Trauma ICU
Misty Wheeler, RN, NE-BC, CCRN
Lacey Spangler, RN, BSN, RN, CCRN

Neurosurgical ICU
Julia Retelski, MSN, RN, CCRN, SCRN, CCNS

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Improving the Culture of Culturing (aka, Culturing Stewardship)

Mohamad Fakih, MD, MPH
Medical Director, Infection Prevention and Control
St John Hospital and Medical Center
Professor of Medicine
Wayne State University School of Medicine
Detroit, MI

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Polling #1

A 45 year old male who is an active intravenous drug user is admitted with fever of 103°F, confusion and respiratory distress. The patient is intubated and admitted to the intensive care unit; the CXR shows multiple pulmonary emboli and the blood cultures grow methicillin resistant Staphylococcus aureus. On day 3, he is still febrile with a temperature of 101.8°F. His blood cultures are still growing gram-positive cocci and the patient has a urinary catheter since intensive care unit admission.

  1. Urine culture
  2. No urine culture
  3. N/A – HRET Staff

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Polling #2

A 73 year old patient with prostatic hypertrophy was admitted to the hospital with abdominal discomfort. On admission, he was afebrile with normal vital signs and blood white cell count. A bladder scan showed a significantly distended urinary bladder. A urinary catheter was placed and 1200 ml of urine was drained. His abdominal pain improved and he did not complain of any respiratory symptoms. The patient spiked a fever of 102°F the next day. His blood pressure was 100 systolic and heart rate 110.

  1. Urine culture
  2. No urine culture
  3. N/A – HRET Staff

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Clinical Evaluation

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

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Bacteriuria with Catheter Use
(Garibaldi et al, Infect Control 1982; 3: 466-70)

Daily bacteriologic monitoring of 1140 cases:

  • Bacteriuria at insertion: 99/1,140 (8.7%) catheterizations
  • 1,041 had no colonization at insertion, 433 removed within 24 hours
  • Of 608 catheterizations >24 hours, 76 (12.5%) developed bacteriuria
  • Risk of bacteriuria was 3% per catheter-day

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Image: Diagram of the routes of entry of uropathogens to catheterized urinary tract. Source is Maki and Tambyah, Emerg Infect Dis 2001;7:1-6.

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Catheter Associated Bacteriuria in ICU
(Clec’h et al, Infect Control Hosp Epidemiol 2007;28:1367-73)

  • 12 ICUs: weekly urine cultures or if symptoms in catheterized patients
  • CAUTI defined as urine culture >103 CFU/ml
  • CAUTI (bacteriuria) rate= 12.9/1000 catheter-days
  • Median time to CAUTI 11 days (range 6-19 days)
  • Median ICU LOS longer for those with CAUTI (28 days) vs. those without (7 days)

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Common Inappropriate Triggers For Urine Culture In Patients With Urinary Catheters

  • Urine color, consistency and smell
  • Pyuria

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Resident Physicians (N=106) and Nurses (N=159): Triggers For Cultures In Catheterized Patients
(Sibai et al, ID Week 2013, presentation 205)

Trigger for Urine Culture Resident Physicians (Answered Yes) Nurses (Answered Yes)
Foul smelling urine 75 (70.8%) 146 (94.8%)
Cloudy urine 84 (79.2%) 146 (94.8%)
Sediments in urine 57 (53.8%) 129 (84.3%)
Darker urine 39 (36.8%) 72 (47.7%)
Chronic UC on admission 46 (43.4%) 115 (74.2%)

All of the above should NOT trigger a urine culture in catheterized patients!

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Resident Physicians and Pyuria: Obtain A Urine Culture In Catheterized Patients
(Sibai et al, ID Week 2013, presentation 205)

Trigger for Urine Culture Answered Yes
Urine WBC 25 cells 71 (67%)
Urine WBC 100 cells 94 (88.7%)
Urine WBC 500 cells 101 (95.3%)

Pyuria in an asymptomatic patient with an indwelling urinary catheter should not be a trigger for culture or antimicrobials

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Pyuria Is Not Diagnostic Of CAUTI
(Hooton, Clin Infect Dis 2010; 50:625–663)

  • Pyuria does NOT help differentiate asymptomatic bacteriuria from CAUTI
  • Pyuria + bacteria CAUTI

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Pyuria and Bacteriuria
(Tambyah, Arch Intern Med. 2000;160:673-677)

  • 761 patients with newly inserted catheters, 10.8% developed bacteriuria or candiduria
  • Defined bacteriuria as >103 CFUs.
  • Women had more bacteriuria (21.2%) than men (7.2%)

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Pyuria and Bacteriuria
(Tambyah, Arch Intern Med. 2000;160:673-677)

Pyuria more common with bacteriuria related to gram negatives than gram positives or funguria.

