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Amenta E, Grigoryan L, Rajan SS, Ramsey D, Kramer JR, Walder A, Chou A, Van JN, Krein SL, Hysong S, Naik AD, Trautner BW. Quantifying the Implementation and Cost of a Multisite Antibiotic Stewardship Intervention for Asymptomatic Bacteriuria. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e115. [PMID: 37502251 PMCID: PMC10369447 DOI: 10.1017/ash.2023.198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 07/29/2023]
Abstract
Objective The intensity of an antibiotic stewardship intervention to achieve clinical impact is not known. We conducted a multisite dissemination project of an intervention to reduce treatment of asymptomatic bacteriuria (ASB) and studied: (1) the association between implementation metrics and clinical outcomes and (2) the cost of implementation. Design/Setting/Participants A central site facilitated a multimodality intervention to decrease unnecessary urine cultures and antibiotic treatment in patients with ASB at 4 Veterans Affairs medical centers. Methods The intervention consisted of a decision support aid algorithm and interactive teaching cases that provided in the moment audit and feedback on how to manage ASB. Implementation outcomes included minutes spent in intervention delivery, number of healthcare professionals reached, and number of sessions delivered. Clinical outcomes included days of antibiotic therapy (DOT), length of antibiotic therapy (LOT), and number of urine cultures ordered per 1000 bed days. Personnel reported weekly time logs. Results Minutes spent in intervention delivery were inversely correlated with two clinical outcomes, DOT (R -0.3, P = .04) and LOT (R -0.3, P = .02). Number of healthcare professionals reached and number of sessions delivered were not correlated with clinical outcomes of DOT (R -0.003, P = .98, R = -0.059, P = .69) or LOT (R +0.073, P = .62, R -0.102, P = .49). Physician champions spent an average of 3.8% of effort on the intervention. The implementation cost was USD 22,299/year per site on average. Conclusions The amount of time local teams spent in delivery of an antibiotic stewardship intervention was correlated with the desired decrease in antibiotic use. Implementing this successful antibiotic stewardship intervention required minimal time.
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Affiliation(s)
- Eva Amenta
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Larissa Grigoryan
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Suja S. Rajan
- UTHealth Science Center, Institute for Stroke and Cerebral Vascular Disease, Houston, TX, USA
| | - David Ramsey
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer R. Kramer
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Annette Walder
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Andrew Chou
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - John N. Van
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
| | - Sarah L. Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sylvia Hysong
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Aanand D. Naik
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Department of Management, Policy and Community Health, University of Texas School of Public Health, Houston, TX, USA
- UTHealth Consortium on Aging, University of Texas Health Science Center, Houston, TX, USA
| | - Barbara W. Trautner
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Krouss M, Alaiev D, Shin DW, Talledo J, Israilov S, Chandra K, Zaurova M, Manchego PA, Tsega S, Cohen G, Bravo N, Kupferman T, Madaline T, Cho HJ. Choosing wisely initiative for reducing urine cultures for asymptomatic bacteriuria and catheter-associated asymptomatic bacteriuria in an 11-hospital safety net system. Am J Infect Control 2023; 51:461-465. [PMID: 36870917 DOI: 10.1016/j.ajic.2023.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/27/2022] [Accepted: 01/04/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Treatment of asymptomatic bacteriuria (ASB) is common. Overtreatment of ASB leads to harm, including adverse effects from antibiotics, antibiotic resistance, and increased length of stay. METHODS This quality improvement initiative targeted inappropriate urine cultures (UC) across 11 hospitals and 70 ambulatory clinics in a safety-net setting. A mandatory prompt for appropriate indications for UC orders and a best practice advisory (BPA) for UC on patients with urinary catheters were created. UC ordering was compared preintervention (June 2020-October 2021) to postintervention (December 2021-August 2022). Variation in hospitals and clinics were assessed, as well as BPA responses by clinician type and specialty. RESULTS Inpatient UCs decreased 20.9% (p < .001), and outpatient UCs was unchanged (2.6% increase, nonsignificant). Inpatient UCs on patients with urinary catheters decreased 21.6% (p < .001). Temporal trends were also assessed. High variation was seen among hospitals and clinics. Low BPA acceptance rates were seen in internal medicine and family medicine clinicians. Attendings showed high acceptance to the BPA compared to other clinicians. CONCLUSIONS This initiative successfully decreased UCs in a large, safety-net system. Further study is needed in assessing variation among hospitals and clinics, as well as among clinician types and specialties.
