National Content Series for All Staff The Culture of Culturing: The Importance of Knowing When to Order Urine Cultures National Content Series for All Staff Welcome to today’s educational session on The Culture of Culturing: The Importance of Knowing When to Order Urine Cultures for the residents we serve. This module is part of the Agency for Healthcare Research and Quality’s (or AHRQ’s) Safety Program for Long-Term Care that addresses Healthcare-Associated Infections (or HAIs) and Catheter Associated Urinary Tract Infections (or CAUTI). This education session was designed specifically for any staff member who works in a long-term care facility. Every team member is important in helping make our long-term care facility a safe place to live and work! Believe it or not, even a test as simple as a urine culture can cause resident harm if used incorrectly. Current as of October 2015

Objectives Upon completion of this training, participants will be able to: Explain why unnecessary urine cultures can lead to increases in CAUTI reporting and resident harms Determine when (or not) to order urine cultures Describe project tools available to help improve urine culture practices Utilize evidence-based communication strategies to more effectively communicate urine culture practices Upon completion of today’s training, participants will be able to: Explain why unnecessary urine cultures can lead to increases in the number of CAUTIs reported and eventually resident harms. Determine when (or not) to order urine cultures—sometimes a urine culture just isn’t needed. Describe project tools available to help improve urine culture practices and where to find these tools. Use communication strategies that are evidence-based to more effectively communicate urine culture practices.

How Can Ordering Urine Cultures Lead To Resident Harms? Urinary catheter present Cloudy, odorous urine, sediments Inappropriate use of urine culture Over-inflated CAUTI rates Inappropriate Treatment and Antibiotic Overuse Miss the correct diagnosis More resistant organisms, Clostridium difficile, increased cost, further health complications Resident Harms Residents with urinary catheters have bacteria in their bladders—usually just colonizing the bladder or “hanging out” there. However, bacteria can make the urine smell bad, look cloudy, or even have some sediment. But these conditions aren’t necessarily harmful, and they certainly aren’t a reason to send a urine culture, particularly if the resident doesn’t have any specific symptoms of a UTI. If a urine culture is sent, and bacteria are found (in other words, a positive urine culture), that resident is almost certainly going to get antibiotics to treat the urine. But the bacteria in the urine may not be causing any actual harm! Meanwhile, the real problem that is causing the resident to have fever, or confusion, or malaise, may actually be missed, because we are “covering the urine.” Also, if you have a positive urine culture in a resident with fever, then you may end up reporting that as a CAUTI—even if the resident clearly has another source of the fever. To make this really clear with a simple example, if your resident has obvious gangrene of the leg, and a fever, but you send a urine culture and that comes back positive— it may accidently get reported as a CAUTI. Similarly, inappropriate ordering of urine cultures can lead to improper use of antibiotics. Thus inappropriate urine culturing can put residents at increased chances of developing drug-resistant bacteria and infections like C diff.

Bacteriuria is Not the Same as CAUTI What is Bacteriuria? Bacteria in the urine Bacteriuria means the resident has a positive urine culture What is the main difference between bacteriuria and CAUTI? Bacteriuria can be symptomatic or asymptomatic Asymptomatic bacteriuria (ASB) CAUTI requires presence of symptoms consistent with UTI Bacteriuria ASB CAUTI Bacteriuria is a compound word that literally means “bacteria in the urine.” In other words, the resident will have a positive urine culture, and an abnormal urinalysis as well. In older adults, the presence of bacteria in the urine is usually asymptomatic, or asymptomatic bacteriuria. We abbreviate asymptomatic bacteriuria as ASB. The main difference between ASB and CAUTI is that CAUTI requires the presence of urinary-specific symptoms and clinical findings consistent with a UTI. The diagram on the bottom of this slide shows this visually. Bacteriuria is the larger category, and ASB and CAUTI are both subsets within bacteriuria. Both are alike in that they involve a positive urine culture, but one has urinary symptoms (CAUTI) and the other doesn’t (ASB). http://www.idsociety.org/Organ_System/#Genitourinary

Common Signs that are Inappropriate Triggers for Urine Cultures Chronically-catheterized patients have bacteriuria 99% of the time. Bacteriuria signs Urine color Urine smell Urine sediment Cloudy urine Pyuria (white blood cells or WBC in the urine) Positive dipstick Bacteriuria is not the same as CAUTI Patients with a urinary catheter in place acquire bacteriuria at the rate of 3-10% per day—so after 30 days, 99.99% of catheterized residents will have bacteria in their urine, usually at high colony counts, and often more than one species. We know this from studies in residents in long-term care settings. Therefore, chronically catheterized patients have bacteriuria 99% of the time. The signs of bacteriuria can often be mistaken as indicating a CAUTI. Bacteriuria signs and symptoms include: urine color, smell and sediment, cloudy urine, WBCs in the urine and a positive dipstick. Most people think that bacteria smell bad! But smell, or cloudiness, etc., are not symptoms of UTI or CAUTI. And treating with antibiotics isn’t going to make these signs go away for long if the catheter stays in place, because the bladder will get colonized with bacteria again. Remember, bacteriuria does not mean the resident has a CAUTI. Nicolle L.E., Bradley S., Colgan, R., et al. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults.Clin Inf Dis 2005; 40:643-54.

