Infectious Complications Related to the Catheter Other than CAUTI (September 9, 2014)

American Hospital Association – Chicago
September National Content Call
September 9, 2014
11:00 AM CT

Operator: This is a recording for the Kathy Drury Teleconference with American Hospital Association Chicago, Tuesday, September 9, 2014 scheduled for 11:00 a.m. Central Time. Ladies and gentlemen, thank you for your patience in holding. We now have our speakers in conference. Please be aware that each of your lines is in a listen-only mode. At the conclusion of our speakers' presentations, we will open the floor for questions. Instructions will be given at that time on the procedure to follow if you would like to ask a question. It is now my pleasure to turn this conference over to Ashley Hoffman. Ms. Hoffman you may begin.

Ashley Hoffmann: Hello everyone and welcome to the September National Content Webinar. We're so excited to have you with us at today's event which will focus on complications dealing with catheter insertion and utilization other than cordis. Quick reminder that the floor is again a presentation that this is a webinar. Please be sure to log in through the webinar link in order to see the slides today. We'll also post a copy of the slides and the recording on our projects website later this week. Now I'd like to introduce our guest speakers for today. Dr. Mohamad Fakih, is a Professor of Medicine at Wayne State University School of Medicine & Hospital Epidemiologist, and Medical Director of Infection Prevention & Control at St. John Hospital & Medical Center, both in Detroit, Michigan. He is also the National Infectious Disease Section Leader for Ascension Health System with more than 100 hospitals. We also have Dr. Nasia Safdar, who is Associate Professor of Infectious Diseases at the University of Wisconsin School of Medicine and Public Health. She is also the Hospital Epidemiologist for the University of Wisconsin Hospital and Clinics. Also joining us is Dr. Kathlyn Fletcher, an Associate Professor of Internal Medicine at the Medical College of Wisconsin and the Milwaukee VA Medical Center. Without further ado, it is my pleasure to introduce our guest speakers, Dr. Fakih?

Dr. Mohamad Fakih: Thank very much, Ashley. First I'm just going to list to you the learning objectives. Each point is one speaker. I'll be talking about the urinary catheters as a potential reservoir for transmission of multi (02:11.9 indiscernible) organisms. Dr. Safdar will be discussing the impact of unnecessary antibiotic overuse and CAUTI C. diff infection. Dr. Fletcher will be discussing the role of unis culture on prevention of claudi. We'll start with a polling question. I'll read it. Which is the following is more likely in patients with urinary catheters? The first, we are starting slides. The first one would be patients developing symptomatic CAUTI, and the second one patients being given inappropriate antimicrobials for asymptomatic bacteria. The third would be patients developing bacteriania from the urinary source. Let's vote.

Ashley Hoffmann: We've got about half of those no responses. We'll give about 30 more seconds to select your choice. All right. I've think we've got everyone's response for them.

Dr. Mohamad Fakih: Okay. 64 percent said that the antibiotics, the patient being given inappropriate antibiotics would advise bacteria. I would vote for the same. The issue is with inappropriate and microbial use I think is a major problem. CAUTI happens not as often as the inappropriate and appropriate use or bacterania is much less likely. That doesn't mean that bacteria often are mistaken as CAUTI, so physicians and clinicians give antibiotics inappropriately. Clinicians even give antibiotics even if someone has had a history of CAUTI. There was a recent study describing that. Bacterania hasn't been about 4 percent or less of cases of bacteria, so it's an uncommon event. When we look at the infectious complications and the relation to the catheter, we focused for the last few years on CAUTI. CAUTI is important but it's not the only infectious complication. You can have quite the CAUTI complications with the upper urinary tract involvement such as the nephritis. Let's think about CAUTI and then developing mentoring and that patient has feeding of bacterania to areas such as the spine, or developing endocartitis or septic arthritis. These can be disaster complications.

Less often talked about, but it's more of an invisible thing, when you have an asymptomatic urinary colonization, you give antibiotics and you develop either a coccus empheseal infection or MDR or colonization C. diff, you develop organisms in the urine. We never figure out why they happen. We think it's part of being in the hospital. Plus the endomicrobal pressure plays a huge role or transmission between patients. When we talk about MDR or colonization there are two implications. Either that organism would cause infection to the patient who is colonized, or that patient who is colonized will be touched by a healthcare worker, or that patient will contaminate with his or her flora the area close to him or her, and then there's so much transmission. Or a health care worker asking if mode of transmission between patients. Patients with informing catheters and colonized urine, there's a much higher risk for them to transfer to the healthcare worker organisms will contaminate over the environment and they will pass for months, especially the gram negatives. And then for my transmission whether it's a blood pressure machine, whether it's anything that is shared with patients, if it's not cleaned between patients, that's what happens.

