PROJECT LEAD(S): Cass Sandoval, Adult Critical Care CNS; Amy Larsen, Adult Critical Care CNS; Lindsay Bolt, Adult Medical CNS

EXECUTIVE SPONSOR(S): 

• True North Outcomes Committee:
  • Art Dominguez, Chief Nursing Officer for Adult Services
  • Nerys Benfield, Chief Medical Officer for Adult Services
  • Debbie Yokoe, Medical Director, Hospital Epidemiology and Infection Prevention

ABSTRACT 

In alignment with UCSF True North goals and national practice guidelines, this initiative aims to develop and implement a program of HAI Diagnostic Excellence for hospital-acquired infections (specifically CLABSI, CAUTI, and CDIFF) in the form of standard work for diagnostic evaluations of urine, blood and C. difficile laboratory testing. This program will include a range of components from practice guidelines, HAI-related testing and collection workflows, related APeX workflows, and analysis/reporting capabilities. The HAI Diagnostic Excellence Program will not only reduce the occurrence of clinically insignificant infections but also can potentially save the organization an approximated $560,000 a year, or more. Indirectly, the output from this initiative will lead to savings through reduced equipment and supply needs and reduced clinician time spent performing these tests. Finally, this initiative maximizes patient safety and outcomes by avoiding unnecessary antibiotic use resulting from the treatment of clinically insignificant test results, aligning with principles of antibiotic stewardship, and overall lowering hospital length of stay.

TEAM 

• Nursing Clinical Leads: Cass Sandoval, Adult Critical Care CNS; Amy Larsen, Adult Critical Care CNS; Lindsay Bolt, Adult Medical CNS
• Nursing Operational Leads: Tristin Penland, Interim ACNO for St Mary’s and St Francis hospitals; Elizabeth Sin, PCD Adult Transitional Care; Janice Elzinga, UD Adult Surgical ICU; Mark Apavatjrut, UD Adult Medical ICU
• Provider Leads: Lindsay Huddleston, MD;  Catherine Lau, MD; Daniel Escobar, MD
• HEIP Leads: Renee Graham-Ojo, Infection Preventionist; Steffanie Lee, Infection Preventionist; Michelle Downing, Infection Preventionist  

PROBLEM 

Hospital acquired infections (HAI) such as CAUTI (catheter-associated urinary tract infections), CLABSI (central line-associated bloodstream infections), and CDI (clostridioides difficile infections) are preventable harms known to increase morbidity, mortality, hospital length of stay and overall hospital costs. While preventing patient harm and returning a patient to at least their baseline level of health is always top priority, it is also acknowledged in the literature that the strict surveillance criteria for these infections is estimated to over-diagnose CAUTI by ~37%, CLABSI by ~30%, and CDI by ~15%–53% (Madden et al., 2018). Clinically, inappropriate testing can lead to overtreatment, often with antibiotics, which itself can lead to adverse drug events such as rash, candidiasis, and diarrhea, as well as increased rates of bacterial resistance and true CDI. 

At UCSF, we know we are over-diagnosing and over-treating these HAIs based on CAUTI, CLABSI, and CDI case reviews where individual cases are discussed. However, the full scope of the problem is unknown since there are patients who develop UTI or bloodstream infections that do not meet the specific surveillance criteria for CLABSI or CAUTI (so do not get review by the HAI committees) but would otherwise be considered clinically insignificant yet still receive antibiotic treatment. It is well established that antibiotic therapy increases a patient’s risk of developing CDiff, potentially hindering our improvement efforts surrounding CDiff.    

In alignment with our True North pillars, reduction work for preventable harms has been in place for several years. One of the few remaining major opportunities shared among the three HAIs is that of diagnostic excellence. As the CDC describes, diagnostic excellence is a broad term that encompasses practices aimed at ensuring the right patient gets the right test at the right time and is given the right treatment (diagnostic stewardship). It also includes systems to support these practices from an EHR/documentation and reporting/quality analytics perspective.  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.). Finally, multiple studies have concluded that implementing diagnostic excellence strategies can aid in diagnosis and improve patient outcomes while also maximizing care efficiency and, ultimately, cost savings to the organization.