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Affiliation(s)
- Mona Krouss
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Daniel Alaiev
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY
| | - Da Wi Shin
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joseph Talledo
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY
| | - Sigal Israilov
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Komal Chandra
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY
| | - Milana Zaurova
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter Alacron Manchego
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY; Department of Pediatrics, NYC Health + Hospitals/Kings County, New York, NY
| | - Surafel Tsega
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY; Department of Medicine, NYC Health + Hospitals/Kings County, New York, NY
| | - Gabriel Cohen
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Nathaniel Bravo
- Department of Infection Control, NYC Health + Hospitals/Queens, New York, NY
| | - Tania Kupferman
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Theresa Madaline
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY
| | - Hyung J Cho
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA
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3
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Cash MC, Hile G, Johnson J, Stone T, Smith J, Ohl C, Luther V, Beardsley J. Sustained impact of an antibiotic stewardship initiative targeting asymptomatic bacteriuria and pyuria in the emergency department. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e148. [PMID: 36483350 PMCID: PMC9726488 DOI: 10.1017/ash.2022.289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To determine whether a multifaceted initiative resulted in maintained reduction in inappropriate treatment of asymptomatic pyuria (ASP) or bacteriuria (ASB) in the emergency department (ED). DESIGN Single-center, retrospective study. METHODS Beginning in December 2015, a series of interventions were implemented to decrease the inappropriate treatment of ASP or ASB in the ED. Patients discharged from the ED from August to October 2015 (preintervention period), from December 2016 to February 2017 (postintervention period 1), and from November 2019 to January 2020 (postintervention period 2) were included if they had pyuria and/or bacteriuria without urinary symptoms. The primary outcome was the proportion of patients prescribed antibiotics within 72 hours of discharge from the ED. The secondary outcome was the number of patients returning to the ED with symptomatic UTI within 30 days of discharge. RESULTS We detected a significant decrease in the proportion of patients with ASP or ASB who were inappropriately treated when comparing the preintervention group and post-intervention group 1 (100% vs 32.4%; P < .001). This reduced frequency of inappropriate treatment was noted 3 years after the intervention, with 28% of patients receiving treatment for ASP or ASB in postintervention group 2. (P was not significant fin the comparison with postintervention group 1.) Among the 3 groups analyzed, we detected no difference in the numbers of patients returning to the ED with a symptomatic UTI within 30 days of ED discharge regardless of whether patients received antibiotics. CONCLUSIONS A multifaceted intervention resulted in a significant decrease in inappropriate use of antibiotics for ASP and/or ASB that was maintained 3 years after implementation.
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Affiliation(s)
- Mary Catherine Cash
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Garrett Hile
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky
| | - James Johnson
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, North Carolina
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Tyler Stone
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, North Carolina
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jessica Smith
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Chris Ohl
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Vera Luther
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James Beardsley
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, North Carolina
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Abstract
Catheter-associated urinary tract infection (CAUTI) remains one of the most prevalent, but preventable, health care-associated infections and predominantly occurs in patients with indwelling urinary catheters. Duration of urinary catheterization is the most important modifiable risk factor for development of CAUTI. Alternatives to indwelling catheters should be considered in appropriate patients. If indwelling catheterization is necessary, proper aseptic practices for catheter insertion and maintenance and use of a closed catheter collection system are essential for preventing CAUTI. The use of intervention bundles and collaboratives helps in the effective implementation of CAUTI prevention measures.
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Affiliation(s)
- Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, F4141 South University Hospital, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5226, USA.
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Durham SH, Hohmann NS, Ragan AH. Implementation of a Urinary Tract Infection Treatment Protocol to Improve Prescribing Practices in the Long-Term Care Facility of a Veteran’s Healthcare System. PHARMACY 2020; 8:pharmacy8030129. [PMID: 32722253 PMCID: PMC7558276 DOI: 10.3390/pharmacy8030129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 11/21/2022] Open
Abstract
Urinary tract infections (UTIs) are a commonly diagnosed problem in long-term care facilities (LTCFs), but antimicrobial treatment is often incorrectly prescribed. Although bacterial resistance to antimicrobials commonly used for UTIs, such as trimethoprim/sulfamethoxazole and fluoroquinolones, has been dramatically increasing, they are still commonly prescribed. The purpose of this project was to determine if implementation of a standard treatment protocol for UTIs, which emphasized correct UTI diagnosis and use of nitrofurantoin and cefpodoxime/ceftriaxone as empiric therapy per the institutional antibiogram, changed clinician prescribing practices. This quasi-experimental model utilized two years of pre-intervention and two years of post-intervention data. Three hundred patient encounters were included. Antibiotics prescribed in the pre-intervention period included: trimethoprim/sulfamethoxazole (32%), ciprofloxacin (14%), amoxicillin (13%), levofloxacin (9%), cefpodoxime (9%), ceftriaxone (8%), amoxicillin/clavulanate (5%), nitrofurantoin (4%), and other (6%). By contrast, antibiotics prescribed in the post-intervention period included: cefpodoxime (46%), nitrofurantoin (30%), ceftriaxone (10%), trimethoprim/sulfamethoxazole (8%), amoxicillin/clavulanate (1%), and other (5%). These differences in prescribed drug between the pre-intervention and post-intervention encounters were statistically significant (p < 0.001). Overall, appropriate empiric treatment was prescribed in only 48/217 encounters (22%) during the pre-intervention period, but this increased to 73/83 encounters (88%) in the post-intervention period (p < 0.001). The results indicate that the treatment protocol was successful in changing prescribing practices and decreasing the use of inappropriate antimicrobials at the LTCF.
