The Culture of Culturing: The Importance of Knowing When to ...

The Culture of Culturing: The Importance of Knowing When to ...

AHRQ Safety Program for Long-Term Care: HAIs/CAUTI The Culture of Culturing The Importance of Knowing When To Order Urine Cultures AHRQ Pub. No. 16(17)-0003-16-EF March 2017 Objectives Upon completion of this training, participants will be able to Explain why unnecessary urine cultures can lead to increases in catheter-associated urinary tract infection (CAUTI) reporting and resident harms Determine when (or not) to order urine cultures Utilize evidence-based communication strategies to more effectively communicate urine culture practices

AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI Urine Culturing 2 How Can Ordering Urine Cultures Lead To Resident Harms? Urinary catheter present Cloudy, odorous urine, sediments Inappropriate use of urine culture Overinflated CAUTI rates Inappropriate treatment and antibiotic overuse Miss the correct diagnosis

More resistant organisms, Clostridium difficile, increased cost, further health complications Resident Harms AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI Urine Culturing 3 Bacteriuria Is Not the Same as CAUTI1 What is Bacteriuria? Bacteria in the urine Bacteriuria means the resident has a positive urine culture What is the main difference between bacteriuria and CAUTI? Bacteriuria can be symptomatic or

asymptomatic Bacteriuria Asymptomatic bacteriuria (ASB) CAUTI requires presence of symptoms consistent with UTI AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI ASB CAUTI Urine Culturing 4 Common Signs That Are Inappropriate Triggers for Urine Cultures1

Chronically catheterized patients have bacteriuria 99% of the time. Bacteriuria signs Urine color Urine smell Urine sediment Cloudy urine Pyuria (white blood cells or WBC in the urine) Positive dipstick Bacteriuria is not the same as CAUTI AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI Urine Culturing 5 Pyuria Is Not Diagnostic of CAUTI2 Pyuria, like bacteriuria, does not help differentiate asymptomatic bacteriuria from CAUTI.

Why? Pyuria in the urine is nonspecific Pyuria can be from The catheter itself Bladder distension Asymptomatic bacteriuria Generally avoid dipsticks in catheterized residents AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI Urine Culturing 6 What Are the Signs and Symptoms of a CAUTI?3 ONE or MORE of the following :

CAUTI Signs and Symptoms Fever Rigors New confusion or functional decline (with NO alternative diagnosis AND leukocytosis) New suprapubic pain or costovertebral angle pain or tenderness New onset hypotension (with no alternate noninfectious cause) Acute pain, swelling, or tenderness of the testes, epididymis, or prostate Purulent (pus) discharge from around the catheter AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI Urine Culturing 7 CAUTI Criteria NSHN* Definitions Pocket Card *National Healthcare Safety Network

AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI Urine Culturing 8 Case Scenario: Mrs. Bell ? Mrs. Bell is an 86-year-old resident of your facility. She is being transferred back from a weeklong stay in the hospital. She has an indwelling urinary catheter, but you are unsure why the catheter has been placed. Yesterday her urine was clear and yellow, but today her urine is cloudy and smells bad. What should be done next? a. b. c.

d. e. Urinalysis Urine culture Urinalysis and antibiotics Culture and antibiotics Nothing AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI Urine Culturing 9 Answer to Mrs. Bells Case Nothing! At least, dont send urine for urinalysis or culture Definitely dont start antibiotics!

You wouldnt really do nothing Ask about what she ate Look at her medications Assess for catheter trauma Assess to ensure she is at her baseline Offer fluids; often a better initial step AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI Urine Culturing 10 SBAR for Health Care Communication4,5 SBAR is a TeamSTEPPs framework for team members to effectively communicate information to one another Communicate the following information: SituationWhat is going on with the resident? BackgroundWhat is the clinical background or context?

AssessmentWhat do I think the problem is? RecommendationWhat would I recommend? SBAR can be used with clinicians and with residents and families AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI Urine Culturing 11 Using SBAR To Communicate With Residents and Families Sometimes, residents and families push for urine cultures and antibiotics SBAR can be used to improve communication with residents and families When forming your SBAR make sure to consider What residents and their families are really asking for Alternatives to ordering cultures and using antibiotics Possible side effects of antibiotic use Promote shared decision making

AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI Urine Culturing 12 References 1. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54. PMID: 15714408. 2. Gould CV, Umscheid CA, Agarwal RK, et al. Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines for the Prevention of Catheter-Associated Urinary Tract Infections 2009. Centers for Disease Control and Prevention. http ://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf. 3. Centers for Disease Control and Prevention. Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance. http ://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf. 4. Team Formation Success Video - Sub-Acute Care. TeamSTEPPS Long-Term Care Version. Rockville, MD: Agency for Healthcare Research and Quality; April 2013. http:// www.ahrq.gov/teamstepps/longtermcare/video/06stry1_good/index.html.

5. Communication: Instructors Slides. TeamSTEPPS Long-Term Care Version: Module 6. Rockville, MD: Agency for Healthcare Research and Quality; November 2012. http:// www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/longtermcare/module 6/igltccommunication.html . Accessed October 1, 2015. AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI Urine Culturing 13

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