Another problem with a pressure with antibiotics and their side effects and physical, more resistant organisms and questions to field. Simple solution would be minimizing catheter exposure and avoiding unnecessary cultures and promoting appropriate antimicrobial use. When we talk about avoiding unnecessary cultures, we talk about deciding on doing a urine culture when clinically it is the pertinent thing to do.

The second polling question: Multi-drug resistant organisms. One of these is correct. Antimicrobial resistance is associated with about $20 billion direct healthcare costs per year. Antimicrobial resistance is associated with $1 billion direct healthcare costs per year. And developing new antibiotics is more important than preventing infection and preventing suppressed of organisms or MDROs. Sorry the slide does not show up.

My data is from the CDC publication last year that discussed antibiotics. Sorry. I think this is good. The CDC mentions it is $20 billion. This is from the antibiotic resistance tracks in 2013. They reported of $20 billion of direct costs to the country. Also what they mention is the four core actions to fight deadly infections. I've been in blue here, preventing infections and preventing further resistance.

If we think about the urinary catheter, again, this is a foreign catheter and having the urine very easily accessible for people to do cultures and to give antibiotics. I think it ties into that first part, tracking of this curious amount of core action plan, improving the use of the patent antibiotics and promoting development of new antibiotics and developing new diagnostic tests for resistant bacteria.

You see Item one is what's more pertinent to us. Let's give you a few examples of carbapenem resistant is the bacteriaceae. Very resistant organisms to many antibiotics. Klebsiella and warny (0:09:29 ph) is the main one, it's also called KPCs, and there is the New Delhi metalovasoestamace (09:36 ph). They are responsible for outpatient hospitals. My policy can be up to 50 percent with limited antimicrobial availability for these organisms.

You can, MMWR 2013 discussed CRE, it's an estimation of the proportion of CREs in the United States. They surveyed acute care hospitals and long-term acute care hospitals, short- and long-term, out texts and auxiliary acute hospitals. What they found out within the first six months of 2012, at least one case of CRE was present in 4 percent of short-term acute care hospitals versus outpass 17.8 percent. The outpass have a higher presence of these organisms versus a CRE in 2004 was much lower. There is a problem. We are seeing more of CRE in the United States facilities and patients' facilities. What about the link between CRE and urinary catheters? When you look at publications, you won't find a publication that says that CRE and the uric acid. You have to dig and see where they're getting these organisms from. This is what I tried to do, is try to share with you different articles and show you how often it originates from the urine.

This is the Emergent Infections Program with three cities: Atlanta, Minneapolis and Portland. They have 72 cases and most of them came from Atlanta, about 59. Most of the CREs or KPCs followed entero vascular and E. coli. The urine was the most common source, 89 percent were urinary organisms. When you look at Table 3, presence of uric acid in the last two days, 47 percent had the urinary catheter. I'm not saying it's the cause or relationship, but it's a good association.

Theory and urinary catheters, what are the implications of these findings? High mortality and other infections, additional resistance to other antimicrobial classes and other novel antimicrobials, and potential (12:05 indiscernible) in a healthcare setting, and CRE potential stress in the community also are not just in the hospital.

What about Altec for ICUs? This is national data published in actually in 2012 comparing SCs to Altecs. The most common organisms in the regular hospital ICUs were E. coli and Candida, in the Altecs; it was for CAUTIs, was cholestial (12:34 ph) the wellness. The Altecs showed more MDR also associated with the CAUTIs, and if you see from the figure here, you look at resistant E faecalis in the Altecs as black, complete forest black. The Altecs are 41 percent, and VRE fecium Altecs is almost 95 percent. Then the Enterobacteriaceae resistant carbapenems almost like CREs, much higher in the Altecs, it's the third, the second circle or oval. So Altecs, the ways they grow and CRE and the list of MPROs. In the same study, they showed - they see more VRE as a list of reported Altecs, and I mentioned that 44 percent versus ICU 7 to 13 percent. The proportion of MDRs to pneumonas CAUTI, I believe, was 25 percent in Altecs versus 12-16 percent in the ICUs. And no significant difference in CRE CAUTI (0:13:45 indiscernible) between Altecs and ICUs, but 42 percent of Altecs supported the CRE CAUTI compared to the ICUs 8-21 percent. Peaberton Ichi also looked at MDRs and CAUTI, 2000 hospitals, CAUTI organisms showed CRE (14:04 indiscernible) 12.5 percent, CRE E. coli 2.3 percent and CRE cecium was in 86 percent of the cases, also resistant E. coli and Fluor resistant in 67 percent. Again, the urine is harboring very resistant organisms. In the same study, if you look at ICU versus non-ICU a little bit more of increased resistance in the non-ICU versus the ICU. You see here in the yellow which was kind of interesting, you see 52 percent for MRSA in the ICU, 63 percent in non-ICU. The resistant NOV CRE faecalis 12 percent in the non-ICU versus 6 percent in the ICU. And similar CREs flora in ICU. There's a platform here although we still need to push in the ICUs because utilization of catheters is high, but the flora is as bad.

