Series: HSR&D Award Recipient

Cyber seminar Transcript

Date: 3/9/2017

Series: HSR&D Award Recipient

Session: The Story of Kicking CAUTI: Achieving Clinical Impact through Interdisciplinary Team Work

Presenter: Aanand Naik, MD; Barbara Trautner, MD, PhD

This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at http://www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm

Moderator: And we are the top of the hour now. So at this time I would like to introduce our speakers joining us today. And the lead author on the paper is Dr. Barbara Trautner. She’s an associate professor of infectious diseases at the Center of Innovations and Quality Effectiveness and Safety at the Michael E. DeBakey Veterans Affairs Medical Center and with Baylor College of Medicine in Houston, Texas.

Joining her today is Aanand Naik. He’s an associate professor of medicine at the Houston Center for Innovations in Quality Effectiveness and Safety, also at the Michael E. DeBakey VA Medical Center in Baylor College of Medicine, and Director of VA Quality Scholars Program Coordinating Center.

So I’d like to thank our two presenters for joining us today. And Dr. Trautner, are you ready to share your screen?

Dr. Barbara Trautner: Yes. Can you see it?

Moderator: We can, thank you.

Dr. Trautner: Okay. Great. Well I’m Barbara Trautner and my colleague, Aanand Naik and I are honored to be able to present our award-winning paper today. We will tell you the story of Kicking CAUTI, or catheter-associated UTI. This was a project that was able to achieve clinical impact through our interdisciplinary teamwork.

So Kicking CAUTI or catheter-associated UTI was essentially an antibiotic stewardship campaign in which we implemented guidelines to teach providers to stop over-diagnosing and over-treating catheter-associated UTI. Catheter-associated UTI at the time, and still is one of the most common reasons for antibiotic overuse in both acute and long-term care.

So we called our project the “No Knee-Jerk Antibiotics Campaign.” And our study logo was two boots, for several reasons. First of all, the two boots emphasize the no knee-jerk aspect of our project. They kind of helped remind people we were in Texas. And most importantly, they link into our algorithm.

We created a diagnostic algorithm to help providers appropriately diagnose CAUTI when it is and isn’t present. And it requires the providers to ask themselves two questions before testing and treating for catheter-associated UTI. We call these two questions doing the Texas two-step. So you’ll see more about the double boot logo when we describe our algorithm. This project was funded by Health Service Research and Development.

Before I give you the narrative story about how the project came to be, though, I need to explain a little bit about the clinical condition behind it. So bacteriuria, or bacteria in the urine simply means a positive urine culture. It means that bacteria are found in someone’s urine. It does not mean that that individual has any symptoms related to the bacteria in their urine. If there are no specific symptoms, it’s called ASB, or asymptomatic bacteriuria.

If there’s a catheter in place and the patient has symptoms that are specifically related to the presence of bacteria in their bladder, such as bladder pain, bladder spasms or a fever without another cause, then that is diagnosed with a catheter-associated UTI.

Multiple evidence-bases guidelines support neither testing for nor treating asymptomatic bacteriuria, because treating it does not help the patient. And in fact, in many cases treatment of asymptomatic bacteria is harmful. In the bigger picture, overtreatment of any condition, overuse of antibiotics for any condition are harmful to all of us. It’s the cost of unnecessary antibiotics. But more importantly perhaps, is the spread of resistant organisms that has resulted from our overuse of antibiotics.

Now as a practicing clinician, I never find the argument that we need to save society to be very compelling when I’m looking at a sick individual in front of me, who’s under my care. Over the last couple of decades of working with persons with over-diagnosed UTI, I came to realize that overtreatment hurts the individual. It’s hurting the individual patient that I’m looking at.

First of all, antibiotics have a number of side effects. Almost all of them cause gastrointestinal side effects, such as diarrhea. They can cause allergic reactions, rash, kidney failure. We have a lot of clostridium difficile in the VA. And every round of antibiotics increases someone’s risk of getting C. diff colitis.

As we know more and more about the microbiome, which is the healthy flora that’s normally in people’s colons, we understand how each course of antibiotics damages that microbiome and encourages resistant flora to emerge within it. I watched patients over the years in my clinic come back after getting round and round after unnecessary antibiotics for their chronic bacteriuria. And I saw their flora becoming more resistant. That was a big inspiration for this project for me.

And a part of the way that overtreatment of asymptomatic bacteria hurts individuals is, we get a false sense of security because we’re quote “covering the urine” and so we don’t proceed with a [xxxx] diagnostic workup. And that [xxxx] important diagnostic delays in missing the true cause of what’s causing the patient’s symptoms.

So overview of what we’re going to cover today. First we’re going to give you the narrative of how our team formed and how the project came to be. Then we’re going to talk about the results and the theoretical framework behind them. We’ll touch briefly on lessons learned and then the next steps on where we’re going.

So first the story of how our team and project formed. So in 2007, it was early morning and I was sitting at a conference on device-related infections. And although I was, as usual, sitting in the front row, I was just as sound asleep as everyone in this picture.

Then they announced, to make things worse, that the expected speaker couldn’t come. So they had substituted another speaker who was going to speak to us about the CMS, or Center for Medicare Services rule change, that hospitals would no longer be reimbursed for never-events, or events that should be preventable.

And one of the things on this list that hospitals would no longer be reimbursed for was catheter-associated UTI. And I snapped to attention. And I thought, that is the stupidest thing I’ve ever heard. Because everyone knows that if you leave a urinary catheter in for long-term, you know the patients that need the long-term chronic catheters, 100% of them will have bacteria in their urine. You know, colonization occurs and they get colonized with bacteria.