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Affiliation(s)
- Spencer H. Durham
- Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, AL 36849-5341, USA;
- Correspondence: ; Tel.: +334-844-7138
| | - Natalie S. Hohmann
- Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, AL 36849-5341, USA;
| | - Addison H. Ragan
- Department of Pharmacy, Central Alabama Veterans Health Care System, Montgomery, AL 36109, USA;
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Anderson K, Bradford N, Edwards R, Nicholson J, Lockwood L, Clark J. Addressing the barriers to optimal management of febrile neutropenia in children with cancer. Eur J Oncol Nurs 2020; 45:101719. [DOI: 10.1016/j.ejon.2019.101719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 10/15/2019] [Accepted: 12/23/2019] [Indexed: 12/25/2022]
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Using clinical decision support to improve urine culture diagnostic stewardship, antimicrobial stewardship, and financial cost: A multicenter experience. Infect Control Hosp Epidemiol 2020; 41:564-570. [PMID: 32131910 DOI: 10.1017/ice.2020.37] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Despite evidence to the contrary, many practitioners continue to inappropriately screen for and treat bacteria in the urine of clinically asymptomatic patients. The purpose of this study was to evaluate the impact of a new order set on the number of urine culture performed, antibiotic days of therapy (DOT), catheter-associated urinary tract infections (CAUTI), and associated financial impact. DESIGN A quasi-experimental before-and-after intervention. SETTING We conducted this study at 5 Catholic Health Initiative (CHI) hospitals in Texas that use the same electronic health record (EHR) system. PATIENTS The study populations included adult patients who had urine culture performed from June 2017 to June 2019. INTERVENTION The intervention (implemented June 25, 2018) was the addition of a new order set in the electronic health record that required practitioners to choose an indication for the type of urine study. The primary outcome was number of urine cultures performed adjusted for the number of total patient days. RESULTS Following implementation of the new order set, the number of urine cultures performed among the 5 sites decreased from 1,175.8 tests per 10,000 patient days before the intervention to 701.4 after the intervention (40.4% reduction; P < .01). Antibiotic DOT for patients with a urinary tract infection indication decreased from 102.5 to 86.9 per 1,000 patient days (15.2% reduction; P < .01). The CAUTI standardized infection ratio was 1.0 before the intervention and 0.8 after the intervention (P = .23). The estimated yearly savings following the intervention was US$535,181. CONCLUSIONS The addition of a new order set resulted in decreases in the number of urine cultures performed and the antibiotic DOT, as well as substantial financial savings.
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Cao Y, Gong Z, Shan J, Gao Y. Comparison of the preventive effect of urethral cleaning versus disinfection for catheter-associated urinary tract infections in adults: A network meta-analysis. Int J Infect Dis 2018; 76:102-108. [PMID: 30243912 DOI: 10.1016/j.ijid.2018.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 09/11/2018] [Accepted: 09/13/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Catheter-associated urinary tract infections (CAUTIs) are the main cause of infectious complications in patients with indwelling urinary catheters (IDCs). However, the best cleaning methods for the prevention of CAUTIs have not been evaluated clearly in previous studies. METHODS An electronic database search was performed, from inception to December 2017. Randomized controlled trials and quasi-experimental trials using different methods of urethral cleaning versus disinfection to prevent CAUTIs were considered. The study selection and data collection were performed independently by two reviewers. The risk of bias assessment was performed using the Cochrane risk of bias scale. The primary outcome was the incidence rates of CAUTIs. A network meta-analysis was conducted to compare the effect among the different methods of urethral cleaning versus disinfection to prevent CAUTIs. RESULTS Thirty-three studies (6490 patients) with seven different methods of urethral cleaning versus disinfection were eligible for inclusion, and the data were summarized in the network meta-analysis. No evidence of heterogeneity (P>0.05) was observed among the studies. The network meta-analysis showed that there was no difference in the incidence of CAUTIs when comparing the different urethral cleaning methods versus disinfection (P>0.05 for all). However, chlorhexidine ranked first in the results of the Bayesian analysis and is recommended for preventing CAUTIs. CONCLUSIONS Current evidence suggests that there are no significant differences among different urethral cleaning versus disinfection methods with regard to CAUTI incidence rates.
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Affiliation(s)
- Yulong Cao
- Department of Hospital-AcquiredInfectionControl, Peking University People's Hospital, Beijing, China
| | - Zhizhong Gong
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Jiao Shan
- Department of Hospital-Acquired Infection Control, Beijing Jishuitan Hospital, Beijing, China
| | - Yan Gao
- Department of Hospital-AcquiredInfectionControl, Peking University People's Hospital, Beijing, China.