Michigan Experiences is another one that I wanted to share with you, 17 hospitals and 4 Altecs, 6 months data. 102 cases, the vast majority of CREs is KPCs. When they evaluated these cases, 61 percent were from urine, 15 percent Astoria, and 10 percent were blood. But look at this, when they look at the involved devices the urinary catheter is present in half of them.

What about nursing homes? There is a perfected evaluation of 15 nursing homes in Southeastern Michigan. They compared patients with or without the device, and their definition of the device was having a urinary catheter or a feeding tube or both. And 60 of the 90 patients had a urinary catheter. The device group had a higher infection rate and 55 percent higher urinary tract infection rate. They were also these patients that had a device were also more likely to become mixed with MDROs. It may be a marker for device of illness and colonization with resistant organisms.

My last slide: What do we learn from these studies? Urinary catheter use is associated with isolation of MDROs. This is seen in acute care setting but also in the long-term acute care hospitals and nursing homes in the ICU and non-ICU, and reducing unnecessary urinary catheter use may help reduce MDRO colonization and can frequently spread in the healthcare setting. I'm going to give the slides to Dr. Safdar. Thank you.

Dr. Nasia Safdar: Thank you Mohamad. Hi everyone. This is Nasia Safdar from Wisconsin. If all of you have read the book, If You Give a Mouse a Cookie, That Ends. We're going to use that same theme. If you give you give a patient a urinary catheter what are the possibilities? Mohamad outlined that it can lead to a lot of MDR lycellations. My part of the talk will focus on what else can happen, and obviously the big pathogen that we are troubling with right now on these slides is Clostridium Difficile infection.

What if somebody has a symptomatic catheter-associated urinary tract infection that requires antibiotics legitimately or asymptomatic bacteria that typically does not need antibiotics? Regardless of that, if they're administered one of the side effects of that can be C. Diff infection.

Next slide. This is one of many papers were published when the outbreak of the new virulent strain of C. Diff was first identified. It spread very rapidly and is now a global problem. 6 percent of eyes lives at UW are the Nap I or the R27 strain which is the epidemic strain which is the epidemic strain that produces 16 and 23 times the amount of toxin that your standard C. Diff strain will produce, all the stations to have nucomoid reactions required collected is often associated with a higher death rate than the non-epidemic strain.

Next slide. Even though we talk about antimicrobials as all of them being able to induce C. difficile, but clearly there is a difference in the risk of the frequency with which they induce C. diff. On the left the column is the frequent inducers of C. diff, and the one following that is infrequent induction, and the ones that rarely induces. You will see that even Vancomycin is listed there as an antibiotic that may induce C. diff. Any antibiotic, even those that are used for treatment of C. diff can also cause it, at least in case reports essential.

But going back to the first column, the ones that are used very commonly in hospital are cephlosporins and fluoroquinolones. Fluoroquinolone use has risen exponentially for obvious reasons. They're oral, while they're inexpensive, they do offset the cost of having to give somebody an IV anti-infective when they have a reason for an antibiotic. It is the Fluoroquinolones that have led to this upsurge in C. diff, many people think, especially the new epidemic strain, because the distinguishing feature of that strain is that is resistant to Fluoroquinolone.

These are also the anti-infectives that are most commonly used for treatment neuropathogens, especially if there is a multi-___ (19:41 indsicernible) resistant neuropathogens, these are often the anti-infectives that are called upon to do their job.

