Laboratory Stewardship: is the IP in the driver’s seat? - PowerPoint Presentation

Slide1

Laboratory Stewardship: is the IP in the driver’s seat?

Barbara DeBaun, RN, MSN, CIC

Improvement Advisor

WIPAG Conference

September 20, 2018

Slide2

Objectives

Describe the primary drivers of antibiotic and laboratory stewardship

Discuss the impact of the ‘culture of culturing’ on antibiotic prescribing practices

Describe how specimen ordering, collection, processing and interpretation impacts antibiotic stewardship

 

Slide3

Antibiotic and Laboratory Stewardship: is the IP in the driver’s seat?

Slide4

Introduction

Slide5

Yesterday’s Headline News

5

Slide6

Today’s Headline News

Single most important factor

Most commonly prescribed drugs

50% not needed or inappropriately prescribed

Commonly used in food animals

Slide7

Antibiotic Resistance Impact

More than 2 million people in the US every year

At least 23,000 deaths

Slide8

C. Difficile and MDRO: primary drivers

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Antibiotic Stewardship Program: Key Elements

Slide10

ASP Team

TJC EP 4 – Hospital has ASP multidisciplinary team that includes (when available):Infectious Disease PhysicianInfection PreventionistPharmacist (s)Practitioner

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Site Specific Self Assessment

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Preauthorization and/or Prospective Audit and Feedback

Significant reduction in use of restricted agents and $$Decreased antibiotic useDecreased antibiotic resistance particularly gram-negative pathogens

Both have advantages and disadvantages

Unintended consequences

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Reduce use of antibiotics associated with high risk of CDI

ClindamycinCephalosporinsFluroquinolones

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Stratified antibiograms

Exposes differences in susceptibilityMay help development of optimized treatment recommendations and guidelines

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Rapid Diagnostics

Slide16

The Culture of Culturing

Slide17

How Culturing Practices Impact…

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Laboratory Stewardship

Slide19

Pre-test Probability

The probability that THIS SPECIFIC PATIENT has the condition that this test is designed to find

Slide20

Urine Screening

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What Happens When Proper Urine Culture Management is Not Implemented

NursingClinician

Laboratory

Pharmacy

ID

IP

Patient

Finance

Improper ordering

Improper collection

False-positive results, workloads

Increased costs

Ineffective antibiotic stewardship

Inaccurate analysis

Increased costs

Adverse effects

Slide22

Reasons for Inappropriate UC and UA Ordering

22

Jones K, Sibai J, Battjes R, Fakih MG. How and when nurses collect urine cultures on catheterized patients: a survey of 5 hospitals. Am J Infect Control 2016; 44:173-6.

Slide23

Reasons for Inappropriate UC and UA Ordering

23

Drekonja DM, Abbo LM, Kuskowski MA, Gnadt C, Shulka MD, Johnson JR. A survey of resident physicians’ knowledge regarding urine testing and subsequent antimicrobial treatment. Am J Infect Control 2013;41:892-6.

Slide24

Randomized study of 208 patients at University of Michigan Health

24

Hartley S, Valley S, Kuhn L, Washer LL, Gandhi T, Meddings J, et al. Inappropriate testing for urinary tract infection in hospitalized patients: an opportunity for improvement. Infect Control Hosp Epidemiol 2013;34:1204-7.

Slide25

Emergency Room

212 patients had UA orders

84.4% lacked symptoms

198 (79.2%) lacked UTI and acute kidney injury

Yin P, Kiss A, Leis JA. Urinalysis orders among patients admitted to the

general medicine service. JAMA Intern Med 2015;175:1711-13.

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Inappropriate treatment of ASB

Increased adverse events, e.g., diarrhea, rash, dizziness, candidiasis, swollen mouth, vertigo

Development of antibiotic resistant bacterial strains

Clostridium difficile

infection

Increased healthcare and laboratory costs

Increased laboratory workload

Slide27

Ultimate outcome

Identify a causative pathogen if present

Preserve the organism at a colony count that reflects the patient’s clinical condition at the time of collection

Avoid introduction of a contaminant that may overgrow or be interpreted as a pathogen

Slide28

Urine Culture Contamination

The College of American Pathologists Q-Probes Studies

Contamination rates:

1998 study: high of 36.8% (906 institutions)

2008 study: high of 41.7% (14,739 specimens, mean rate of 15.0%)

Slide29

Impact of UC Contamination

1-year randomized, retrospective ED or inpatient study with contaminated UCs (>2 organisms at ≥10,000 CFU/ml)

139 complications in 64 of 131 patients:

Initiation of antibiotics – 48.8%

Urinary catheter removal – 13%

Placement of a new catheter – 12%Collection of additional UC – 8.4%1-year extrapolation: 869 unnecessary interventions

Klausing

BT, Tillman SD, Wright PW, Talbot T. The influence of contaminated urine cultures in inpatient and emergency department settings. Am J Infect Control 2016;44:1166-7.