TARGET 

• Fewer deviations from existing practices for ordering and collecting specimens
• Fewer HAI deemed to be clinically insignificant
• Achieve True North SIR goals for CAUTI, CLABSI and CDiff  

GAPS 

We have a large diverse provider population involved in patient care who independently 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 

Developing a program of diagnostic excellence will include the following:

• Establishing best practices for testing and treating CLABSI, CAUTI, and CDIFF based on currently available literature, guidelines, and community standards.
• Adapting those best practices to create UCSF standard work for testing and treating.
• Develop EHR workflows to support that standard work for direct care clinicians.
• Develop standard work for assessing process measures and compliance with new workflows through newly developed reports and a feedback loop to clinicians.
• Develop reporting workflow on compliance to promote transparency and sustainability. This would likely occur at True North Outcomes meetings.
• Develop education and dissemination plan to socialize new standard workflows to nursing, ordering clinicians, clinical care partners, and laboratory and phlebotomy staff.
• Education campaign highlighting proper specimen collection for testing.

Initial scope would include adult inpatient areas at Parnassus, Mission Bay, and Mount Zion campuses.

Anticipated barriers include the following: 

• There may be specific questions that arise during standard work development that do not have definitive answers in the current body of literature. This would require consensus decision with a group of subject matter experts.
• Creating a build in the EHR may require waiting for analyst workflow availability. There may also be limitations of our EHR system that are unavoidable.
• It is expected that changing the current culture and workflow for testing will be challenging. Many of the existing practices are deeply rooted and will require patience as those practices are de-implemented and new workflows introduced and established.

Potential adverse events include the following:

• There is a potential of delayed treatment of a true infection if a specific patient condition falls outside the guidelines of standard work. Based on experiences at other organizations, this is a fear rarely actualized, though is always possible.

Equity considerations:

• In our current state, we are unable to assess any gaps in equity due to gaps in our analytic capabilities. Assessing for and addressing any equity gaps in our performance with CLABSI, CAUTI, and CDiff would be a high priority consideration for this work.

PROPOSED EHR MODIFICATIONS 

In the current state, there is considerable variability in practice between clinicians in both ordering and collecting lab specimens. There is also minimal clinical decision support built into APeX to reduce the cognitive burden of adhering to existing workflows, further contributing to variability in practice.

We currently rely on manual chart reviews and live huddles to investigate each infection. Recently, a Qualtrics survey was developed to collect data from these huddles but is not fully integrated with APeX. There are reports also available to identify certain data relevant to HAI review. However, they provide a small portion of the data required for case review.

Our goal requires the following in the EHR/APeX:

• Decision support and “smart” order panels for testing indications and specimen collection. For example, populating a specific set of orders based on whether a patient has an indwelling urinary catheter or not.
• Report build for assessing compliance with approved workflows, also allowing the organization to promote clinician accountability.

RETURN ON INVESTMENT (ROI) 

Based on AHRQ data of cost to the organization per infection from 2017 that is adjusted for inflation to 2021, and our average performance over the past 5 years (Jan 2020 – Jan 2025), we could expect the following ROI:

If we consider a 10% reduction in infections resulting from diagnostic excellence work through Caring Wisely (studies show this a reasonable estimate which also aligns with our True North goals), and the estimated costs from above, we could expect the following savings to the organization in the first year:

In summary, while this data is not specific to UCSF, we can safely assume that the cost to UCSF is at least comparable to the median costs estimated by AHRQ. Using those estimates, the combined annual cost to UCSF for CLABSI, CAUTI, and CDIFF is about $5.5 million. Using a conservative reduction estimate of 10% resulting from Diagnostic Excellence work, we can estimate an annual savings of about $550,000. Note: these estimate ONLY considers infections classified as CLABSI, CAUTI, or CDIFF. It does NOT count infections in patients who do not meet criteria for CLABSI or CAUTI, meaning the actual cost and savings to the organization are likely higher than these conservative estimates.

SUSTAINABILITY 

After the initial infrastructure is built during the funding year, the existing structure of True North Outcomes, which encompasses CLABSI, CAUTI, and CDIFF committees, will support ongoing maintenance, reporting, and other enhancements identified. Part of the intervention will be identifying a standard workflow that encourages sustainability of the program.

BUDGET 

• Materials/Supplies (printing, socialization/dissemination materials): $ 2,000
• Support for non-clinical time for team members/Project manager: $30,000
• Report writer: $ 9,000
• Data analysts: $9,000
• Total: $50,000