IMPROVING THE MANAGEMENT OF URINARY TRACT INFECTIONS (UTIs):

A Collaborative Approach Between the Antimicrobial Stewardship and Clinical Improvement Teams

DONNA LEUNG PRAB GILL

On behalf of

ASPIRES (Jennifer Grant, Tim Lau, Felicia Laing, Salomeh Shajari) and Professional Practice (Jean Carr, Shairoz Vellani)

Feb 28, 2014

Our Story • The Issue • The Background • The Solution • The Teamwork • The Outcome • The Sustainability Plan • The Lessons Learned • The Next Steps

The Issue • Urinary Tract Infections (UTIs)

– Common infections acquired in hospital – Bacteriuria prevalence high

• 50% in institutionalized elderly patients

• Asymptomatic Bacteriuria (ABU) – Presence of bacteria in urine; no symptoms

• No treatment required

– Clinicians believe asymptomatic bacteriuria (ABU) is misdiagnosed as UTI

The Issue

• Unnecessary Ordering of Urine Cultures and Treatment of ABU – Overuse antibiotics – Increase adverse drug events

• Clostridium difficile infection – Develop antibiotic resistant bacteria – Increase healthcare costs

• Laboratory, antibiotic, and hospital costs

The Background • ASPIRES

– Antimicrobial Stewardship • Use of antibiotics appropriately

– Improves patient outcomes – Reduce adverse drug events – Reduce antibiotic resistance – Reduce hospital costs

– In January 2013, ASPIRES approached VGH Hospitalist group

• Identified urinary tract infections (UTIs) area for improvement

The Solution

• UTI Clinical Management Algorithm 1. Develop diagnostic criteria

• Collaboration between ASPIRES, hospitalists, pharmacists, nurses, and physicians

2. Appropriate urine sampling 3. Optimize empiric antibiotic based on local

susceptibilities 4. Educate hospitalists and nurses 5. Measure outcomes

The Solution

• UTI Algorithm – Team approach

• ASPIRES • Physicians • Nurses • Pharmacists • All providers!!!

The Teamwork • Catheter-associated Urinary Tract

Infection (CAUTIs) Initiative – Efforts to reduce CAUTIs – Preventative strategies (4 key areas):

1. Avoiding unnecessary urinary catheters 2. Aseptic insertion techniques 3. Guidelines for care/management and urine sampling 4. Daily review of catheter necessity and prompt

removal

The Teamwork • ASPIRES and CAUTI Joint Education

– In February 2013, launch hospitalist wards at VGH • Educate hospitalists and nurses • CAUTI and ASPIRES joint education sessions

– Appropriate insertions (indications/technique) – Care, management, and removal of urinary catheters – Appropriate symptomology and urine sampling

• UTI algorithm posted on units and discussed at weekly huddles Change in practice for nursing Model to sustain continuous improvement

– In September 2013, expansion to Richmond Hospital using clinical pharmacist support

The Outcomes

Urine Sampling

Indicators

Average Number of Cultures Per Period Cultures Per 1000 Patient Days Pre

(Apr 2012 – Jan 2013)

Post (Feb 2013- Aug 2013)

Pre (Apr 2012 - Jan

2013)

Post (Feb 2013- Aug

2013) All Urine Cultures 98.6 88.3 3.0 2.6 Mixed Organism Cultures 13.9 15.2 0.42 0.44 No Growth Cultures 49.5 39.5 1.5 1.2 Repeated Cultures (within 48 h of previous culture) 10 6.8 0.31 0.20

Number of Urine Cultures Ordered Pre- and Post-intervention

3.3 2.7

4.2

5.5

3.6

0.9

2.1

3.6

2.3

0.6 0.9

3.6

0

1

2

3

4

5

6

N C

ultu

res

per 1

000

Patie

nt D

ays

Redundant Urine Cultures Per 1000 Patient Days at Hospitalist Units, VGH

UTI Algorithm Launch

Ave: 3.0

↓30% redundant cultures!