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Trautner BW, Prasad P, Grigoryan L, Hysong SJ, Kramer JR, Rajan S, Petersen NJ, Rosen T, Drekonja DM, Graber C, Patel P, Lichtenberger P, Gauthier TP, Wiseman S, Jones M, Sales A, Krein S, Naik AD. Protocol to disseminate a hospital-site controlled intervention using audit and feedback to implement guidelines concerning inappropriate treatment of asymptomatic bacteriuria. Implement Sci 2018; 13:16. [PMID: 29351769 PMCID: PMC5775527 DOI: 10.1186/s13012-018-0709-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 01/09/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Antimicrobial stewardship to combat the spread of antibiotic-resistant bacteria has become a national priority. This project focuses on reducing inappropriate use of antimicrobials for asymptomatic bacteriuria (ASB), a very common condition that leads to antimicrobial overuse in acute and long-term care. We previously conducted a successful intervention, entitled "Kicking Catheter Associated Urinary Tract Infection (CAUTI): the No Knee-Jerk Antibiotics Campaign," to decrease guideline-discordant ordering of urine cultures and antibiotics for ASB. The current objective is to facilitate implementation of a scalable version of the Kicking CAUTI campaign across four geographically diverse Veterans Health Administration facilities while assessing what aspects of an antimicrobial stewardship intervention are essential to success and sustainability. METHODS This project uses an interrupted time series design with four control sites. The two main intervention tools are (1) an evidence-based algorithm that distills the guidelines into a streamlined clinical pathway and (2) case-based audit and feedback to train clinicians to use the algorithm. Our conceptual framework for the development and implementation of this intervention draws on May's General Theory of Implementation. The intervention is directed at providers in acute and long-term care, and the goal is to reduce inappropriate screening for and treatment of ASB in all patients and residents, not just those with urinary catheters. The start-up for each facility consists of centrally-led phone calls with local site champions and baseline surveys. Case-based audit and feedback will begin at a given site after the start-up period and continue for 12 months, followed by a sustainability assessment. In addition to the clinical outcomes, we will explore the relationship between the dose of the intervention and clinical outcomes. DISCUSSION This project moves from a proof-of-concept effectiveness study to implementation involving significantly more sites, and uses the General Theory of Implementation to embed the intervention into normal processes of care with usual care providers. Aspects of implementation that will be explored include dissemination, internal and external facilitation, and organizational partnerships. "Less is More" is the natural next step from our prior successful Kicking CAUTI intervention, and has the potential to improve patient care while advancing the science of implementation.
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Affiliation(s)
- Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA. .,Baylor College of Medicine in Houston, Houston, TX, USA.
| | | | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, Suite 600, Houston, TX, 77098, USA
| | - Sylvia J Hysong
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
| | - Jennifer R Kramer
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
| | - Suja Rajan
- Department of Management, Policy and Community Heath, University of Texas (UT) - School of Public Health (SPH), E-319, 1200 Pressler Street, Houston, TX, 77030, USA
| | - Nancy J Petersen
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
| | - Tracey Rosen
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
| | - Dimitri M Drekonja
- Infectious Diseases (111F), Minneapolis VA Medical Center, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Christopher Graber
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, 11301 Wilshire Blvd, 111-F, Los Angeles, CA, 90073, USA
| | - Payal Patel
- Division of Infectious Diseases, III-i, University of Michigan, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | | | | | - Steve Wiseman
- Division of Infectious Diseases, III-i, University of Michigan, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Makoto Jones
- George E. Wahlen Veterans Affairs Medical Center, Mailstop 182, 500 Foothill Drive, Salt Lake City, UT, 84148, USA
| | - Anne Sales
- Department of Learning Health Sciences, University of Michigan Medical School, 209 Victor Vaughan Building, 2054, 1111 E. Catherine St, Ann Arbor, MI, 48109-2054, USA
| | - Sarah Krein
- VA Ann Arbor Center for Clinical Management Research, North Campus Research Complex, Building 16-333W, 2800 Plymouth Rd, Ann Arbor, MI, 48109-2800, USA
| | - Aanand Dinkar Naik
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
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Abstract
Catheter-associated urinary tract infection (CAUTI) remains one of the most prevalent, yet preventable, health care-associated infections and predominantly occurs in patients with indwelling urinary catheters. Targeted strategies for prevention of CAUTI include limiting urinary catheter use; physician reminder systems, nurse-initiated discontinuation protocols, and automatic stop orders have successfully decreased catheter duration. Alternatives to indwelling catheters should be considered in appropriate patients. If indwelling catheterization is necessary, proper aseptic practices for catheter insertion and maintenance and closed catheter collection system is essential for preventing CAUTI. The use of "bladder bundles" and collaboratives aids in the effective implementation of CAUTI prevention measures.
