PROPOSAL TITLE: Hospital Acquired Infection (HAI) Reduction through Diagnostic Stewardship

PROJECT LEAD(S):  HAI Committee Leads (PCD/CNS, MD, HEIP)

EXECUTIVE SPONSOR(S):

• Art Dominguez, Chief Nursing Officer, Adult Services
• Nerys Benfield, Interim Chief Medical Officer, Adult Services

ABSTRACT  

Our goal is to develop clinical decision support in the form of practice guidelines, HAI related testing algorithms and EHR support for clinicians surrounding diagnostic stewardship of urine, blood, and C. difficile laboratory testing. By standardizing clinical criteria required for testing, we anticipate fewer tests being performed during diagnostic evaluations and lower rates of CAUTI, CLABSI and CDI. This initiative would also lead to lower health system costs in the form of reduced supply use for specimen collection and isolation precautions in the case of CDI, fewer laboratory technician resources for processing specimens and reduced medication costs for antibiotics. It would lead to indirect savings by redirecting valuable clinician time spent ordering, obtaining samples, and then analyzing and acting on results that likely do not represent true infection. Most importantly, it would improve patient safety by avoiding unnecessary antibiotics and potentially the related adverse drug effects that a large percentage of patients are affected by. Other ripple effects could be reduced antibiotic resistance rates if fewer diagnostic tests are ordered and fewer antibiotics prescribed, fewer central line procedures/days in the case of CLABSI and shorter hospital lengths of stay across the board.

TEAM

• Deborah Yokoe, HEIP Medical Director
• CAUTI Committee: Tristin Penland, PCD; Amy Larsen, CNS; Catherine Lau, MD; Nithila Asokaraj, HEIP
• CLABSI Committee: Tristin Penland, PCD; Vivian Huang, CNS; Cass Sandoval, CNS; Lindsey Huddleston, MD; Renee Graham-Ojo, HEIP
• CDI Committee: Elizabeth Sin, PCD; Lindsay Bolt, CNS; Daniel Escobar, MD; Michele Downing, HEIP

PROBLEM

Excellent patient care is at the heart of UCSF mission, vision and values. One of our strategic priorities in the category of quality and safety is to achieve zero patient harm. To do so, we aim to minimize hospital acquired infections (HAIs), which are measured and tracked on our internal Zero Harm Dashboard. HAIs such as CAUTI (catheter-associated urinary tract infections), CLABSI (central line-associated bloodstream infections), and CDI (clostridioides difficile infections) contribute to increased morbidity, mortality, hospital costs, and length of stay. Many cases deemed to be HAIs may not in fact be true infections. Due to surveillance definitions created by the CDC, when no other source of a pathogen is cultured or clinically validated, in a given patient simply having a central line or urinary catheter present along with general symptoms can lead to an HAI attribution and often times to patient treatment. In the case of CDI, sending samples for testing too soon or too often for example can lead to overdiagnosis and overtreatment of patients who may be truly infected. Inappropriate treatment of HAIs also can lead to adverse drug events such as rash, candidiasis, and diarrhea, as well as increased rates of bacterial resistance and true C. difficile infections, additional healthcare costs, and longer hospital stays. HAI rates based on surveillance definitions may over diagnose CAUTI by ~37%, CLABSI by ~30%, and CDI by ~15%–53% (Madden et al., 2018). Public reporting of HAI rates as a quality measure is required, which may also harm a healthcare institution’s reputation and weaken patient and family’s confidence in their care if infection rates are high. HAI rates are also tied to reimbursement penalties. In 2023, the Society for Healthcare Epidemiology of America (SHEA), the Infectious Disease Society of America (IDSA), and the Association for Professionals in Infection Control and Epidemiology (APIC) published a compendium of practice recommendations for HAI prevention in acute-care hospitals, listing diagnostic stewardship as an essential practice (Yokoe et al.). Diagnostic stewardship is a core element of antimicrobial stewardship, working upstream from and synergistically with antimicrobial stewardship efforts to prevent overdiagnosis and overtreatment, thereby improving value and quality of care while safely reducing healthcare costs.

