how can facilities implement a stewardship and cauti
TRANSCRIPT
9/1/2018
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HOW CAN FACILITIES
IMPLEMENT A STEWARDSHIP AND CAUTI REDUCTION
PROGRAM?
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NADONA
How can Facilities Implement a Stewardship and CAUTI Reduction
Program?
Cindy Fronning RN-BC, CDONA,
FACDONA, RAC-CT, IP-BC, AS-BC
Director of Education
NADONA
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NADONA
Penicillin
Sulfa
Bactrim
1.0 Contact Hours Participants must complete entire activity. No partial credit will be awarded Participants must submit a post event evaluation form
This CNE activity has been jointly provided by Terri
Goodman & Associates collaboratively with NADONA
Terri Goodman & Associates is an approved provider of continuing nursing education by the Texas Nurses Association - Approver, an accredited approver by the American Nurses Credentialing Center’s commission
AccreditationThis activity is provided through an unrestricted educational grant from Ocean Spray.
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Disclosures
• Cindy has no relationships with
commercial entities related to the
healthcare industry.
• Cindy is the Director of Education for
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Objectives
The participant will be able to:
1. Describe how facilities can implement a Stewardship and CAUTI reduction program
2. Explain the need for an interprofessional team to
collaborate on a facility Antibiotic Stewardship Program
3. Identify proper communication mechanisms to
breakdown communication barriers
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Penicillin
Sulfa
Bactrim 6
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Focus on CAUTIReduction
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Goal
• Reduce:
– Complications
– CAUTIs (Catheter Associated UTIs)
– Unnecessary Catheters
– Costs
– Mortality and Morbidity
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Key Implementation Steps
• Identify Champions and gather a team
• Conduct a readiness assessment
• Plan for implementation
• Introduce new policies and procedure to
staff
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Insertion of Catheters• Eliminate unnecessary insertion
• Provider indication for insertion
• Medically necessary (Survey)
• Urinary retention that cannot be treated or corrected
medically or surgically, for which alternative therapy is
not feasible, and which is characterized by:
– Documented post void residual (PVR) volumes
in a range over 200 milliliters (ml);
– Inability to manage the retention/incontinence
with intermittent catheterization;
• Persistent overflow incontinence, symptomatic
infections, and/or renal dysfunction.
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Provider Indications cont.• Medically necessary cont.
• Contamination of Stage III or IV pressure ulcers with urine
which has impeded healing, despite appropriate personal
care for the incontinence;
• Terminal illness or severe impairment, which makes
positioning or clothing changes uncomfortable, or which is
associated with intractable pain.
QM = Neuro-genic Bladder
Obstructive Uropathy
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Insertion of Catheters cont.
• Consider Alternatives
• External catheter for men
• Programmed toileting
• Intermittent (“in-and-out” or “straight”)
catheterization;
• Suprapubic catheter
• Practice Aseptic technique
• Hand Hygiene
• Skin and Site AntisepsisNADONA
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Care and Removal• Timely discontinuation of unnecessary
indwelling catheters
• Regular Assessment
• Automated Reminders
• Adherence to Aseptic Technique
• Nurse-driven protocol
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Building aCoalition
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Antibiotic Stewardship is a Team Sport• Administrators
• Medical Directors
• Prescribers
• Consulting Pharmacists
• Director of Nursing
• Infection Preventionists
• Medical Laboratory Leaders
• Resident
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Create an Understanding that Physicians:• Play a significant role in shaping the care in the
facility
• Tend to be fairly autonomous; may not be employed by the facility
• Are primarily interested in treating illness –typically not trained to focus on improving safety and preventing harm
• Are likely unaware of safety efforts in the facility; most have limited time to volunteer for supporting the safety agenda
• May not readily embrace changeNADONA
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How to Engage Physicians and Providers