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Affiliation(s)
- Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
| | - Sanjay Saint
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA; Division of General Medicine, Department of Internal Medicine, University of Michigan Health System, 2800 Plymouth Road, Building 16, Room 430 West, Ann Arbor, MI 48109-2800, USA; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
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11
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Naik AD, Skelton F, Amspoker AB, Glasgow RA, Trautner BW. A fast and frugal algorithm to strengthen diagnosis and treatment decisions for catheter-associated bacteriuria. PLoS One 2017; 12:e0174415. [PMID: 28350833 PMCID: PMC5370115 DOI: 10.1371/journal.pone.0174415] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/08/2017] [Indexed: 02/02/2023] Open
Abstract
Objectives Guidelines for managing catheter-associated urinary tract infection (CAUTI) and asymptomatic bacteria (ASB) are poorly translated into routine care due in part to cognitive diagnostic errors. This study determines if the accuracy for CAUTI and ASB diagnosis and treatment improves after implementation of a fast and frugal algorithm compared with traditional education methods. Materials and methods A pre and post-intervention with contemporaneous comparison site involving inpatient and long term care wards at two regional Veterans Affairs Systems in United States. Participants included 216 internal medicine residents and 16 primary care clinicians. Intervention clinicians received training with a fast and frugal algorithm. Comparison site clinicians received guidelines education. Diagnosis and treatment accuracy compared with a criterion standard was assessed during similar three-month, pre- and post-intervention periods. Sensitivity, specificity, and likelihood ratios were compared for both periods at each site. Results Bacteriuria management was evaluated against criterion standard in 196 cases pre-implementation and 117 cases post-implementation. Accuracy of bacteriuria management among intervention participants was significantly higher, post-implementation, than those at the comparison site (Intervention: positive likelihood ratio (LR+) = 8.5, specificity = 0.89, 95% confidence interval (CI) = 0.78−1.00; comparison: LR+ = 4.62, specificity (95%CI) = 0.79 (0.63−0.95). Further, improvements at the intervention site were statistically significant (pre-implementation: LR+ = 2.1, specificity (95%CI) = 0.60 (0.50−0.71); post-implementation: LR+ = 8.5, specificity (95%CI) = 0.89 (0.78−1.00). At both sites, there were similar improvements in negative LR from pre- to post-implementation: [Intervention site = 0.28 to 0.08; comparison site = 0.13 to 0.04]. Inappropriate management of ASB declined markedly from 32 (40%) to 3 (11%) cases at the intervention site. Conclusions A fast and frugal algorithm improves diagnosis and treatment accuracy for CAUTI and reduces inappropriate treatment of ASB. Fast and frugal algorithms that realign diagnostic intuitions and treatment norms can enhance translation of evidence into practice.
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Affiliation(s)
- Aanand D. Naik
- Houston Center of Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America
- Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- * E-mail: (AN); (BT)
| | - Felicia Skelton
- Houston Center of Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America
- Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Amber B. Amspoker
- Houston Center of Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America
- Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Russell A. Glasgow
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, Denver, Colorado, United States of America
| | - Barbara W. Trautner
- Houston Center of Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America
- Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- * E-mail: (AN); (BT)
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Grigoryan L, Naik AD, Horwitz D, Cadena J, Patterson JE, Zoorob R, Trautner BW. Survey finds improvement in cognitive biases that drive overtreatment of asymptomatic bacteriuria after a successful antimicrobial stewardship intervention. Am J Infect Control 2016; 44:1544-1548. [PMID: 27397910 DOI: 10.1016/j.ajic.2016.04.238] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/22/2016] [Accepted: 04/22/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lack of guideline knowledge and cognitive biases are barriers that drive overtreatment of catheter-associated asymptomatic bacteriuria (ASB). We explored whether providers' knowledge and attitudes toward management of ASB differed before and after a multifaceted guidelines implementation intervention, reported elsewhere. METHODS We surveyed providers' knowledge of guidelines, cognitive-behavioral constructs, and self-reported familiarity with the relevant Infectious Diseases Society of America guidelines. The survey was administered to providers in the preintervention (n = 169) and postintervention (n = 157) periods at the intervention site and postintervention (n = 65) at the comparison site. RESULTS At the intervention site, the mean knowledge score increased significantly during the postintervention period (from 57.5%-69.9%; P < .0001) and fewer providers reported following incorrect cognitive cues (pyuria and organism type) for treatment of ASB. The knowledge of guidelines was higher in the postintervention sample after adjusting for provider type in the multiple linear regression analysis. Cognitive behavioral constructs (ie, self-efficacy, behavior, social norms, and risk perceptions) and self-reported familiarity with the guidelines also significantly improved during the postintervention period. CONCLUSIONS We identified and targeted specific barriers that drive overtreatment of ASB. Guideline implementation interventions targeting cognitive biases are essential for encouraging the application of ASB guidelines into practice.
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Affiliation(s)
- Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
| | - Aanand D Naik
- Houston VA Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Deborah Horwitz
- Houston VA Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Jose Cadena
- South Texas Veterans Healthcare System, San Antonio, TX; Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center, San Antonio, TX
| | - Jan E Patterson
- South Texas Veterans Healthcare System, San Antonio, TX; Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center, San Antonio, TX
| | - Roger Zoorob
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
| | - Barbara W Trautner
- Houston VA Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Section of Infectious Diseases, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX.