Image: Screen shot of Table 2 from article titled: Urine White Blood Cell Counts in Hospitalized Patients with Catheters.

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Pyuria and Bacteriuria
(Tambyah, Arch Intern Med. 2000;160:673-677)

Pyuria cannot predict bacteriuria

Image: Screen shot of Table 3 from article titled: Utility of Pyuria for the Diagnosis of CAUTI*.

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Absence of Pyuria
(Hooton, Clin Infect Dis 2010; 50:625–663)

  • IDSA guidelines:“The absence of pyuria in a symptomatic patient suggests a diagnosis other than CA-UTI”

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Color or Odor
(Hooton, Clin Infect Dis 2010; 50:625–663)

  • IDSA guidelines: “In the catheterized patient, the presence or absence of odorous or cloudy urine alone should not be used to differentiate CA-ASB from CA-UTI or as an indication for urine culture or antimicrobial therapy.”

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Screening Urine Cultures!!

The practice: “screening culture on admission”, “standing orders” or “reflex orders” for urine cultures based on urinalysis results

  1. May not help the hospital avoid non-reimbursement
  2. May increase utilization of additional resources (testing, antibiotics, consults)
  3. May adversely affect patients by exposing them to inappropriate testing and treatments

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Pre-Printed Orders: Foley Catheter Protocol

Image: Screen shot of a catheter protocol or order. it describes the where a urinalysis is not appropropriate.

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Pre-Printed Orders: Foley Catheter Protocol

Image: Screen shot of a catheter protocol or order. it describes the where a urinalysis is not appropropriate.

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How to Reduce Unnecessary Urine Cultures

  1. Evaluate current processes for obtaining urine cultures (avoid automatic triggers or screening cultures with no appropriate indications)
  2. Evaluate practice patterns (avoid PAN culturing)\
  3. Provide education on when it is appropriate to obtain urine cultures

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How to Reduce Unnecessary Urine Cultures

  1. Have periodic audits on urine culture use in the intensive care units to look for trends
  2. Promote appropriate urinary catheter use to reduce risk of bacteriuria/ funguria

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Discourage Urine Culture Use

  • Urine quality: color, smell, sediments, turbidity (do not constitute signs of infection).
  • Screening urine cultures (whether on admission or before non-urologic surgeries).
  • Standing orders for urinanalysis or urine cultures without an appropriate indication.
  • "PAN" culturing (mindfulness in evaluating source is key).
  • Obtaining urine cultures based on pyuria in an asymptomatic patient.
  • Asymptomatic elderly and diabetics (high prevalence of asymptomatic bacteriuria)
  • Repeat urine culture to document clearing of bactereriuria (no clinical benefits to patients).

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Appropriate Urine Culture Use

  • Part of an evaluation of sepsis without a clear source (CAUTI is often a diagnosis by exclusion).
  • Based on local findings suggestive of CAUTI (example, pelvic discomfort or flank pain).
  • Prior to urologic surgeries where mucosal bleeding anticipated or transurethral resection of prostate.
  • Early pregnancy (avoid urinary catheters if possible).

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Key Points Related to Obtaining Urine Cultures

  • Make sure clinicians are aware of the appropriate indications to obtain urine cultures.
  • Point out the risk of indiscriminate urine culture use on patient outcomes.
  • Address the local "culture" or practice of clinicians at your institution to align with optimal patient care.
  • Avoid ordering cultures without a clinical assessment of the patient's condition.

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Culturing Stewardship and Other Preventative Measures: Large Hospital ICUs

Image: Bar chart titled "CAUTI SIR for 50 Adult ICU Beds". Dates shown are from July-Sep. 2013 to Oct-Dec 2014. There are data points where there are arrows. The first is where there is a spike in cases due to an influenza epdemic. The next data point it says "ICU team only responsible for urine culture ordering". The last 2 data points show much lower rates.