Next slide please. How does C. diff play into antimicrobial use in hospitalizations? The pathogenesis appears to be that an individual gets hospitalized and then gets antimicrobial exposure. In our scenario it could be from asymptomatic bacteria or it could be from a CAUTI. Then the acquired C. diff from the environment, and because it's a forward producing organism, it's extraordinarily difficult to completely get rid of C. diff from the environment. Any time the environment is inhospitable it simply becomes a spore and that can last forever. You then acquire C. diff from the environment and one of the two things will very quickly happen. Either the person will get C. difficile colitis, or they will be asymptomatic C. diff colonization. These are the scenarios particularly attractive because if they get C. diff colitis, then of course there's all the treatment that needs to happen. But if somebody gets colonized while they may themselves not get symptomatic, they are certainly more than capable of transmitting it to other individuals in the facility, many of whom are very susceptible to getting C. difficile infections and adverse consequences if they do get it.

Next slide. The overall colectomy rate from C. difficile is about 8 per 1,000 down C. difficile cases. There is a debate about whether that is rising or not. Some facilities have reported an upsurge in it. Other multi-site studies have reported that while the rate is high, it at least it doesn't seem to be rising. Nonetheless, this is a significant issue with C. diff because it causes a lot of morbidity and in many cases mortality. Unlike colectomy, there's really no debate on the attributable mortality from C. difficile. That is clearly on the rise. It increased from 3,000 deaths per year during 1999, to 14,000 between 2006 and 2007 and that's a substantial increase even more so when you consider that over 90 percent of the past or current patients over the age of 65 years, which is what most of the population is expected to be in a few years from now.

Next slide please. There is also a great deal of costs associated with C. diff, about $4.8 billion in U.S. acute-care facilities. The burden and the cost of C. difficile in non-acute care facilities has not been well studied at this point, but it is expected to be even higher and to increase as the volume in skilled nursing facilities and long-term acute care homes is projected to grow. One of these sebaceous locedis (22:16 ph) that doesn't help is the fact is that there is a high recurrence rate. It ranges from about 20-30 percent for the first occurrence, but if somebody has had a first recurrence, they their likelihood of getting a second recurrence is about 50 percent and then it goes higher the more number of recurrences increase. There is no good treatment for recurrences in the sense that while we often use management that has been generally used for years. It is more anecdote that it is evidence, and the best thing on the horizon is probably fecal microbiotic transplantation that does have over 95 percent success rate.

What will happen if somebody gets a recurrence of C. diff or they get severe disease? They get an increased length of stay with C. difficile, they may need ICU care if they're severely ill, and now are coming back full circle if they're severely ill, they will likely need a urinary catheter. That was my last slide I believe, and I'm going to, oh actually we have a couple of more. Thank you, Ashley.

There are a lot of things we can do to reduce C. difficile infection. While Mohamad talked about antibiotic use and I think stewardship in addition to infection control is the second prong of our strategy to prevent C. diff.

Next slide. But even those it's easy to say, the devil really is in the details. If you have, this is one study that looked at about 100 consecutive patients with C. diff. They found that in most of them, at least one preceding course of antibiotics was inappropriate. By that theory, then debriefing inappropriate use should lead to reductions in C. diff. But again, defining how to reduce inappropriate use and to sustain that reduction has often proved to be a challenge.

Next slide. This is one study and there are examples of others, but this was one that looked at impact of antibiotic stewardship specifically on C. diff. In the first half of the slide on the left you see that they used an educational intervention. The blue line is MRSA, the purple line is C. diff, and the red one is extended-spectrum beta-lactamases producing gram negatives, the solid green is Septra-axon consumption. The similar other studies that have looked at educational intervention, you'll see that they didn't really notice a major decline. Septra-axon decreased to some extent but not markedly so, and the lines that highlight the various HIs didn't change dramatically. When you compare that to the next intervention when step tracks in the formerl restricted from use, meaning that somebody had to actually call the stewardship team and make a case and make an argument for why they needed it. That degree of restriction dramatically declined the use of Septra-axon as you see in the olid green, but also led to reductions in all of the major HIs. If we are really to use antibiotic stewardship in our favor, it means that we have to use fairly stringent, drastic tactics to reduce cedis with this intervention.
Next slide. And now I will hand it over to Dr. Fletcher.

Kathlyn Fletcher: Thank you. We're going to change gears a little bit and talk about some data from a project that I've been working on that's a little bit more qualitative than the data that we've been talking about. I wanted to start by saying that some very nice work, in terms of trying to understand what the barriers and facilitators are from preventing actually using urinary catheters when they're not supposed to be used, to preventing inappropriate use. Some very nice work has already been done by Sarah Karine and Molly Herod out of the University of Michigan, the Ann Arbor VA.

I went back to some of their work to look to see exactly what they had been hearing about. We'll talk a little bit about that, and then I'll talk about some of the results that we're seeing in our newer interviews that we've been doing.