Pyuria is Not Diagnostic of CAUTI Pyuria, like bacteriuria, does not help differentiate asymptomatic bacteriuria from CAUTI. Why? Pyuria in the urine is non-specific Pyuria can be from The catheter itself Bladder distension Asymptomatic bacteriuria Generally avoid dipsticks in catheterized residents Pyuria, is pus or white blood cells in the urine. It is also a non-specific symptom that does not indicate CAUTI. A dipstick is often used to test for Pyuria. Like urine smell, color or cloudiness, pyuria is non-specific. Pyuria can result from the catheter itself, bladder distention or ASB. Because pyuria is common in catheterized residents and it is non-specific, the recommendation is to avoid dipsticks for catheterized residents. Hooton, Clin Infect Dis 2010; 50:625–663

What are the Signs and Symptoms of a CAUTI? ONE or MORE of the following: CAUTI Signs and Symptoms Fever Rigors New confusion or functional decline (with NO alternative diagnosis AND leukocytosis) New suprapubic pain or costovertebral angle pain or tenderness New onset hypotension (with no alternate site of infection) Acute pain, swelling or tenderness of the testes, epididymis or prostate Purulent (pus) discharge from around the catheter We just discussed non-specific urinary symptoms that do not indicate a CAUTI and can mislead us into ordering unnecessary urine cultures. So, now let’s review the signs and symptoms that indicate a CAUTI. CAUTIs are indicated by the presence of one or more of the following: Fever Rigors New confusion or functional decline (without alternative diagnosis AND increased WBC count in the blood)—in older adults you have to meet all these criteria to say that CAUTI is the cause of confusion or decline. New pain or tenderness in the suprapubic region (above the pubic bone in the abdomen) or costovertebral angle (in the angle between the bottom of the ribs and the spine)—now this is really pretty specific for CAUTI New onset of hypotension WITHOUT an alternative site of infection Acute pain, swelling or tenderness of the testes, epididymis or prostate Pus discharge from around the catheter

CAUTI Criteria NSHN Definitions Pocket Card A really helpful tool that can be used at the bedside for all staff is the NHSN Definitions Pocket Card, found on the LTC Safety website in the resources section. This card is worth printing out and distributing, as it can help guide your decision making. It provides detailed definitions for the constitutional criteria for long-term residents; for example fever, leukocytosis, mental status change and functional decline. It also provides clinical decision guidance to define CAUTI. Additional Facilitator’s Notes Have copies of the NSHN Definition pocket cards available for staff. Encourage staff to use the pocket cards to help remember the CAUTI definition and keep it at their finger tips.

Case Scenario: Mrs. Bell ? Mrs. Bell is an 86-year-old resident of your facility. She is being transferred back from a week-long stay in the hospital. She has an indwelling urinary catheter, but you are unsure why the catheter has been placed. Yesterday her urine was clear and yellow, but today her urine is cloudy and smells bad. What should be done next? Urinalysis Urine culture Urinalysis and antibiotics Culture and antibiotics Nothing Now let’s apply our knowledge to a case scenario. Mrs. Bell is an 86-year-old resident of your facility. She is being transferred back from a week-long stay in the hospital. She has an indwelling urinary catheter, but you are unsure why the catheter has been placed. Yesterday her urine was clear and yellow, but today her urine is cloudy and smells bad. Looking at the choices offered, what would you do next? [Pause] Additional Facilitator’s Notes Pause to allow staff to work through the case scenario, either independently or in small groups.

Answer to Mrs. Bell’s Case Nothing! At least, don’t send urine for urinalysis or culture Definitely don’t start antibiotics! You wouldn’t really do nothing Ask about what she ate Look at her medications Assess for catheter trauma Assess to ensure she is at her baseline Offer fluids; often a better initial step The correct answer is nothing! Well, you wouldn’t really do nothing, but all of the other options are inappropriate based on Mrs. Bell’s case. As resident caregivers, we aren’t ever going to do “nothing.” However, she doesn’t need a workup for UTI, at this point. Instead, you could: Ask about what she ate, Look at her medications, Assess for catheter trauma, and Assess to ensure she is at her baseline. Based on Mrs. Bell’s condition, offering fluids is a better initial step.