1. Develop a common purpose (patient safety, efficiency) show them statistics on their residents
2. View physicians as partners (not barriers) Be prepared – thus earn respect
3. Identify physician champions early
4. Standardize evidence-based processes – This is a part of your ICPC and Antibiotic Stewardship plan
5. Provide support from leadership for the efforts of the physician champion NADONA
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How to Engage Nurses1. Develop a common purpose (patient safety)
2. View nurses as partners (not barriers)
3. Identify nurse champions early
4. Standardize evidence-based processes (and make the right thing to do, the easy thing to do)
5. Provide support from leadership for the efforts of the nursechampion
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Collaboration Yields Success
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Infection Preventionists Case Managers
• Reduce CAUTI
• Reduce antibiotic use
• Reduce potential of
increased resistance and
Clostridium difficile disease
Less complication ( mechanical
or infectious) = lower costs
Nurse Educator/Unit
Manger/DON
Physical Therapists
Leader and supporter to the bedside
nurse
Makes appropriate urinary catheter
use a priority and a safety issue
Helps to address any barriers
encountered by the bedside nurse
The urinary catheter reduces mobility in
patients: “one-point restraint”
Rapid recovery (Improvement in
ambulation) may be hampered by the
catheter
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Communication
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Communication Vehicles• Suspected Urinary Tract Infection (UTI-
SBAR):
– Situation
– Background
– Assessment
– Recommendation
• Helps guide communications between nursing home staff and prescribingclinicians -
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Situation
• Who you are and unit
• Resident’s Name
• Reason for contacting the Provider
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Background• Provide a comprehensive but focused
background on the resident’s pertinent medical history
• Mention any key comorbidities
• Share other concerns
• Current catheter
• Dialysis
• Incontinence
• Medication Allergies
• Coumadin usageNADONA
Assessment• Provide your clinical assessment based on
objective facts and clinical observation• Fever• New back /flank pain
• Acute pain
• Shaking/ Chills
• Change in Mental status
• Hypotension
• Review the current medication listing
• Assess for potential antibiotic-related adverse events
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Recommendation
• State your recommendation to theprovider
• Ask for clarification on any furtherdetails
• Document the discussion and repeat back any orders given
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AHRQ
SBAR
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AHRQ
SBARcont.
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McGeer’s
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Table 5. Gastrointestinal Tract Infection (GITI) Surveillance Definitions
Syndrome Criteria Selected Comments*
Gastroenteritis Must fulfill at least 1 criteria.
□ Diarrhea: ≥ 3 liquid or watery stools above what is normal for the resident within 24 h
□ Vomiting: ≥ 2 episodes in 24 h
□ Both of the following sign or symptom
□ Stool specimen positive for a pathogen (e.g., Salmonella, Shigella, E coli O157:H7,
Campylobacter species, rotavirus)
□ At least one of the following criteria
□ Nausea
□ Vomiting
□ Abdominal pain or tenderness
□ Diarrhea
• Exclude non-infectious causes of symptoms such as new medications causing diarrhea,
nausea, or vomiting or diarrhea resulting from initiation of new enteral feeding
• Presence of new GI symptoms in a single resident may prompt enhanced surveillance for
additional cases
• In the presence of an outbreak, stool specimens should be sent to confirm the presence of
norovirus or other pathogens (e.g., rotavirus, E coli O157:H7)
Norovirus
gastroenteritis
Must fulfill both 1 AND 2.
□ 1. At least one of the following criteria
□ Diarrhea: ≥ 3 liquid or watery stools above what is normal for the resident within 24 h
□ Vomiting: ≥ 2 episodes in 24 h
□ 2. A stool specimen positive for norovirus detected by electron microscopy, enzyme immunoassay,
or molecular diagnostic testing
• In the absence of lab confirmation, a norovirus gastroenteritis outbreak (≥ 2 cases in a LTCF)
may be assumed if all of the Kaplan Criteria are present
o Vomiting in >50% of affected persons
o A mean or median incubation period of 24-48 h
o A mean or median duration of illness of 12-60 h, and
o No bacterial pathogen is identified in stool culture
Clostridium difficile
infection
Must fulfill 1 AND 2.