Next slide please. Some of the barriers to appropriate use of urinary catheters that have been described before include things that won't surprise you, but lack of physician and nursing engagement was their number 1, one. When they described those in a little bit more detail, they heard about physician disinterest in getting the catheters out, nurses not really recognizing the potential severity of the problems that resulted from having urinary catheters when they weren't necessary. They referred to loosely coupled errors. I think about this like that the person who puts in the catheter may or may not see these severe CAUTI that results from it because it may be days to weeks after that actually occurs. The problem with putting in a catheter, and what actually happens with that catheter later, is not necessary coupled in the mind of one person.

They also noted workload issues, leading to work-arounds. That's not hard to imagine, especially for nursing, having patients without catheters may often be the workload problem than having patients with catheters. Then a lot of actually weighing the risk of catheters versus other issues. We know, of course, that having catheter in could lead to falls, but having a catheter out can also theoretically lead to falls because patients are getting up to the bathroom more and may or may not wait for the nurse to come if they call on the call light. There was some evidence in those other studies about the nurses really trying think about well if I take this catheter out am I really helping the patient? They also noted patient and family requests for catheters and for leaving catheters in for longer than maybe the medical team thought. This was especially true in older patients who were incontinent and the families didn't want to think about them in diapers or sitting in a wet bed of course. That was a barrier that they heard about and noticed.

Another significant barrier that they found was the practice in the EDs. Long before the patients even got to the floors or to the ICUs, some Emergency Departments had a policy that they would just put in catheters. When they explored that they found that the EDs really thought that they were helping. In some ways they were helping themselves by making it more convenient to putting the catheter in the patient because if there's not such easy access to bathrooms for example in the ED, and samples, etc. But they also thought that they were helping the floors, the ward nurses who they perceived really wanted the catheters in when the patients arrived on the floor.

Next slide please. Emollients are also delineated from facilitators to appropriate urinary catheter use which are listed on this page. These were things like engaging the physicians and the nurses. Specifically they talked about the importance of nurse champions and local unit-level nurse champions to be helpful in this education and engagement endeavor. In terms of patient requests for catheters, they heard about from their interviewees that patient education was necessary but that that could overcome some of the patient barriers.

Then they also heard about places that really engaged their ED leadership to try to inform them more about what they really wanted on the wards and what was best for the patient. They talked about education and also monitoring which we'll come back to again in terms of I'm giving the ED feedback on the number of patients that came up to the wards with catheters in place.

Next slide please. Then I want to tell you a little bit about our study and what we've been hearing about. One of the goals of this study was to better understand unit level culture around CAUTI prevention. We have conducted interviews and done observations at four institutions. We visited and interviewed people from two units at each site. We've been to eight different units. We included in our interview list nurses from that ward, nurse educators, physicians and then also hospital leadership as well, infection preventionists, quality officers, people in charge of safety. We have a pretty broader representation from each of these units. We are currently in the process of qualitatively analyzing these transcripts. I'm going to tell you some interim results that I think are interesting along with some quotes that we've been using, but our final product may end up looking somewhat different than this because we haven't finished analyzing all of the interviews. I'm sorry, somebody is pounding a nail into a wall near me. I hope you can't hear that.

Okay, next slide please. All right. You'll see that many of our barriers actually mirror the barriers that Karine and Herod described, but we do have a few things that expanded on them. I wanted to talk to you a little bit and use their framework. We did certainly hear about physical barriers.

Specifically we heard about buy-in being fairly sporadic. We didn't necessary hear about disinterest on the part of most physicians, but rather that there was disinterest on the part of some. For example, this unit medical director said: “Some people see it and some people don't. The people who actually see it, you know, are more prone to doing the thing. The people who don't, you know, just think it's a burden.”

Next slide. Other physician barriers that we heard about is knowledge of the problem, and also maybe lack of knowledge of the financial consequences. This infection control professional told us: “I think certain ones, that is physicians, feel it's very important. And I think other ones will once they realize how it affects the general welfare of patients, plus reporting and plus not getting paid for infections any more. I think there's not enough knowledge-base on their part on how this is going to affect the bottom line financially as well as, you know, the patient.” Here implying that if physicians knew more about the problem and the problems with inappropriate catheter use as well as the fact that it's really going to start affecting or really is affecting the bottom line that maybe they would be more interested in helping out with this problem.