Antibiotic Treatment for UTIs

Prescribed Empirically for UTI

Prescribed for Overall Treatment of UTI

Pre-intervention

(n=15)

Post-intervention

(n=7)

Pre-intervention

(n=15)

Post-intervention

(n=7) Ciprofloxacin 75% 50% ↓ 47% 43% ↓ Amoxicillin 0% 50% ↑ 20% 29% ↑ Piperacillin-tazobactam

25% 0% ↓ 7% 0% ↓

↑ use of recommended appropriate antibiotic ↓ broad-spectrum antibiotic and ↓ costs

Common Antibiotics Used for UTI Treatment in Chart Audit

Overall Antibiotic Utilization • Use of “UTI

Algorithm” recommended antibiotics pre vs post – Increased use

• Ceftriaxone, co-trimoxazole, nitrofurantoin

– Decreased use • Ciprofloxacin, piperacillin-

tazobactam, vancomycin

Antibiotic Utilization in Defined Daily Doses Per 100 Patient Days

Antibiotic Pre (Sept 2012-Jan 2013 )

Post (Feb 2013-Jul

2013)

% Change in Utilization

amoxicillin Orl 2.0 1.7 -17.7

amoxicillin-clav Orl 2.6 2.3 -11.5 ampicillin Inj 2.8 2.2 -24.1 ceFAZolin Inj 0.9 1.0 14.6 ceftriAXONE Inj 1.9 2.7 40.1 ceFURoxime Orl 1.9 1.9 -2.8 cephalexin ORL 1.1 1.6 44.7 ciprofloxacin Inj 1.4 1.0 -31.8 ciprofloxacin Orl 0.5 0.1 -74.5 cotrimoxazole Orl 1.4 1.7 21.2 doxycycline ORL 1.0 0.9 -8.9 moxifloxacin Inj 1.0 0.9 -7.8 moxifloxacin Orl 2.8 2.7 -4.1 nitrofurantoin Orl 0.7 0.9 25.7

piperacillin-tazobactam Inj 3.6 3.2 -11.1 vancomycin Inj 1.3 0.8 -40.5 vancomycin Orl 0.4 0.4 10.3

Pharmacist Intervention

• Richmond Hospital – September 2013 to November 2013

• Clinical pharmacist reviewed adherence UTI algorithm • 48 UTI cases

– Urine analysis ordered with culture: 100% – Initial treatment

» Appropriate: 81% » Antibiotics modified by pharmacist: 16%

– At 48 hours with culture results » Appropriate: 60% » Antibiotics narrowed by pharmacist: 25%

The Sustainability Plan Ongoing Surveillance at Unit Level – Breakthrough Lanes

The Lessons Learned • Practice change requires both nursing and

physician involvement

• Weekly huddles and nursing staff education sessions increase awareness and action plans

• Ongoing feedback on treatment and education to physicians required improve engagement and sustainability

The Next Steps • Continue weekly huddles and nursing staff

education sessions • Audit and feedback physicians optimize

antibiotic use • Periodical audits to monitor urine cultures and

antibiotic use for improvement opportunities • Continuous feedback to nursing and physician

groups

Acknowledgments

• Doris Bohl, Clinical Nurse Educator, VGH

• Marilyn Shamatutu, Clinical Nurse Educator, VGH

19

Questions?

ANTIMICROBIAL STEWARDSHIP PROGRAMME: Innovation, Research, Education, and Safety

Dr. Jennifer Grant – ASPIRES Medical Director (Jennifer.Grant@vch.ca; 604-875-4111 local 69503)

Dr. Tim Lau – ASPIRES Pharmacist (Tim.Lau@vch.ca; 604-875-4111 local 63361)

Donna Leung – UBC Pharmacy Student

PROFESSIONAL PRACTICE

Prab Gill – Acting Director, Professional Practice – Nursing (Prab.Gill@vch.ca; 604-875-4111 local 55203)