Slide30

Specimen traveling adventures

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Best Practice Education

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Urine Handling after Collection (w/in 2 hrs. of collection)Refrigeration (2°C-8°C)

Preservation

Limitations: designated refrigerators not always available; temperature monitoring requirements; space; funding

Preservative maintains original organism load for 72h at room temperature

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Reflex TestingReflex or confirmatory testing is a protocol whereby additional laboratory testing may be performed on a patient sample based on the results of the initial test

Example: A urinalysis with elevated WBC signals the potential for a bacterial infection and a confirmatory urine culture is ordered on the same or complimentary specimenOrdering: UA with reflex33

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Reflex Testing

Triggers

for reflexive urine cultures:

Leukocyte Esterase – moderate to large

Nitrite – positive

WBC - ≥5-10 per hpf

Bacteria - positive

Slide35

Reducing CAUTI with UC Intervention

Intervention study, Mayo Clinic (Rochester, MN)

2015 John M. Eisenberg Patient Safety Award

Used 6 C’s of CAUTI reduction including “Culture urine only when indication is clear” with modification of EMR and “Scrub-the-Urine-Port”

CAUTI reduced by 70%

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Stool Samples

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Screening for

C. difficile

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Hospital-onset diarrhea

Tube feeding

Laxatives

Enemas

Medications

Other infectionsUnderlying disease

Slide39

CDI Studies that included data

35% to 50% of patients tested for

C. difficile

do not have clinically significant diarrhea

20% to 40% of patients recently received a laxative

More studies are needed to compare

C. difficile

diagnostic assays that include high quality data on both patient symptoms and patient outcomes

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Diarrhea Decisions

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Diarrhea Ordering Decisions

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Blood Cultures

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Blood culture goals

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Impact of Blood Culture Contamination

Suboptimal treatment of patient

Increased financial burdens

Potential over-reporting of CLABSI

Garcia RA. AJIC 2015

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What part of a 3% contamination rate is good for the patient?

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ABC Hospital (example)Patient Safety Implications of Blood Culture Contamination

Blood Culture Contamination

Blood Cultures - ED

833

Cultures Performed Monthly

10,000

Cultures Per Year

300

Patients per Year

3.0%

Contamination

Rate

Blood Culture Contamination

Increased risk of CDI

Increased risk of AKI

MDRO’s: MRSA, VRE, etc.

Counter to Antibiotic Stewardship

Additional patient days

Increased risk of HAI/HAC

Inappropriate & Unnecessary Antibiotic Utilization

Extended Length of Stay

Negative Impact on CMS Quality Outcome Metrics

Avoids readmissions

Reduces hospital reimbursement

Impacts VBP incentive dollars

Increases false-positive CLABSI, MRSA reporting (SIR penalties)

25

Patients Affected Monthly

by False Positives

Patients Impacted

1

Alahmadi Y.M, M.A. Aldeyab, J.C. McElnay, M.G. Scott, F.W. Darwish Elhajji, F.A. Magee, et al. Clinical and economic impact of contaminated blood cultures within the hospital setting. J Hosp Infect. 2011 Mar; 77(3): 233-6.

2

Gander R.M., L. Byrd, M. DeCrescenzo, S. Hirany, M. Bowen and J. Baughman. Impact of Phlebotomy-Drawn Blood Cultures on Contamination Rates and Health Care Costs in a Hospital Emergency Department. JCM 2009 Apr: 47(4): p. 1021 -1024

Slide47

47

NegativeTrue Positive

All

Blood Cultures

Positive

Blood Cultures

False Positive

1.

Zwang

O, Albert RK. Analysis of Strategies to Improve Cost Effectiveness of Blood Cultures. J Hosp Med. 2006 Sep;1(5):272-6

.

40%

of all positive cultures are actually

False Positive

False positives are a

“preventable error”

and a

misdiagnosis

of sepsis

Inaccuracies Diagnosing

Sepsis

Slide48

48

The Challenge

Current best practices can’t solve the problem of blood culture contamination.

.

2.

Mark E Rupp, R Jennifer

Cavalieri

, Cole

Marolf

, Elizabeth

Lyden

; Reduction in Blood Culture Contamination Through Use of Initial Specimen Diversion Device. 

Clin

Infect Dis 2017 cix304.

doi

: 10.1093/

cid

/cix304

Human Factor(s):

Risk of contamination during assembly and preparation of supplies, and skin prep

1.

