1. APIC Chapter 13 Journal Club
May 17, 2017
Good Afternoon, my name is RKH, and I am here to present an article for the Journal Club.
Presented by: Ramona Karam-Howlin RN BSN CIC

2. The article was taking from the Infection Control and Hospital Epidemilogy Journal Feb 2017, Vol 38, no 2- The topic of the Study was …

3. OBJECTIVES
A non-experimental comparative before and after study performed to evaluate interventions to reduce CAUTI’s
ICU’s are required to publicly report CAUTI rates to NHSN. These rates impact institution’s value-based purchasing reimbursement

4. BACKGROUND
The American College of Critical Care Medicine (ACCCM) and the Infectious Diseases Society of America (IDSA) note that catheter-associated bacteriuria are:
typically indicative of colonization
rarely symptomatic
infrequent cause of fever or secondary bloodstream infection
Therefore, should not be treated
This study supported the recommendations of the AMCC and IDSA that Catheter associated bacteriuria are:

5. kidney transplantation recipients neutropenic patients
BACKGROUND
When evaluating fever in the critically ill, urine cultures should only be evaluated in patient populations at high risk of invasive infection:
kidney transplantation recipients
neutropenic patients
recent genitourinary surgery
obstruction
Their recommendation

6. 2013 - best practices for bladder catheter use
METHODS
Efforts to decrease CAUTIs was a two prong approach:
best practices for bladder catheter use
assessment of competency with catheter insertion and maintenance
maintaining a closed system
initiation of a nursing driven protocol for catheter removal
improved fidelity of electronic documentation of catheters
implementation of preservative tubes for specimen collection
periodic maintenance audits of catheters
stewardship of culturing
So the study started with Efforts to decrease CAUTI’s using a two prong approach, in they instituted best practices for bladder catheter use, which was the following:

7. METHODS
A team representing all intensive care unit (ICU) disciplines (e.g., pediatric, medical, surgical, neurologic, cardiac, heart failure, and cardiothoracic surgery) and infection prevention (IP) was assembled in 2013 to address the institutional goal of reducing CAUTI rates.
In 2013, a team representing the all ICU’s such as… and IP was assembled to address the institutional goal of reducing CAUTI’s

8. Stewardship of culturing
In 2014, consensus was obtained
to consider recommended guidance for evaluating a new fever in the critically ill. This approach was adopted by all ICU disciplines over the course of the intervention period.

9. January 1, 2013, through December 31, 2014 Data compiled from all ICUs
METHODS
January 1, 2013, through December 31, 2014
Data compiled from all ICUs
Comprised 215 adult and 25 pediatric ICU beds of a 1,268-bed tertiary-care academic medical center
Surveillance for CAUTI and hospital-acquired bloodstream infection (HABSI) according to the NHSN definition was conducted routinely, and results were prospectively recorded in an IP database
Study period began from Jan 1, 2013 through Dec 31, in which data was compiled from all ICU;s comprised 215 adult and 25 peds ICU beds of a

10. METHODS
Rates of CAUTI, HABSI, and HABSI due to Enterobacteriaceae species were calculated and compared
Device utilization ratios (DURs) were calculated
Urine culture orders were tracked by service
χ2 test was used to evaluate differences between rates
The rates of CAUTI, Hospital Acquired Blood stream infections and HABSI related to Enterobacteriacea species were calculated and compared, as well as Device Utilization Ratios. Urine cx’s orders were tracked by service, and Chi square test was used to evaluate differences between rates

11. RESULTS Year ICU admissions Patient Days DUR
# of urine cultures collected
2013
11,117
74,705
0.7
4,749
2014
11,589
75,569
0.68
2,479
So in year they had …
Then in 2014, they had… but look at the number of urine cx’s collected, that was cut almost in ½ was when they introduced “stewardship of culturing”

12. RESULTS 2013 CAUTI RATES 3.0/1000 catheter days 2014 CAUTI RATES
(P=.0003; rate ratio, ; 95%CI, )
2013 HABSI RATES
2.8/1000 patient days
2014 HABSI RATES
2.4/1000 patient days
So what this is saying is that the data collected showed that even with the decrease numbers of cultures taking, it didn’t show a difference when it came to secondary blood stream infections caused by urosepsis pathogens. This stayed the same, so this was a good study in that it showed no difference in secondary blood cx’s
(P=.15)
2013 HABSI secondary to Enterobacteriaceae
0.71/1000 patient days
2014 HABSI secondary to
Enterobacteriaceae
0.66/1000 patient days
( P= .72; rate ratio 1.1;95% CI, ).

13. This graft shows how in the beginning of their study they show that they were collecting about 1900 urine cx in the first q 13, and showed a decrease, here the study was focused on catheter insertion, maintenance, and removal. In the First quarter of 2014, this appears to be the beginning of adding “stewardship of culturing” Evaluating the patient for S/S before sending a urine cx. It shows over time that their urine cx collection and their CAUTI rates decreased significantly
figure 1. Catheter-associated urinary tract infection (CAUTI) rate (by quarter) during the pre-intervention period (2013) and intervention period (2014) associated with number of urine cultures

14. CONCLUSION
Approach began with attention to best practice for insertion, maintenance, and removal of Foley catheters. Subsequently, we emphasized “Stewardship of testing” by following published guidance for evaluation of a fever prior to ordering a urine culture in a critically ill patient. The culmination of these efforts was a significant reduction in CAUTIs
This was the author’s conclusion- that their approach began with attention to best practice…

15. The approach focuses on the decision to test, “preculture” strategy of applying stewardship to diagnostics-which was:
Evaluation of a fever prior to ordering a urine culture in a critically ill patient

16. PROS
LIMITATIONS
No increase in overall HABSI or HABSI was attributed to Enterobacteriaceae, making it unlikely that bacteremic urinary tract infections went unrecognized.
Increase acuity level of the institution
Published guidelines were not really explained in the study
Approach to culturing was not mandated at the start of post intervention period
May not be generalizable to rural or smaller institutions
ICU’s, only
Started with high rate
Compliance with bundle?
Limitations- Compliance bundle, or lack of bundle compliance attributed to them having high CAUTI rates

17. Interventions to reduce CAUTI’s at Mount Sinai
Implemented an algorithm
SO what can we bring back to our institutions regarding CAUTI’s- We found that at our institution we were having a similar issue- patient is febrile, blood, urine cx are ordered. So there is now an algorithym to assist the providers when to send a urine cx. By doing this we are hoping to decrease use of antibiotics that would eventually may cause resistance, as well as preventing patients from acquiring C. diff due to unnecessary treatment for patients that are colonized.

19. Special Thanks
to Dr. Tania Bubb