Next slide please. Other things that we heard about that I thought were particularly interesting and these mostly came up in the ICU settings were the time for checklists. That's I guess not terribly surprising. Physicians saying that they have limited time. A lot of sick patients and if they're on rounds, and they have to choose at the end of rounding on a patient whether they're going to talk about a major problem with the – sorry, it's very loud. If they have to choose between going through a checklist and a safety checklist that includes whether or not the catheter can come out versus one more medical problem of the patients and they're obviously going to choose the medical problem and possibly divert the discussion of the checklist to one of the more junior members of the team who may or may not take care of it.

The other aspect of this that we heard about from the faculty physicians, is their level of interest in the checklist versus other things. Here what we heard about was some people thinking very eloquently about if I am in the room with a patient who has great respiratory physiology on their ventilator screen, then I'm going to choose that than reviewing the checklist. It isn't that I don't think the CAUTIs are important, or that having the lines out as important. That isn't where my function is. There are those sorts of physician barriers realizing that they had a choice to make and choosing the part of the medical care that gave them joy even though they understood that the rest of it was important too.

Next slide. We also did hear about nurse barriers and similar to the physician barriers we heard about enthusiasm which was not uniform across the nurse population. As one unit medical director told us, there are mixed feelings. The people or nurses who see the value in it are actually very, very enthusiastic about it. The people who think it's burdensome because it's another thing for them to do are not really enthusiastic. There are mixed feelings about it actually, really similar to the quotes that we heard about the physician involvement and interest.

Next slide please. Other nurse barriers that were similar to Karine and Herod found workflow issues, and the risk of Foley versus other risks. I think this quote catches both of them nicely from an RN on one of those wards. She said:  “I think they always agree with, you know, best practices. I just think sometimes workflow or, you know, if you have a patient who, yes they can void, but every time the patient uses the urinal they make a big mess. We're not worried about the patient's skin. That's another issue with incontinence in this environment. You know, the benefits versus the risk of placing of Foley catheter. Yeah, they probably want to go ahead and place that Foley catheter. Maybe we can try that kind of catheter or something else first. I think those are, I guess, I kind of mentioned that before, but I think those are the day-to-day clinical practice frustrations where it's sometimes hard to do the right thing.”

Next slide. Then this came up with both nurses and physicians so I wanted to bring it up. This is especially true in the ICU, that there is a belief in the needs of close monitoring of Is and Os. True or not in every case, but we heard about it quite a bit. For example, one nurse educator said: “Most of our patients are critically ill, so we do need the Foleys so we can measure output, you know? Have very Is and Os for patients, but we do try to remove them as quickly as possible.” And then another RN who said in response to a question about what lessons they've learned for implementing catheter associated urinary tract prevention efforts: “I give more attention to the ICUs. I would say that again, while we're very justified you know, most of the time, in having Foley catheters, we do truly need them. I think sometimes we give ourselves a free pass when maybe we didn't deserve it, and you know, maybe we should spent a little more time in that practice environment to see if we can decrease the number of actual Foleys that we have and still be able to achieve good, you know, intake and output. It's challenging, but you know, there be opportunities there.” You can see I think in both of those quotes, both the acknowledgement that they're hiding behind the accurate Is and Os, and yet continuing to invoke the accurate Is and Os.

Next slide. We actually did not find significant patient and family barriers in the discussions that we had with these units. It occasionally came up, but everybody that we talked to about it thought that they could overcome it pretty easily with some education.

Next slide. We did also uncover some interesting administrative barriers. The most significant one I would say was an issue around measuring and reporting. One infection control professional said this to us when we asked about what lessons she had learned. She said, “Do you have all day? It's not as simple as it seems, especially when you have a computerized record, and you have so many different factors involved, and so many different people involved in making decisions. What is important and not important and how to roll it out. And also, just the documentation of it. You know? You want it measured, but they're not agreeing in how to document it or how to measure it.”

What she was talking about here was the great number of different organizations that they actually had to report out data to, and her feeling that it was not the same data that each organization wanted, so they ended up collecting all this data and putting it together in different ways to please UHC, or SKIP or the CDC. They found that to be frustrating along with the changing of definitions, etc., all rolled up with all these other issues, like how to even roll it out when you have an EHR.

Next slide please. The other administrative barrier that we heard about was just the need for, and the difficulty in having, dedicated sustained attention to that issue. This infection control professional said: “So that's the other hardship in having to dedicate people underneath to be able to follow through on it. It can't be just the infection team doing it. It has to be on every floor. It has to be an act of involvement. You actually need champions on the unit level.” I would add, from what we heard from others it needs to be sustained unit champions on the unit level. It can't be this year it's CAUTI, and next year it's something else.

