IMPROVING THE MANAGEMENT OF URINARY
TRACT INFECTIONS (UTIs):
A Collaborative Approach Between the
Antimicrobial Stewardshi...
Our Story
•
•
•
•
•
•
•
•

The Issue
The Background
The Solution
The Teamwork
The Outcome
The Sustainability Plan
The Less...
The Issue
• Urinary Tract Infections (UTIs)
– Common infections acquired in hospital
– Bacteriuria prevalence high
• 50% i...
The Issue
• Unnecessary Ordering of Urine Cultures
and Treatment of ABU
– Overuse antibiotics
– Increase adverse drug even...
The Background
• ASPIRES
– Antimicrobial Stewardship
• Use of antibiotics appropriately
–
–
–
–

Improves patient outcomes...
The Solution
• UTI Clinical Management Algorithm
1. Develop diagnostic criteria
•

Collaboration between ASPIRES, hospital...
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 s...
The Teamwork
• ASPIRES and CAUTI Joint Education
– In February 2013, launch hospitalist wards at VGH
• Educate hospitalist...
The Outcomes
Urine Sampling
Number of Urine Cultures Ordered Pre- and Post-intervention
Average Number of Cultures Per Period

Indicato...
Antibiotic Treatment for UTIs
Common Antibiotics Used for UTI Treatment in Chart Audit
Prescribed
Empirically for UTI

Pre...
Overall Antibiotic Utilization
Antibiotic Utilization in Defined Daily
Doses Per 100 Patient Days

• Use of “UTI
Algorithm...
Pharmacist Intervention
• Richmond Hospital
– September 2013 to November 2013
• Clinical pharmacist reviewed adherence UTI...
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 e...
The Next Steps
• Continue weekly huddles and nursing staff
education sessions
• Audit and feedback physicians optimize
ant...
Acknowledgments
• Doris Bohl,
Clinical Nurse Educator, VGH

• Marilyn Shamatutu,
Clinical Nurse Educator, VGH
Questions?
ANTIMICROBIAL STEWARDSHIP PROGRAMME:
Innovation, Research, Education, and Safety
Dr. Jennifer Grant – ASPIRES M...
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Management of Urinary Tract Infections through a Collaborative Approach with Antimicrobial Stewardship and Clinical Improvement Teams

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This presentation was delivered in session F1 of Quality Forum 2014 by:

Prab Gill
Acting Director, Professional Practice
Vancouver Coastal Health

Donna Leung
Pharmacy Student
UBC

Published in: Health & Medicine
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Management of Urinary Tract Infections through a Collaborative Approach with Antimicrobial Stewardship and Clinical Improvement Teams

  1. 1. 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
  2. 2. Our Story • • • • • • • • The Issue The Background The Solution The Teamwork The Outcome The Sustainability Plan The Lessons Learned The Next Steps
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. The Solution • UTI Algorithm – Team approach • • • • • ASPIRES Physicians Nurses Pharmacists All providers!!!
  8. 8. The Teamwork • Catheter-associated Urinary Tract Infection (CAUTIs) Initiative – Efforts to reduce CAUTIs – Preventative strategies (4 key areas): 1. 2. 3. 4. Avoiding unnecessary urinary catheters Aseptic insertion techniques Guidelines for care/management and urine sampling Daily review of catheter necessity and prompt removal
  9. 9. 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
  10. 10. The Outcomes
  11. 11. Urine Sampling Number of Urine Cultures Ordered Pre- and Post-intervention Average Number of Cultures Per Period Indicators All Urine Cultures Mixed Organism Cultures No Growth Cultures Repeated Cultures (within 48 h of previous culture) 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) 98.6 13.9 49.5 88.3 15.2 39.5 3.0 0.42 1.5 2.6 0.44 1.2 10 6.8 0.31 0.20 N Cultures per 1000 Patient Days Redundant Urine Cultures Per 1000 Patient Days at Hospitalist Units, VGH 6 4.2 4 3 ↓30% redundant cultures! 5.5 5 3.3 Ave: 3.0 2.7 2.1 2 1 3.6 3.6 3.6 2.3 0.9 0.6 0 UTI Algorithm Launch 0.9
  12. 12. Antibiotic Treatment for UTIs Common Antibiotics Used for UTI Treatment in Chart Audit Prescribed Empirically for UTI Prescribed for Overall Treatment of UTI Preintervention (n=15) Postintervention (n=7) Preintervention (n=15) Postintervention (n=7) Ciprofloxacin 75% 50% ↓ 47% 43% ↓ Amoxicillin 0% 50% ↑ 20% 29% ↑ Piperacillintazobactam 25% 0% ↓ 7% 0% ↓ ↑ use of recommended appropriate antibiotic ↓ broad-spectrum antibiotic and ↓ costs
  13. 13. Overall Antibiotic Utilization Antibiotic Utilization in Defined Daily Doses Per 100 Patient Days • Use of “UTI Algorithm” recommended antibiotics pre vs post – Increased use • Ceftriaxone, co-trimoxazole, nitrofurantoin – Decreased use • Ciprofloxacin, piperacillintazobactam, vancomycin Antibiotic Pre (Sept 2012Jan 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 piperacillintazobactam Inj 3.6 3.2 -11.1 vancomycin Inj 1.3 0.8 -40.5 vancomycin Orl 0.4 0.4 10.3
  14. 14. 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%
  15. 15. The Sustainability Plan Ongoing Surveillance at Unit Level – Breakthrough Lanes
  16. 16. 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
  17. 17. 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
  18. 18. Acknowledgments • Doris Bohl, Clinical Nurse Educator, VGH • Marilyn Shamatutu, Clinical Nurse Educator, VGH
  19. 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) 19

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