Diagnostic stewardship includes:

1. Implementation of institutional protocols for appropriate evidence-based indications for HAI diagnostics (urine cultures in patients with indwelling catheters for CAUTI, blood cultures for CLABSI, C. diff PCR for CDI).
2. Education of providers and nurses about the importance of diagnostic stewardship, providing indications for diagnostics.
3. Incorporation of institutional protocols and indications into the electronic health record with decision support for clinical practice.
4. Training on appropriate diagnostic testing collection to reduce contamination.
5. Creation of a system for assessing and tracking process measures and compliance with established institutional protocols for ongoing adherence to best practices in diagnostic stewardship.

A series of Failure Mode and Effects Analysis (FMEA) was recently conducted in each HAI Committee to identify and address potential problems, listing essential practices and noting institutional gaps. Each FMEA involved a multidisciplinary group of subject experts, including providers, nurse leaders, clinical nurse specialists, and infection preventionists. All three HAI groups ranked diagnostic stewardship as a high-priority initiative, listed in the top 2 essential practices of greatest priority in each committee. Scoring and prioritization considered the severity of the existing gap’s potential effect on the system, frequency of occurrence, and difficulty to detect a failure in current state. Once diagnostic stewardship was identified as a top priority to address practice gaps in HAI, the individual committees drafted CAUTI, CLABSI, and CDI Prevention Guidelines that included diagnostic stewardship practices and appropriate indications for diagnostic testing. The HAI Prevention Guidelines were disseminated to nursing and provider teams and posted online under UCSF Clinical Guidelines. While overdiagnosis and overtreatment are difficult to track and quantify, Hospital Epidemiology & Infection Prevention (HEIP), nursing, and provider colleagues review each HAI case. Within these interdisciplinary HAI huddles, it was noted that inappropriate diagnostic testing persisted in practice even after dissemination of HAI Prevention Guidelines. This indicates that more education for healthcare providers and improved clinical decision-making support is necessary to ensure optimal diagnostic stewardship. The EHR can be a powerful tool to reach clinicians when ordering and collecting diagnostic specimens, helping to reduce over diagnosis and subsequent overtreatment.

TARGET

Goal: We aim to safely reduce the number of unnecessary HAI diagnostic tests for CAUTI, CLABSI and CDiff for adult hospitalized patients at UCSF when appropriate indications are not met.

Counterbalance Measures: We aim to ensure diagnostic testing is ordered and performed when indicated, and true positive HAIs are treated as clinically appropriate.

Expected quantitative benefits:

• Decrease in unnecessary diagnostic tests
• Fewer unnecessary antibiotics prescribed
• Decrease in false positive results and HAI harm metrics
• Maximized payer reimbursement
• Improved institutional ranking and scores
• Increase in bed availability
• Increased patient satisfaction

Expected qualitative benefits:

• Improved staff satisfaction for providers, nurses and lab personel
• Improved patient flow
• Improved institutional reputation

GAPS

This problem exists due to overdiagnosis and overtreatment of clinically insignificant (asymptomatic) or false positive results:

• Asymptomatic bacteriuria (up to 100% in chronic urinary catheters)
• Asymptomatic colonization of C. diff (10% inpatient, 5-10x more common than infection)
• Treatment of contaminated blood cultures
• Frequent blood cultures in patients at low risk for BSI and unnecessary follow-up blood cultures

This can occur for several reasons including knowledge deficit as when antimicrobial therapy is continued for days without clear indications once started. We also have a large diverse provider population involved in patient care who can order HAI diagnostic tests. It is difficult to keep providers up to date on current diagnostic guidelines and mindful of diagnostic stewardship. Other provider related reasons include disbelief in diagnostic stewardship or malpractice concerns. At times, there may be a lack of documentation to support the diagnostic indication (e.g., 3 loose stools for CDI) and sometimes patients or families themselves play a role when insisting on a given diagnostic work up.