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Hysong SJ, Kell HJ, Petersen LA, Campbell BA, Trautner BW. Theory-based and evidence-based design of audit and feedback programmes: examples from two clinical intervention studies. BMJ Qual Saf 2016; 26:323-334. [PMID: 27288054 DOI: 10.1136/bmjqs-2015-004796] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 04/25/2016] [Accepted: 05/06/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Audit and feedback (A&F) is a common intervention used to change healthcare provider behaviour and, thus, improve healthcare quality. Although A&F can be effective its effectiveness varies, often due to the details of how A&F interventions are implemented. Some have suggested that a suitable conceptual framework is needed to organise the elements of A&F and also explain any observed differences in effectiveness. Through two examples from applied research studies, this article demonstrates how a suitable explanatory theory (in this case Kluger & DeNisi's Feedback Intervention Theory (FIT)) can be systematically applied to design better feedback interventions in healthcare settings. METHODS Case 1: this study's objective was to reduce inappropriate diagnosis of catheter-associated urinary tract infections (CAUTI) in inpatient wards. Learning to identify the correct clinical course of action from the case details was central to this study; consequently, the feedback intervention featured feedback elements that FIT predicts would best activate learning processes (framing feedback in terms of group performance and providing of correct solution information). We designed a highly personalised, interactive, one-on-one intervention with healthcare providers to improve their capacity to distinguish between CAUTI and asymptomatic bacteruria (ASB) and treat ASB appropriately. Case 2: Simplicity and scalability drove this study's intervention design, employing elements that FIT predicted positively impacted effectiveness yet still facilitated deployment and scalability (eg, delivered via computer, delivered in writing). We designed a web-based, report-style feedback intervention to help primary care physicians improve their care of patients with hypertension. RESULTS Both studies exhibited significant improvements in their desired outcome and in both cases interventions were received positively by feedback recipients. SUMMARY A&F has been a popular, yet inconsistently implemented and variably effective tool for changing healthcare provider behaviour and, improving healthcare quality. Through the systematic use of theory such as FIT, robust feedback interventions can be designed that yield greater effectiveness. Future work should look to comparative effectiveness of specific design elements and contextual factors that identify A&F as the optimal intervention to effectuate healthcare provider behaviour change. TRIAL REGISTRATION NUMBER NCT01052545, NCT00302718; post-results.
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Affiliation(s)
- Sylvia J Hysong
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Baylor College of Medicine, Houston, Texas, USA
| | | | - Laura A Petersen
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Baylor College of Medicine, Houston, Texas, USA
| | | | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Baylor College of Medicine, Houston, Texas, USA
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Overtreatment of Asymptomatic Bacteriuria: Identifying Targets for Improvement. Infect Control Hosp Epidemiol 2015; 36:470-3. [DOI: 10.1017/ice.2014.73] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Treatment of asymptomatic bacteriuria contributes to antimicrobial overuse in hospitalized patients. Indications for urine culture, treatment, and targets for improvement were evaluated in 153 patients. Drivers of antimicrobial overuse included fever with an alternative source, altered mental status, and leukocytosis, which led 435 excess days of antimicrobial therapy.Infect Control Hosp Epidemiol 2014;00(0): 1–4
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Kizilbash QF, Petersen NJ, Chen GJ, Naik AD, Trautner BW. Bacteremia and Mortality with Urinary Catheter–Associated Bacteriuria. Infect Control Hosp Epidemiol 2015; 34:1153-9. [DOI: 10.1086/673456] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective.Although catheter-associated urinary tract infection (CAUTI) and catheter-associated asymptomatic bacteriuria (CAABU) are clinically distinct conditions, most literature describing the risks of bacteriuria does not distinguish between them. We studied the relationship between catheter-associated bacteriuria and bacteremia from a urinary source in CAUTI relative to that in CAABU. Second, we investigated whether the presence or absence of urinary symptoms in catheterized patients with bacteriuria was associated with bacteremia from any source or mortality. Finally, we explored the effect of antimicrobial treatment of bacteriuria on subsequent bacteremia from any source and mortality.Design.We performed a retrospective cohort study with 30 days of follow-up after an initial positive urine culture. CAUTI and CAABU were defined by Infectious Diseases Society of America guidelines.Setting. A large tertiary care facility.Patients.All inpatients with a urinary catheter (external or indwelling) and a positive urine culture between October 2010 and June 2011.Results.We captured 444 episodes of catheter-associated bacteriuria in 308 patients; 128 (41.6%) patients had CAUTI, and 180 (58.4%) had CAABU. Three episodes of bacteriuria were followed by bacteremia from a urinary source (0.7%). CAUTI, rather than CAABU, was associated with bacteremia from any source, but neither CAUTI nor CAABU predicted subsequent mortality. Use of antimicrobial agents to treat bacteriuria was not associated with either bacteremia from any source or mortality.Conclusions.Bacteremia from a urinary source was infrequent, and there was no evidence of an association of mortality with symptomatic versus asymptomatic bacteriuria in this population. Antibiotic treatment of bacteriuria did not affect outcomes.
