Traditionally, antimicrobial stewardship programs have engaged prescribers of antibiotics in their stewardship interventions, rather than other members of the medical team, such as nurses, said Valeria Fabre, MD, an assistant professor of medicine in the division of infectious diseases at the Johns Hopkins University School of Medicine in Baltimore.
A CDC-funded pilot study that targeted overuse of urine cultures at her hospital from 2018 to 2019 took a different approach. “The [antimicrobial stewardship] team recognized that we had not formally integrated nurses into our efforts, and we wanted to create an opportunity for bedside nurses to contribute to stewardship activities,” she said. “We wanted to empower nurses to question the necessity of a urine culture . . . because positive urine cultures are a major driver of antibiotic use in hospitalized patients, and once a urine culture is positive, it is harder to change a provider's mind about not prescribing an antibiotic that is not clinically indicated.”
How it works
On a 24-bed general medicine unit of the hospital, nurses were tasked with reviewing the need for every urine culture. “We had developed algorithms that walked the nurse through how to work up that patient, and if the algorithm led to the pathway that a culture was not needed, then they would bring that to the ordering provider and have a conversation about whether that urine culture was needed,” said Dr. Fabre.
Before implementing the intervention, she provided nurses in the unit with education and training on the principles of diagnostic stewardship. “We tried to focus education on, ‘A urine culture should be sent only if you have a suspicion for a urinary tract infection, because many patients may have bacteria in the urine without having an infection,’” Dr. Fabre said. “I also gave feedback to the hospitalists as well regarding urine culture order appropriateness and urine culture rates so . . . they could see how they were performing.” In addition, Ashley Pleiss, RN, lead clinical nurse in the department of medicine for the hospital, served as nurse champion on the unit.
After the intervention, urine cultures decreased from 2.30 to 1.52 per 100 patient-days on the unit, whereas on a control unit, they increased from 2.17 to 3.10 cultures per 100 patient-days, according to results published in the November 2020 Joint Commission Journal on Quality and Patient Safety.
For Dr. Fabre, the real success was the engagement of nurses in diagnostic stewardship. “I think that our biggest result was really how much nurses were interested and engaged in participating in stewardship activities,” she said. Ms. Pleiss added that the experience was also rewarding for the nurses. “It was definitely a lesson learned that that's probably how you can effect bigger change: by including the bedside nurses in these decisions.”
Whatever the intervention, changing unit culture and clinician practice is always a challenge, Ms. Pleiss noted. At the start, not all nurses and nursing support technicians were collecting urinalyses appropriately, introducing bacteria into the urine, “so we had to do a lot of re-educating about urine collection practices as well,” she said.
The educational aspect was also challenging due to some non-evidence-based practices taught during training, Ms. Pleiss said. “Nursing students and med students are taught to think immediately if your patient has altered mental status, they probably have a [urinary tract infection],” she said. “This was one of those misconceptions that we really had to educate everyone on when it comes to indications for obtaining a culture based on signs and symptoms.”
But the biggest challenge, Ms. Pleiss said, was that nurses believed they might get physicians in trouble for collecting urine for a culture when it wasn't indicated by the algorithm. “It was really a lot of me having to reaffirm to the nurses, ‘The physicians aren't going to get in trouble. We just wouldn't be doing our job if we issued the order without having inquired about it first,’” she said.
Before the intervention was launched, a key step involved enlisting support from the hospitalist group for collaborating with nurses, Dr. Fabre said. “If you have a group that is not willing to talk to their nurses, it's hard to have an intervention like this that required open communication between them,” she said.
While the CDC funding for the study has stopped, the intervention has made a lasting impact on the nurses, Dr. Fabre said. “At some point, they don't need it anymore, and I could tell towards the end [of educational sessions] when we would open for questions, there were fewer questions every time because you start seeing the same cases and people become familiar with what they are supposed to do,” she said.
Dr. Fabre added that there has been interest from other hospitals in the intervention's tools. “All the tools that we developed, all the educational material, the algorithms . . . it does require a lot of time to put all that together, so we wanted to make it available for everyone,” she said. A free toolkit is available online.