SBAR for Health Care Communication SBAR is a TeamSTEPPs framework for team members to effectively communicate information to one another Communicate the following information: Situation―What is going on with the resident? Background―What is the clinical background or context? Assessment―What do I think the problem is? Recommendation―What would I recommend? SBAR can be used with clinicians and with residents and families Effective communication is another important element of reducing unnecessary urine cultures and preventing CAUTIs. Clear communication is one of the most important responsibilities of every health care team member. Miscommunication has been found to be a root cause in 66% of medical errors.* Communication is defined as the transfer or exchange of information from a sender to a receiver with a result in shared understanding. In communicating, we need to consider: 1) whom we are speaking with, and 2) how we are communicating (verbally and non-verbally). Today we will focus on verbal communication. Effective communication is: 1) complete, 2) clear, 3) brief, and 4) timely I’d like to demonstrate the SBAR technique for communication. SBAR is an acronym that helps you remember the components and order of effective communication between health care team members: Situation – what is happening with the resident? Background – what is the clinical background or context? Assessment – what do I think the problem is? Recommendation – What would I recommend? Lets use Mrs. Bell’s case to practice SBAR. A possible SBAR might look as follows: I understand you were notified that Mrs. Bell was transferred back from the hospital. She now has an indwelling urinary catheter in place. While her urine is cloudy, she is still doing well without any symptoms of UTI. (situation) It appears the catheter was placed in the hospital, but there is no indication provided for it. We are participating in the LTC-HAIs/CAUTI project, and one of the key steps to preventing CAUTI is to remove urinary catheters unless they are medically indicated. (background) On my assessment, Mrs. Bell does not meet any of the indications for a catheter, per the documentation from the hospital, nor does she need further testing of her urine; however, she might be a little dehydrated today, which might account for her cloudy urine. (assessment) I would like to get that catheter out today and perhaps we can encourage fluids? (recommendation) Additional Facilitator’s Notes *The Joint Commission Root Causes and Percentages for Sentinel Events (All Categories) January 1995–December 2005. Accessed on 10/1/2015: http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/longtermcare/module6/igltccommunication.html Team Formation Success Video - Sub-Acute Care: TeamSTEPPS® Long-Term Care Version. April 2013. Agency for Healthcare Research and Quality, Rockville, MD.

Using SBAR to Communicate with Residents and Families Sometimes, residents and families push for urine cultures and antibiotics SBAR can be used to improve communication with residents and families When forming your SBAR make sure to consider What residents and their families are really asking for Alternatives to ordering cultures and using antibiotics Possible side effects of antibiotic use Promote shared decision-making Even though family members and residents may not be familiar with SBAR, it can be a helpful tool to outline your conversation about urine cultures and antibiotic use. If all staff members use this approach to conversations, you will be more consistent in messaging and communication with family members and residents. Let’s use the case study we discussed earlier in this presentation to practice using SBAR with Mrs. Bell’s family members. A possible response to family’s concern using SBAR may sound something like this. Start by saying… I know you are concerned about your mother and I am too. (situation) Mrs. Bell had a catheter placed while she was in the hospital, but they did not give any indication for the catheter placement. (background) Many residents with indwelling catheters develop something called bacteriuria. It basically means they have a little bacteria in their urine. It can cause the urine to become cloudy and smell bad, but it is not a reason to be alarmed—it is very common. The nature of her urine could also be caused by her medication or what she ate yesterday. I am more concerned that we get this catheter removed to ease your mother’s comfort and make sure she is not at risk for a catheter- associated urinary tract infection. (assessment) I am recommending that we increase your mothers fluids, to make sure she is not dehydrated. I am also recommending to the physician that we reassess her need for a catheter and get it removed as soon as possible. This will most likely clear up the color and smell of her urine and make her feel more comfortable. (recommendation). The materials that accompany today’s training include fictional resident situations for you to practice using SBAR to communicate with your teammates about the residents’ need for a urine culture.

Stay Updated with Useful Resources NHSN CAUTI Definition Pocket Cards C.A.U.T.I. Infographic Antibiotics Brochure As we wrap up today’s discussion, I’d like to thank you for viewing this presentation. We need all staff’s input to reduce HAIs and CAUTIs in long-term care facilities. The following resources are available to you as participants in the AHRQ Safety Program for Long-term Care: HAIs/CAUTI project. We hope that these resources will be helpful on your journey to reduce CAUTIs and HAIs and improve your facility’s culture of safety. Facilitator’s Notes Resources: The first resource is a link to the AHRQ Safety Program for Long-term Care: HAIs/CAUTI project website. On the website you will find a variety of tools to help you prevent CAUTIs and improve your facility’s culture of safety. The second resource is a link to the TeamSTEPPS for Long-term Care web page. TeamSTEPPS is a communication and teamwork system that offers solutions to improving collaboration and communication within health care facilities. The resources on this page are specifically designed for the long-term care environment. The third resource is a link to NHSN Criteria CAUTI Definition Pocket Cards. The fourth resource is a link to the CAUTI mnemonic infographic The fifth resources is a link to the “When Do You Need An Antibiotic?” brochure that you can share with residents and families to explain appropriate antibiotic use.

References Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee (HICPAC) approved guidelines for the Prevention of catheter-associated urinary tract infections, 2009. Available at http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf. Centers for Disease Control and Prevention. Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance (online). Accessible at: http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf. National Healthcare Safety Network (NHSN). Long-term Care Facility (LTCF) Component Healthcare Associated Infection Surveillance Module: UTI Event Reporting [online]. Al Qas-Hanna, Am J Infect Control 2013;41 (12): 1173-77 Stone ND, Ashraf MS, Calder J. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol 2012;33(10):965-977.