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Antibiotic Stewardship in the ICU

William Miles, MD, FACS, FCCM, FAPWCA
Director of Surgical Critical Care
Clinical Professor of Surgery
University of North Carolina, Chapel Hill-Charlotte Campus
Carolinas Medical Center

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Disclosures

Nothing to disclose

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Antibiotic Stewardship in the ICU

Some Points to Consider

  • Resistance to antibiotics exists in nature before medicine actually discovers or uses them
  • Antibiotics have societal impacts
  • Pressure from antibiotic mismanagement forces significant resistance
  • 70% of antibiotics in America go to food production

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Antibiotic Stewardship in the ICU

Antimicrobial Treatment Considerations

  • Must be timely: any delay in starting them increases mortality significantly
  • Appropriate: must cover spectrum of pathogens
  • Pharmacokinetics: adequate dose and intervals
  • Narrowing and Discontinuation: based on clinical data, ICU microbiology data, and clinical response

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Antibiotic Stewardship

Image: Bar chart showing the importance of initial, appropriate antibiotic therapy. The chart compares all-cause mortality and infection-related mortality, which is much higher then when inadequate antimicrobial treatment is used, compared to adequate antimicrobial treatment.

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Antibiotic Stewardship in the ICU

Novel Antibiotic Development

  • 1980’s: 16 new antibiotics released
  • 1990’s: 10 new antibiotics released
  • 2000’s: 5 new antibiotics released
  • 2008-2012: ONLY 1 new antibiotic developed!

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Antibiotic Stewardship in the ICU

What is Antimicrobial Stewardship

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

Dellit T et al Clin Infect Dis 2007;44:159

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Antibiotic Stewardship

  • IDSA
  • Joint Commission
  • CMS-California mandate
  • CDC
  • Physician Leadership Forum
  • ATS/ACCP/SCCM

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Antibiotic Stewardship in the ICU

Goals of Antibiotic Stewardship

Image: Diagram showing interactions of goals. Combat the Emergence of Resistance leading to Control Costs leading to Improve Clinical Outcomes which lead back to the first goal.

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Antibiotic Stewardship in the ICU

Stewardship Strategies

Patient Evaluation → Education/Guidelines

Choice of Antimicrobial → Formulary Restrictions

Prescription Ordering and Dispensing Antimicrobial ← Computer assisted strategies

Review and Feedback-includes all

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Antibiotic Stewardship in the ICU

Economic Considerations for Antibiotic Stewardship

  • Antibiotic use restriction and costs should not be the only focus
  • Antibiotic costs are a small percentage of treatment costs
  • Costs from hospital LOS, total Healthcare costs and Infection Prevention should be considered
  • Patients’ Quality and return to a functional life

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Antibiotic Stewardship in the ICU

Prescribing Antibiotics

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

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Antibiotic Stewardship in the ICU

  • Antimicrobial Stewardship Principles important
  • Utilize Pharm D, Infection Preventionist
  • Prevent MDROs

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Antibiotics in UTI

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

http://www.hopkinsmedicine.org/amp/guidelines/Antibiotic_guidelines.pdf-2015S

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Duration UTI Treatment

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

http://www.hopkinsmedicine.org/amp/guidelines/Antibiotic_guidelines.pdf-2015S

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Treatment Notes UTI

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

http://www.hopkinsmedicine.org/amp/guidelines/Antibiotic_guidelines.pdf-2015S

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Antibiotic Stewardship

Must coincide with Infection Control/Prevention

  • Prevention:
    • Optimal management of urinary catheters
  • Control:
    • Hand hygiene
    • Contact precautions
    • Active surveillance
    • Education
    • Environmental Cleaning Standards
    • Improved Communication between Facilities

www.cdc.gov

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As The Wheels Turn

Image: Diagram showing different star shapes surrounding a center star with the words Antibiotic Stewardship. Surrounding the center star are stars with the words Micro Lab, Providers, Infection Control, QI/QA, and Pharmacy.

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Multi-Drug Resistant Organisms

  • CRE
  • MRSA
  • C Diff Colitis
  • All possible in ICU management and prolonged urinary catheter and long term antibiotic use
  • Antibiotic stewardship and Urinary Catheter removal protocols are essential tools for prevention of MDROs

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Antibiotic Stewardship

Image: Screen shot from a table of an antimicrobial stewardship program's impact with rapid PCR blood culture testing. Taken from the article titled 'An Antimicrobial Stewardship Program's Impact with Rapid Polymerase Chain Reaction Methicillin-Resistant Staphylococcus aureus/S. aureus Blood Culture Test in Patients with S. aureus Bacteremia".