□ 1. At least one of the following criteria
□ Diarrhea: ≥ 3 liquid or watery stools above what is normal for the resident within 24 h
□ Presence of toxic megacolon (radiologic finding of abnormal large bowel dilatation)
□ 2. At least one of the following diagnostic criteria
□ Stool sample positive for C difficile toxin A or B, or detection of toxin-producing C difficile by
culture or PCR in stool sample
□ Pseudomembranous colitis identified in endoscopic exam, surgery, or histopathologic exam of
biopsy specimen
• Individual previously infected with C difficile may continue to be colonized even after symptoms
resolve
• In the setting of an outbreak of GI infection, individuals could be C difficile toxin positive
because of ongoing colonization and also be
co-infected with another pathogen. Other surveillance criteria should be used to differentiate
between infections in this scenario
□ GITI criteria met □ GITI criteria
NOT met
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Antibiotic
Stewardship
Goals
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Six Goals of Antibiotic Stewardship
Programs1. Reduce antibiotic consumption and inappropriate
use
2. Reduce Clostridium difficile infections
3. Improve patient outcomes4. Increase adherence/utilization of
treatment guidelines5. Reduce adverse drug events
6. Decrease or limit antibiotic resistance– Hardest to show
– Best data for health-care associated gram negative organisms
Tamma PD, Cosgrove SE. Infect Dis Clin North Am. 2011 25:245 Ohl CA, Luther VP. J. Hosp. Med. 2011;6:S4
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Nine Factors to Consider When
Selecting an Antibiotic1. Spectrum of coverage
2. Patterns of resistance
3. Evidence or track record for the specified infection
4. Achievable serum, tissue, or body fluid
concentration (e.g. cerebrospinal fluid, urine)
5. Allergy
6. Toxicity
7. Formulation (IV vs. PO); if PO assess
bioavailability
8. Adherence/convenience (e.g. 2x/day vs.6x/day)
9. CostNADONA
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Principles of Antibiotic Therapy• Empiric Therapy (85%) Directed Therapy (15%)
• Infection not well defined Infection well defined
(“best guess”) Narrow spectrum
• Broad spectrum One, seldom two drugs
• Multiple drugs Evidence usually stronger
• Evidence usually only 2 randomized Less adverse reactions
controlled trials Less expensive
• More adverse reactions
• More expensive
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Why So Much Empiric Therapy?• Need for prompt therapy with certain infections
– Life or limb threatening infection
– Mortality increases with delay in these cases
• Cultures difficult to do to provide microbiologic definition (i.e. pneumonia, sinusitis, cellulitis)
• Negative cultures
• Provider Beliefs– Fear of error or missing something
– Not believing culture data available
– “Patient is really sick, they should have ‘more’ antibiotics”
– Myth of “double coverage” for gram-negatives e.g.pseudomonas
– “They got better on drug X, Y, and Z so I will just continue those”
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To Increase use of Directed Therapy for
Outpatients:• Define the infection 3 ways
– Anatomically, microbiologically, pathophysiologically
• Obtain cultures before starting antibiotics
– Often difficult in outpatients (acute otitis media,
sinusitis, community-acquired pneumonia)
• Narrow therapy often with good supporting evidence– Amoxicillin or amoxicillin/clavulanate for AOM,
sinusitis and CAP
– Penicillin for Group A Streptococcal pharyngitis
– 1st generation cephalosporin or clindamycin for
simple cellulitis
– Trimethoprim/sulfamethoxazole or cipro/levofloxacin for cystitis
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Tenets of Proper StewardshipTenet = Principle or belief
Tenet 1: Treat bacterial infection, not
colonization
Tenet 2: Do not treat sterile inflammation or
abnormal imaging without infection
Tenet 3: Do not treat viral infections with
antibiotics
Tenet 4: Limit duration of antibiotic
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Tenet 1: Treat Bacterial Infection, not
Colonization• Many patients become colonized with
potentially pathogenic bacteria but are notinfected– Asymptomatic bacteriuria or Foley catheter colonization
– Tracheostomy colonization in chronic respiratory failure
– Chronic wounds and decubiti
– Lower extremity stasis ulcers
– Chronic bronchitis
• Can be difficult to differentiate– Presence of WBCs not always indicative of infection
– Fever may be due to another reason, not the
positive culture
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Other Tenets of Antibiotic Stewardship
• Limit duration of surgical prophylaxis to <24 hours perioperatively
• Use rapid diagnostics if
available (e.g. respiratory viral
PCR)
• Solicit expert opinion if needed
• Prevent infection
– Use good hand hygiene and infection control
practices
– Remove cathetersNADONA
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Conclusions• Antibiotic Resistance is one of the largest
threats to public health of our time
• It takes ongoing and transparent collaboration to reduce risk and improve prescribing practices
• You don’t have to have a prescription pad to influence change and practice
• Engage the RESIDENT
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Key References• Centers for Medicare and Medicaid Services
(CMS). Catheter Associated Urinary Tract Infection Prevention tracker.
• Centers for Disease Control and Prevention. CAUTI Prevention. Electronically accessed from www.cdc.gov/hai 2017.
• Gould, CV, et al. Guideline for the Prevention of Catheter-Associated Urinary Tract Infections.
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Contact Hours
• You will receive an email within 2 weeks
that will have the eval link.
• Please fill out the eval and when
completed the certificate of attendance
and contact hour will be sent to you.
• Thank you for attending!!!!
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Cindy Fronning
Director of Education
Penicillin
Sulfa
Bactrim 41
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