Next slide please. With those barriers in mind, and then thinking about what some of the things were that these institutions had been implementing. I just put together this slide of what sounded like to us to be some effective strategies. Feeding back the data seems to be very important, feeding it back to the frontlines. It's not just feeding back all of the data. In one example we saw they really followed these three principles. They kept it simple. They used one measurement that they consistently fed back to the unit each unit in the hospital. They used day since last CAUTI because it was easy to grasp, it was easy for everybody to understand, it was easy to compare one unit to another. But every month that's what they gave them. They didn't give them their rate of CAUTIs, they didn't give them their rate of inappropriate use, they just said, day since last CAUTI and everybody in the hospital talked about it.

They kept it consistent. They did it every month. Everybody knew it was coming. It was coming via emails, the emails looked the same. I think that was very helpful. Then they also put in a rewards system for good performance. If a unit went a certain number of days without a CAUTI they received a water bottle and if they went longer, they received a fruit basket. You can see what I mean. People, the ward started talking about this, and they started trying to be those wards that were getting those prizes.

Then another principle that we pulled from the interviews that we've done so far is that the enthusiasm and support needs to come both from the top down, like everybody needs to believe that the hospital administration cares about this, but it also needs to come from the bottom up, those unit-level champions who are training and educating one-on-one, seemed very important.

Then finally this idea of the sustained focus. It's not lost amongst all the competing priorities that we're working on trying to prevent all the HAIs, early ambulation and all of the other initiatives. There needs to continue to be some focus on each one moving forward. I don't know how to do that, but that seemed to be important.

Next slide. In summary, I would say that at this interim stage, our data supports the models that were proposed by Karine and Herod. Physician barriers we found had lessened but they were still present. The nurse barriers appeared to be similar to what they described, and we think that the patient barriers are also lessening.

We did also identify some new administrative barriers specifically around reporting issues. We feel that at this point, probably the best recommendations is to make sure that it is a sustained effort with a simple message which may be the key to actually moving the needle on this issue. That is all I have. Thank you.

Ashley Hoffmann: Thank you all so much for sharing this information especially the interviews and the quotes. I think those are really helpful. We'd now like to open up the call to questions from our audience. Operator can you begin the Q&A session by giving the instructions:

Operator: Thank you very much. Ladies and gentlemen, at this time we would like to open the floor for questions. If you would like to ask a question, please press *1 on your touchtone phone now. Questions will be taken in the order in which they are received. If at any time you would like to remove yourself from the questioning queue, please press *2. Once again, as a reminder, if you would like to ask a question, please press *1 on your touch tone phone now.

Ashley Hoffmann: You guys can also enter questions into the chat, so if we don't get to them on the calls, we can send them to our guest speakers and get a response out to you that way.

Operator: Thank you. Our first question will come from Jane Johnston, Shore Memorial.

Jane Johnston: Hi. Thanks for taking my question. We're very involved with working with our frontline staff. The problem that we're running into with maintaining Foleys is we really don't have any great ideas for non-acute retention patients, especially the old guys. I was wondering if anyone had some novel ideas that they are trying.

Dr. Mohamad Fakih: Would you explain a little bit more, by non-acute retention you mean someone with a chronic urinary catheter?

Jane Johnston: Chronic retention, usually—

Dr. Mohamad Fakih: Is this obstructive or non-obstructive?

Jane Johnston: It's usually with big prostates.

Dr. Mohamad Fakih: With obstructive it's really tough.

Jane Johnston: I know and that's—

Dr. Mohamad Fakih: Lacing the catheter, you know, you can't do straight cathing in a narrow, in these cases. It's usually the reason why it's there, it's the inability to drain. In these cases what we do is we suggest urology to evaluate whether these chronic patients need to be chronic or either surgical intervention for the size of the prostate, or other alternatives for the patients with a catheter.

Jane Johnston: Okay, thank you.

Operator: Thank you. Once again, as a reminder, if you would like to ask a question please press *1, on your touch tone phone now. Our next question will come from Peggy Thompson, Tampa General Hospital.

Peggy Thompson: Hi. This question is for Dr. Fakih. Dr. Fakih, we've done a lot of work on reducing catheters days, and actually our utilization rates are quite low in our intensive care units. We've turned our efforts toward reducing unnecessary urine cultures. One of the things we're in the process of trying to implement is restricting urine cultures to the criteria that you outlined in one of your recent presentations. One of the questions that's come up recently is what about patients with sudden onset of delirium, specifically gerontology patients. I wasn't quite sure how to respond to that question.