However, that’s asymptomatic bacteria. But most people think it’s catheter-associated UTI if there’s bacteria there and they overtreat it. I started thinking about that. Well, wait, we can’t prevent CAUTI, or catheter-associated UTI. But we can prevent people from falsely diagnosing CAUTI when the patient only has asymptomatic bacteriuria.

So I got really inspired by this idea, and I started typing. I had my laptop and there I was, typing away in the front row. And I got so excited that I had to go back to my room and keep typing this proposal where I was going to teach people the difference when asymptomatic bacteria in catheter-associated UTI so that hospitals could bring down their CAUTI rate.

Well by the end of this two day conference, I had a little five page proposal. But then the problem was, I started knocking on doors, “pick me, pick me, fund my proposal”. But at the time I was a microbiology basic science researcher who also ventured into translational research with some clinical trials.

I actually didn’t know what health services research was. I wasn’t actually aware of our health services research center that was across the street from the building. So I started talking to my usual program officers and they all would kind of say, “no, this isn’t our type of proposal”. Somehow I ended up emailing it to Laura Peterson, who is the director of our COIN. And thankfully she read at least the first page, saw enough of it to say, “you know, Barbara, this is actually a health services research proposal. You need some health services research team members”. And she introduced me to the first two members of my team.

That eventually led to our Kicking CAUTI project. So we had some obstacles, though, in getting to this project. Let me see. Can they see my cursor [xxxx]?

Moderator: Yes, we can.

Dr. Trautner: Awesome. Okay. So I work here. I had a microbiology lab here in this building. This is the Veterans hospital, the Houston VA Hospital. Well the Health Services Research Building of which I was blissfully unaware of happens to be located across the street. And it’s a bit of a distance.

So, but Laura told me to go meet with some people. So I made the little trek from the building here, across the parking lot. And then you had to cross Almeda, which is a really busy street. And then you get the parking lot over here. And then you walk all the way to the end of the building. And you go in right there at the end.

However, as I was to discover, once you get there, boy is it worth it. The building behind these doors was an incredible think tank environment where we were working to improve the delivery of health care. And I got introduced to a lot of people who brought really good ideas to the project, which I will introduce the team more later. But the bottom line is, once I got through those doors, I figured I needed to do whatever I could do to stay here. This is a good place to work.

So here is our team. There’s me. I’m an infectious diseases doctor, I’m a clinician. One of the first people I met, I think Adam was actually slightly before Aanand, was Adam Kelly, who was psychometrician. Because I had mentioned to Laura that I was going to be doing a lot surveys, trying to figure out why people were overtreating for asymptomatic bacteriuria.

So Adam said, “I’m a psychometrician”. And I said, “what is a psychometrician?” After that auspicious start he asked me, “well what do you need in your tool box to make this project a reality?” And I asked him, “what is a tool box?”

So Adam was very patient translating for me. But we decided we had to bring in an expert on translation of health services research speak to me. Which is Aanand Naik. Now he’s billed himself as a geriatrician and a quality improvement scientist. But I’m going to call him an implementation scientist. And also his geriatrician skills were very useful because long-term care is one of the places where you have the most urinary catheters in the VA, and we were seeing the most overtreatment.

So between Aanand and Adam and I, we started to shape this into an actual proposal that was a guideline to build the patient project. And then they pulled in Nancy Petersen, who was a senior biostatistician who had helped us with the study design. And Sylvia Hysong, industrial and organizational psychologist, who’s a real expert in delivery of audit and feedback.

Then later in our project of when she arrived in the United States from Europe, Larissa Grigoryan joined, but she had been studying epidemiology of UTI and antibiotic overuse for UTI in Europe and brought a lot to the analysis of our project.

So as you can see, we’re pretty evenly balanced between MDs and PhDs. And that was great. Because as a clinician, I’m kind of practical. I just want to get it done. I wanted to see the clinical outcomes. That’s the only part I felt like I was comfortable with. But the PhDs were much more purist. And they made me define the measures and the intervention and how we were going to deliver it very clearly upfront.

Well that, of course, is what ended up making this such a high-quality project. Because we did pick our measures and we did stay consistent in our delivery so that at the end of this we had something that we could evaluate and hopefully generalize.

Okay. So now there’s something really important missing from our team though. We omitted a key stake holder from the planning team. And this related to my hubris as a physician at the time. In the hospital, who collects urine cultures? Who maintains urinary catheters? Well, it’s of course, nurses.

And I’ll talk a little later about how we overcame this obstacle, but nurses should have been part of the planning and implementation of our project from the get-go, rather than later. So after we would meet, the team would have just shredded my proposal, my ideas. You know, everything I had on paper was going to need to be rewritten, different things needed to be done, redone. So this would be my view as I looked out crossing Almeda again. And I don’t know if you can see, but that is the VA hospital way over here.

And here is the hot street. And I crossed it, I would initially feel very dejected because my proposal had been so shredded by the team. But by the time I would get to the VA hospital, I would realize again, you know, they’re just making it better.

Every suggestion they make is more work, but it’s a learning curve. And it’s going to be a better proposal. And I’d start rewriting it when I got back to the hospital. And after two rounds of submission as an IR, it got funded. And we started the work in April 2010. Very grateful to my team for the ongoing suggestions for improvement.

So now that we’ve talked about how the project and the team formed, let’s talk about our results and the conceptual model and the science behind this. First of all, we had a survey that we designed to measure the cognitive biases that were driving the overtreatment that we observed. So I had an algorithm that was formed with the principles of behavioral economics in mind. Our intervention was centered around audit feedback. And the implementation itself became a demonstration of putting the evidence integration triangle into practice.