INTERVENTION

Our proposed intervention includes the following elements:

• Pre- and post-intervention provider and nursing knowledge surveys
• Briefly survey wide sample of adult inpatient providers and nurses to assess their baseline understanding of HAI diagnostic stewardship principles, indications, implications of overdiagnosis and available resources
• Staff education on diagnostic stewardship and UCSF HAI Prevention Clinical Guidelines (2023): CAUTI Prevention Guideline, CLABSI Prevention Guideline, CDIFF Prevention Guideline
• Nursing education on documentation and specimen collection
• Focus on documentation of indications (e.g., fever, loose stool), reducing contamination of cultures and collection of inappropriate stool samples (e.g., formed stool, <7 days)
• EHR clinical decision-making support
• Create diagnostic orders that list appropriate indications
  • Soft stop if indications not met or not selected
  • BPA recommending reflex urine culture in immunocompetent patients
  • BPA consideration for patients in comfort care
• Create specimen collection best practice reminders
  • BPA or soft stop if indications not met or specimen likely rejected (e.g. documentation of formed stool, indwelling urinary catheter (IUC) > 7 days)
• HAI case reviews
• Continue HAI case review huddles for each identified CAUTI, CLABSI, and CDI case with HEIP, nursing, and provider involvement to identify trends and opportunities
• Collect information on appropriateness of diagnostic testing
• Diagnostic stewardship dashboard
• Create dashboard to aggregate and trend data on appropriateness of diagnostic testing
• Collect and trend contamination rates and measure efficacy of interventions
• Ongoing discussion and improvement in True North HAI Outcomes Committee
• Discuss regular feedback from staff and case review data
• Plan for further education or EHR modification with engagement from key stakeholders
• Collaborate with Antimicrobial Stewardship Committee when appropriate

PROPOSED EHR MODIFICATIONS

Though diagnostic orders exist, we propose to enhance them with clinical decision support as outlined in the description of our intervention. BPAs/soft stops would be new for CAUTI and CLABSI related elements and require modification for CDI. A new dashboard for monitoring diagnostic stewardship is also within the scope of this project.

RETURN ON INVESTMENT (ROI) 

Estimated direct cost savings and/or revenue enhancement to the health system from the proposed project include the following:

• AHRQ Estimates (2017):
• CAUTI: $13,793 ($5,019–$22,568)
• CLABSI: $48,108 ($27,232–$68,983)
• CDIFF: $17,260 ($9,341–$25,180)
• Cost includes test equipment, lab performing test, nursing time to collect urine, empiric antibiotic therapy, replacement device cost (replacing line and time associated)
• One study specific to CAUTI performed at USC demonstrated a reduction of lab expenditure of $920-3900/month through decreasing urine cultures by about 230 per month.

SUSTAINABILITY

CAUTI, CLABSI, and CDI Leadership Committees can manage ongoing enhancements once initial systems are created and implemented.

BUDGET

• Project member protected salary time for project implementation: $45,000
• Development and dissemination of educational materials: $5,000

References

1. Agency for Healthcare Research and Quality (2017). Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions.
2. American Board of Internal Medicine Foundation (2014). Unnecessary Tests and Procedures In the Health Care System What Physicians Say About The Problem, the Causes, and the Solutions. www.choosingwisely.org/wp-content/uploads/2014/04/042814_Final-Choosing-Wisely-Survey-Report.pdf.
3. Madden, G. R., Weinstein, R. A., & Sifri, C. D. (2018). Diagnostic Stewardship for Healthcare-Associated Infections: Opportunities and Challenges to Safely Reduce Test Use. Infection control and hospital epidemiology, 39(2), 214–218. https://doi.org/10.1017/ice.2017.278
4. Yokoe, D. S., Advani, S. D., Anderson, D. J., Babcock, H. M., Bell, M., Berenholtz, S. M., Bryant, K. A., Buetti, N., Calderwood, M. S., Calfee, D. P., Dubberke, E. R., Ellingson, K. D., Fishman, N. O., Gerding, D. N., Glowicz, J., Hayden, M. K., Kaye, K. S., Klompas, M., Kociolek, L. K., Landon, E., … Maragakis, L. L. (2023). Executive Summary: A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute-Care Hospitals: 2022 Updates. Infection control and hospital epidemiology, 44(10), 1540–1554. https://doi.org/10.1017/ice.2023.138
5.  https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-p...