Dr. Mohamad Fakih: That's a great question. Theoretically if someone develops delirium, it may be related to sepsis, and part of working out the patient's sepsis is looking at the urinary tract. I think what we do if you remember the presentation, what we focus on is a good clinical evaluation of the patient. If the clinical evaluation suggests that the delirium may be related to an infectious quality, and there is no other sources. The patient doesn't have evidence of wharfing respiratory function. You don't see evidence of pneumonia. There is no other accountable catastrophe, and the patient has a catheter, part of the evaluation if you feel clinically that this may be a source then the legitimate thing to do is to run the urine culture. These would not be the mainstream cases. What we usually see, and I'm very impressed with what you did, first of all you used urinary catheter harm, by utilization and also you're pushing for appropriate germ culturing. One of the things we have seen in many hospital is these automatic orders for urine cultures either based on a urine analysis, that's a screening urinalysis, and we know a lot of patients with uric acid will develop a urinary inflammatory response to a foreign body. Then a urine culture based on that process, why tell the urine if it's not based on a clinical impression of someone evaluating the patient, I don't it's fair to our patients. This is what we push for, a better evaluation before ordering these tests. I don't know if I answered your question.

Peggy Thompson: You did. I think one of the things we're struggling with is the pan culturing. We're a teaching hospital we get a fair amount of patient has a fever spike, they've got a Foley catheter in, and then we get the automatic urine culture ordered. We've tried to put some specific criteria down for ordering the urine culture that will eliminate those, but we don't want to make them so stringent that we can't get cultures in patient populations that we really need them in.

Dr. Mohamad Fakih: Let me give you an example. We have a surgical intensive care unit which has a lot of neuro trauma. You would imagine neuro trauma you get a lot of seizures related to the CNRs. We for the longest time had a very high SAR, and the last 6 months there has been a great drop in our SAR. One major thing that was different recently is that the surgical intensive unit owned this. They had their teams almost closed unit. Still people can come in and write orders, but for the last 6 or 7 months it's only their unit team that's writing the orders. They know the patient the most, so if there's any change in the condition, they know it better than someone let's say, another doctor or another surgeon who has just seen the patient just one time, or an internist. I think we go back to making sure that ones that know the patient the best is the way that patient, it makes a huge difference in accountability. When it is only one group that is dealing with that patient, they know the patient very well, they have a plan, they can understand what the fever is about, and there's no other source, then it is something important for them to do the urine culture if this is the source they're worried about. We don't want people to stop doing urine culture, but we're pushing for appropriate utilization of these tasks.

Peggy Thompson: Right, right. Thank you very much.

Dr. Mohamad Fakih: Mm-hmm (affirmative).

Operator: Thank you. Once again as a reminder, if you would like to ask a question, you may press *1 on your touchtone phone now. At this time we have no further questions in the queue.

Ashley Hoffmann: While we wait for questions, eventually you guys are thinking of some good ones for our presenters. I do want to remind everyone to take a quick moment to complete an evaluation of today's webinar. You'll find a link on the left side of your screen in the chat, just a quick survey about our presenters, and the content, and if there is anything else you would like us to present on upcoming webinars. I'll also give you a quick preview of our upcoming webinars for October, November and December. You'll see the topics there on the right side. Next month we have Dr. Lisa Lubomski, who will be presenting on the fast fact sheet and science of safety. She'll also have a unit team presenting with her, so be sure to join us then.

Operator: Again, as a reminder, to ask a question you may press *1 on your touchtone phone now. Ms. Hoffmann, at this time, we have no questions.

Ashley Hoffmann: Any last thoughts or words from our guest speakers today.

Dr. Mohamad Fakih: We thank the audience. I think honestly I think it was a great thing to talk about DROs, C. Diff and also linking it to how to remove the catheters. It was something I learned from today, it's not just focusing on the NDROs, but thinking how we can use all these things and put them together to help us reduce the harm of the catheter.

Katlyn Fletcher: I agree. I learned some things too. Thank you to the other speakers.

Ashley Hoffmann: Likewise. All right. To the audience again, if you have any questions, feel free to contact us. I've put the email address in the chat as well, so you can send us questions at any time, and we can send those to our presenters today. We'd like to thank everyone for your participation on today's call for the great questions. We'll give you four minutes back of your day.

Dr. Mohamad Fakih: Thank you.

Operator: Thank you very much ladies and gentlemen, at this time, this conference has not concluded. You may disconnect your phone lines and have a great rest of the week. Thank you.