Skin Flora:

You can disinfect but not sterilize the skin; Up to 20% of skin flora remains viable in the keratin layer of the skin even after skin prep

1

2.

Skin Plugs:

Skin plugs

, when present,

will ALWAYS enter the culture specimen bottle, and commonly will contain microorganisms

3.

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Clinical Benefits of Reducing Blood Culture Contamination 49

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Blood culture diversion

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CLINICAL PRACTICE GUIDELINE:Prevention of Blood Culture Contamination

SPECIMEN DIVERSIONMicroscopic skin fragments that may contain bacteria can enter the specimen container through the needle during venipuncture (Patton & Schmitt, 2010).Diverting the initial 1-2 mL of blood into a sterile container has been shown to decrease blood culture contamination in emergency department patients, inpatients, and outpatients over 16 years of age (Patton & Schmitt, 2010).

51

Slide52

52

93

% increase

Reduction in Blood Culture Contamination Through the Use of Specimen Diversion Device

Clinical Infectious Diseases -

2017:65 (15 July)

12-Month Intervention

904 patients

(1,808 cultures)

Contamination Rate

Increased 12-Fold without device

Researcher calculated the study institution would

save $1.8M

6-Months

1,342 patients

(2,684 cultures)

6-Months

1,453 patients

(2,905 cultures)

Study Device

Slide53

53

Peer-reviewed Published Clinical Study and Major Medical Conference Poster Presentations

Institution

(Publication/Conference)

Study

Period

Starting

BC

Contamination

Rate

Steripath

®

BC

Contamination

Rate

Reduction with Steripath

®

%

Cost

Savings

Additional

Impacts

University of Nebraska Medical Center

(Clinical Infectious

Diseases July 2017)

12-months

2.6%

0.2%

(P=0.001)

92%

$1.8M

(annually)

88%

reduction compared to Phlebotomy at 1.8% within study

San Antonio Military Medical Center

(DOD

Healthcare Quality Safety Award

2016)

5-months

7.7%

0.6%

92%

$235

K

(5 months)

ED: DOD Healthcare Quality and Safety Award Winner, 2016

San Antonio Military Medical Center

(

SHEA 2017)

14months

Reduced Vancomycin DOT by 37% (P=0.007)

Greater de-escalation of Vancomycin DOT was best achieved through a combination of a PCR and Steripath

®

Medical University

of South Carolina

(

Institute for Healthcare Improvement

2016)

8-months

4.2%

0.6%

86%

Not

reported

Approved for hospital-wide

use in 2017

Rush University Medical Center

(IDSA

-

IDWeek

2017

)

3-months

4.3%

0.6%

86%

Not

reported

Simple and effective method for

reducing blood culture contamination

Lee Health System (4

sites)

(Submitted to Journal of Emergency Nursing)

7-months

3.5%

0.6%

(P=0.0001)

83%

$640K

(7 months)

ED: Commitment

to Excellence Award

Medical University

of South Carolina

(

Institute for Healthcare Improvement

2017)

20-months

4.6%

0.9%

80%

$745K

(20-months)

Complies with CDC,

TJC, and federal mandates to improve Antibiotic Stewardship and patient safety

VA - North Texas Health Care System

(Greenbelt Project 2016)

6-months

5.3%

1.7%

(Blended Rate at 50% compliance)

68%

$332K

(5 months)

Reduced BC steps from 22 to 12 steps (45% reduction)

ED: Manager

of the Year

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Are Cultures Drawn From CVC More Likely to Be Contaminated Than Cultures Obtained Via Venipuncture?

Author

Journal

Year

Comment

Tonnesen

JAMA

1976

8%

discordance: peripheral blood vs catheter

Felices

Crit

Care

Med

1979

6.5% discordance:

peripheral blood vs catheter

Bryant

Am J

Clin

Path

1987

18% contamination rate, 83% of (+)

Cx from catheters were contaminants

Souvenir

J

Clin Micro1998

2.0%

vs

1.7% contamination rate (P=0.46)

DesJardin

Ann Intern Med

1999

9.1% False (+)

Ramsook

ICHE

2000

3.4%

vs

2.0% contamination rate (P=0.04)

Everts

J

Clin

Micro

2001

3.8%

vs

1.8% contamination rate (P=0.001)

Norberg

JAMA

2003

9.1%

vs

2.8% contamination rate (P<0.001)

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In summary… how/what/why/when we culture matters…

Slide56

Connecting the Dots

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Thanks

Barbara DeBaun RN, MSN, CIC

bdebaun@cynosurehealth.org