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Abstract
From 5-10% of elderly residents of long-term care facilities require chronic indwelling catheters for management of urine voiding. These residents are always bacteriuric, because of biofilm formation along the catheter, and experience increased morbidity associated with urinary tract infection. A wide variety of bacteria or yeast species are isolated. Occasional episodes of symptomatic infection may be accompanied by localizing genitourinary findings. However, when fever is present and there are no localizing findings, symptomatic infection is a diagnosis of exclusion. Many of these episodes are not from a urinary source, so critical clinical evaluation is always necessary. A urine specimen for culture should be obtained from patients with symptomatic infection prior to institution of antimicrobial therapy. When the catheter has been present for 2 weeks or longer, it should be replaced and the urine specimen collected through the new catheter. This provides a specimen of bladder urine without biofilm contamination, and catheter replacement also improves clinical outcomes. Treatment algorithms with a goal of limiting inappropriate treatment of asymptomatic bacteriuria have been developed. Empiric antimicrobial therapy should be avoided when possible. Guidelines for prevention of catheter-acquired urinary infection should be followed. The most important of these is to avoid use of a urinary catheter whenever possible and, when there is no longer an indication for the catheter, to remove it promptly.
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Trautner BW, Petersen NJ, Hysong SJ, Horwitz D, Kelly PA, Naik AD. Overtreatment of asymptomatic bacteriuria: identifying provider barriers to evidence-based care. Am J Infect Control 2014; 42:653-8. [PMID: 24713596 DOI: 10.1016/j.ajic.2014.02.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 01/31/2014] [Accepted: 02/03/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Inappropriate use of antibiotics to treat asymptomatic bacteriuria (ASB) is a significant contributor to antibiotic overuse in hospitalized patients despite evidence-based guidelines on ASB management. We surveyed whether accurate knowledge of how to manage catheter-associated urine cultures was associated with level of training, familiarity with ASB guidelines, and various cognitive-behavioral constructs. METHODS We used a survey to measure respondents' knowledge of how to manage catheter-associated bacteriuria, familiarity with the content of the relevant Infectious Diseases Society of America guidelines, and cognitive-behavioral constructs. The survey was administered to 169 residents and staff providers. RESULTS The mean knowledge score was 57.5%, or slightly over one-half of the questions answered correctly. The overall knowledge score improved significantly with level of training (P < .0001). Only 42% of respondents reported greater than minimal recall of ASB guideline contents. Self-efficacy, behavior, risk perceptions, social norms, and guideline familiarity were individually correlated with knowledge score (P < .01). In multivariable analysis, behavior, risk perception, and year of training were correlated with knowledge score (P < .05). CONCLUSIONS Knowledge of how to manage catheter-associated bacteriuria according to evidence-based guidelines increases with experience. Addressing both knowledge gaps and relevant cognitive biases early in training may decrease the inappropriate use of antibiotics to treat ASB.
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Affiliation(s)
- Barbara W Trautner
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX.
| | - Nancy J Petersen
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Sylvia J Hysong
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Deborah Horwitz
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - P Adam Kelly
- Southeast Louisiana Veterans Health Care System, New Orleans, LA; Section of General Internal Medicine and Geriatrics, Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX; Section of Geriatrics, Department of Medicine, Baylor College of Medicine, Houston, TX
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Manage catheter-related urinary tract infection in the elderly in long-term care by limiting catheter use and avoiding the inappropriate use of antimicrobials. DRUGS & THERAPY PERSPECTIVES 2014. [DOI: 10.1007/s40267-014-0130-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Chenoweth CE, Gould CV, Saint S. Diagnosis, Management, and Prevention of Catheter-Associated Urinary Tract Infections. Infect Dis Clin North Am 2014; 28:105-19. [DOI: 10.1016/j.idc.2013.09.002] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Naik AD, Trautner BW. Doing the right thing for asymptomatic bacteriuria: knowing less leads to doing less. Clin Infect Dis 2014; 58:984-5. [PMID: 24577289 DOI: 10.1093/cid/ciu011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Aanand D Naik
- Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center
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Trautner BW, Grigoryan L. Approach to a positive urine culture in a patient without urinary symptoms. Infect Dis Clin North Am 2013; 28:15-31. [PMID: 24484572 DOI: 10.1016/j.idc.2013.09.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Asymptomatic bacteriuria (ASB) is a condition in which bacteria are present in a noncontaminated urine sample collected from a patient without signs or symptoms related to the urinary tract. ASB must be distinguished from symptomatic urinary tract infection (UTI) by the absence of signs and symptoms compatible with UTI or by clinical determination that a nonurinary cause accounts for the patient's symptoms. The overall purpose of this review is to promote an awareness of ASB as a distinct condition from UTI and to empower clinicians to withhold antibiotics in situations in which antimicrobial treatment of bacteriuria is not indicated.