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Practical Implementation of Antibiotic Stewardship

2 ICUs Work In Implementing Antibiotic Stewardship And Appropriate Urinary Culturing

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Practical Implementation of Proper Culturing: 2 ICUs Experience

Surgical Trauma ICU
Misty Wheeler, RN, NE-BC, CCRN
Lacey Spangler, RN, BSN, RN, CCRN

Neurosurgical ICU
Julia Retelski, MSN, RN, CCRN, SCRN, CCNS

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Carolinas Medical Center Surgical Trauma ICU

  • Carolinas Medical Center is part of Carolinas HealthCare System in Charlotte, NC
  • 874 licensed beds, quaternary referral hospital
  • Level 1 Trauma Center, Largest  teaching hospital in NC

Surgical-Trauma ICU
Neurosurgical ICU

  • 29 bed multispecialty trauma and surgical unit including transplant and immunotherapy patients
  • 29 bed multispecialty Neurology and Neurosurgical unit

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Surgical-Trauma ICU CAUTI Reduction 2014-2015

Image: Line chart showing the CAUTI reduction in a surgical-trauma ICU from 2014-2015.

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NSICU CAUTI Reduction 2014-2015

Image: Line chart showing the relationship between number of urine cultures sent to lab and CAUTI rate by month 2014-2015.

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ICU Urine Culture Initiatives

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

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Antibiotic Stewardship

Conclusions

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

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Antibiotic Stewardship andProper Culturing

  • They go hand in hand
  • Synergy with Teamwork
  • With team effort and following CUSP CAUTI Policies and Guidelines can be achieved

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Safety Culture: Interpreting the Results

Pat Posa, RN, BSN, MSA, FAAN
System Performance Improvement Leader
St. Joseph Mercy Hospital

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What Is A Culture?

Represents a set of shared attitudes, values, goals, practices and behaviors that makes one until distinct from the next.

Unspoken, implicit, taken for granted

Largely invisible

Measure culture at the unit level

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Institute of Medicine

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

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A Positive Safety of Culture

…..recognizes the inevitability of error and proactively seeks to identify latent threats

Nieva, VF Qual Saf Health Care 2003;12(suppl)

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Chaos, Culture, and Predictability

  • Improve predictability = less chaos = better safety:
    • Standardized interactions, checklists, familiarity
  • Reduce predictability = more chaos = worse safety:
    • New Manager, New Location, New Technology

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Why Measure Unit Culture?

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

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Survey Action Planning

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

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Safety Culture Drill Down

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

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Changing the Culture Related to CAUTI

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

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Teamwork Climate is the Consensus of Frontline Caregiver Assessments Related to Collaboration

Example Teamwork Climate Scale Items:

  • In this clinical area, it is difficult to speak up if I perceive a problem with patient care
  • Disagreements in this clinical area are resolved appropriately (i.e. not who is right, but what is best for the patient)
  • The physicians and nurses here work together as a well-coordinated team

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Safety Culture Debriefing

  • Review results with staff
  • One strategy is to focus on:
    • 5 areas with the most positive results
    • 5 areas with the most opportunities

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Summarize 5 Most Positive

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

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Summarize 5 Least Positive

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

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Summarize 5 Least Positive

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

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Evidence Based Local Solutions: Teamwork “If-Then”

  • If staffing levels inadequate/info lost at shift change:
    • Then Morning/Shift Briefings
  • If interdisciplinary patient management issues:
    • Then Daily Goals
  • If conflicts unresolved/role clarity lacking:
    • Then Shadowing Exercise
  • If difficulty speaking up:
    • Then standardizing with SBAR or Critical Language

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Evidence Based Local Solutions: Safety “If-Then”

  • If staff lack consensus about quality and safety issues?
    • Then educate on the science of safety
  • If staff feel unengaged in safety and quality?
    • Then build grassroots with Learning from Defects
  • If staff feel unengaged, unsafe, & unresourced for quality?
    • Then build infrastructure & capacity with Psychological Safety and Executive Partnerships

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Thank you!

Questions?

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Funding

Prepared by the Health Research & Educational Trust of the American Hospital Association with contract funding provided by the Agency for Healthcare Research and Quality through the contract, “National Implementation of Comprehensive Unit-based Safety Program (CUSP) to Reduce Catheter-Associated Urinary Tract Infection (CAUTI), project number HHSA290201000025I/HHSA29032001T, Task Order #1.”

Return to CAUTI Toolkit Information for Specialty Audiences Page

Page last reviewed December 2017
Page originally created December 2015
Internet Citation: Urine Culture Practices in the ICU; Antibiotic Stewardship; Practical ICU Tools; Using Results from the Safety Culture Surveys. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/urine-culture-practices-icu-slides.html