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Affiliation(s)
- Barbara W Trautner
- Department of Medicine, Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030, USA; Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby, Houston, TX 77098, USA
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Majdzadeh R, Baradaran Seyed Z. How to implement clinical practice guidelines in iran. IRANIAN RED CRESCENT MEDICAL JOURNAL 2013; 15:e9702. [PMID: 24719697 PMCID: PMC3971789 DOI: 10.5812/ircmj.9702] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 03/31/2013] [Accepted: 05/09/2013] [Indexed: 11/16/2022]
Abstract
Background: Evidence-based medicine would come to the result by evidence-based implementation. Clinical Practice Guidelines (CPG) as one of the evidence-based knowledge products requires appropriate interventions after being produced to be applied. Objectives: The aim of this qualitative study was to identify the strategies for application of CPGs produced in Iran. Materials and Methods: The purposive snowball sampling was performed and it continued until reaching the theoretical saturation. In-depth semistructured individual interviews and Focus Group Discussion (FGD) were performed aiming at triangulation. The thematic framework approach was used for the analysis. Results: Twelve interviews were conducted with three health system policy makers and decision makers, four experienced in the production or adaptation of clinical practices, and five experts in evidence-based medicine development and education. In addition, 11 policy makers, managers, and decision makers of the health system took part in FGD. The proposed interventions were classified in the following themes: Health professionals-oriented, Financial, Organizational, Regulatory, and Multifaceted interventions. Conclusions: Along with adaptation and development process of CPGs, their utilization should also be planned; otherwise spent time and money would be in vain. Certainly, imposing above-mentioned interventions with the ultimate goal of sustainable behavior change in health system service providers is beyond the capacity of specific groups or few academic centers. It requires the participation of all practitioners under the monitoring and support of the Ministry of Health and Medical Education. Deployment of the family physician plan and referral system is an opportunity which must be considered a trophy.
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Affiliation(s)
- Reza Majdzadeh
- School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Zahra Baradaran Seyed
- School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Zahra Baradaran Seyed, School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran. Tel: +98-9124240074, E-mail:
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Chenoweth C, Saint S. Preventing catheter-associated urinary tract infections in the intensive care unit. Crit Care Clin 2013. [PMID: 23182525 DOI: 10.1016/j.ccc.2012.10.005] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Urinary tract infection remains one of the most common healthcare-associated infections in the intensive care unit and predominantly occurs in patients with indwelling urinary catheters. Duration of catheterization is the most important risk factor for developing catheter-associated urinary tract infection (CAUTI). General strategies for preventing CAUTI include measures such as adherence to hand hygiene. Targeted strategies for preventing CAUTI include limiting the use and duration of urinary catheters, using aseptic technique for catheter insertion, and adhering to proper catheter care. Anti-infective catheters may be considered in some settings. Successful implementation of these measures has decreased urinary catheter use and CAUTI.
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Affiliation(s)
- Carol Chenoweth
- Division of Infectious Diseases, Departments of Internal Medicine and Infection Control and Epidemiology, University of Michigan Health System, Ann Arbor, MI 48109-5378, USA.
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Trautner BW, Bhimani RD, Amspoker AB, Hysong SJ, Garza A, Kelly PA, Payne VL, Naik AD. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak 2013; 13:48. [PMID: 23587259 PMCID: PMC3664217 DOI: 10.1186/1472-6947-13-48] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 04/04/2013] [Indexed: 11/17/2022] Open
Abstract
Background Overtreatment of catheter-associated bacteriuria is a quality and safety problem, despite the availability of evidence-based guidelines. Little is known about how guidelines-based knowledge is integrated into clinicians’ mental models for diagnosing catheter-associated urinary tract infection (CA-UTI). The objectives of this research were to better understand clinicians’ mental models for CA-UTI, and to develop and validate an algorithm to improve diagnostic accuracy for CA-UTI. Methods We conducted two phases of this research project. In phase one, 10 clinicians assessed and diagnosed four patient cases of catheter associated bacteriuria (n= 40 total cases). We assessed the clinical cues used when diagnosing these cases to determine if the mental models were IDSA guideline compliant. In phase two, we developed a diagnostic algorithm derived from the IDSA guidelines. IDSA guideline authors and non-expert clinicians evaluated the algorithm for content and face validity. In order to determine if diagnostic accuracy improved using the algorithm, we had experts and non-experts diagnose 71 cases of bacteriuria. Results Only 21 (53%) diagnoses made by clinicians without the algorithm were guidelines-concordant with fair inter-rater reliability between clinicians (Fleiss’ kappa = 0.35, 95% Confidence Intervals (CIs) = 0.21 and 0.50). Evidence suggests that clinicians’ mental models are inappropriately constructed in that clinicians endorsed guidelines-discordant cues as influential in their decision-making: pyuria, systemic leukocytosis, organism type and number, weakness, and elderly or frail patient. Using the algorithm, inter-rater reliability between the expert and each non-expert was substantial (Cohen’s kappa = 0.72, 95% CIs = 0.52 and 0.93 between the expert and non-expert #1 and 0.80, 95% CIs = 0.61 and 0.99 between the expert and non-expert #2). Conclusions Diagnostic errors occur when clinicians’ mental models for catheter-associated bacteriuria include cues that are guidelines-discordant for CA-UTI. The understanding we gained of clinicians’ mental models, especially diagnostic errors, and the algorithm developed to address these errors will inform interventions to improve the accuracy and reliability of CA-UTI diagnoses.
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Affiliation(s)
- Barbara W Trautner
- Houston Health Services Research and Development Center of Excellence, Michael E, DeBakey VA Medical Center, Houston, TX, USA
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