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Transcript

Changing the Culture of Culturing · The SHEA Podcast

• 0:49
  SPEAKER_02: Today we're going to be discussing a fun-filled area of controversy in both antibiotic stewardship as well as laboratory stewardship, which is the diagnostic stewardship and changing cultures surrounding blood cultures out there.
• 1:03
  SPEAKER_02: And this has really become an area that antimicrobial stewardship programs, infectious disease providers, infection control providers, et cetera, have really, I think, started to understand is a little bit more complex than we had all started or had all thought for a long time.
• 1:21
  SPEAKER_02: And the issue with blood cultures is that we send them for a variety of things.
• 1:26
  SPEAKER_02: And I think that we as clinicians really feel that it is a standard part of a workup for most infectious types of presentations that we see, both in the emergency department as well as in general medicine and general surgery services, and certainly in our intensive care units.
• 1:43
  SPEAKER_02: And so in many academic centers and in many other hospitals around the country, it's not uncommon to see laboratories reporting numbers of blood cultures in excess of 30,000 blood cultures per year.
• 1:54
  SPEAKER_02: And when you look at both the fiscal impact of that to the laboratory budget, to the hospital budget, to the blood volume of the patient, as well as I think the more challenging component of this, which is really the clinical significance of blood culture contamination.
• 2:13
  SPEAKER_02: And so often we run into situations where we have a result that pops up that is positive on a blood culture that may in no way, shape, or form fit the clinical presentation that's in front of us.
• 2:26
  SPEAKER_02: Yet because there is a positive microbiologic result, so often we find ourselves in a situation where providers feel compelled to treat, or there's just confusion about what to do with that blood culture.
• 2:39
  SPEAKER_02: And so I think that one of the things that stewardship programs and lab stewardship programs are really trying to endeavor to move forward with is a better set of criteria and a better understanding on the part of providers as to when blood cultures are potentially useful and when they're not.
• 2:56
  SPEAKER_02: And I think the underlying current for all of that really also needs to remain with a strict emphasis on trying to minimize contamination.
• 3:05
  SPEAKER_02: Because we have seen repeatedly through the clinical and microbiologic literature over the past several decades that blood culture contamination results in increased length of stay, results in increased antibiotic use, and results in a variety of other clinical situations which are really not optimal patient care.
• 3:24
  SPEAKER_02: And so I think that, you know, from a stewardship standpoint on a clinician side, we have really kind of moved into okay, how do we try to put together rule sets or criteria that are effectively communicated to frontline providers such that we're ensuring that blood cultures, when they're done, are really optimally done and that we're trying to minimize those situations where blood cultures are being drawn, where maybe they're not as useful or where they're just flat out not useful at all.
• 3:54
  SPEAKER_02: And so I think that from a stewardship standpoint, we have really kind of gone down the road of trying to do a lot of the things that we've done with antibiotic stewardship, which is really putting together guidelines and rule sets and EMR reminders and, you know, all of the things that have become kind of frontline for day-to-day operation of stewardship programs.
• 4:14
  SPEAKER_02: But I think that one of the things that we're increasingly recognizes is this is a behavioral change issue.
• 4:20
  SPEAKER_02: And I am certainly no behavioral change expert, so I'm going to kick this over to Julie for her to talk a little bit about the sociologist's approach to how to kind of handle behavior change with regards to blood culture management.
• 4:34
  SPEAKER_00: Oh, thank you so much, Jim.
• 4:36
  SPEAKER_00: Yeah, so I think that these kinds of change targets in healthcare tend to be thought of as an issue of knowledge or an issue of logistics or technical limitations.
• 4:48
  SPEAKER_00: So, for example, you know, the reason why clinicians overuse blood cultures might have to do with the fact that they simply don't know when it's appropriate to use them, or there's something about the ordering system or the way in which they access these blood cultures that makes them more prone to overuse it.
• 5:04
  SPEAKER_00: And I think that, you know, we need to move beyond sort of just knowledge and technical ways of thinking about these kinds of issues and move into thinking them more as social problems and problems of norms and group behavior and culture.
• 5:19
  SPEAKER_00: And so, as a medical sociologist who studies antibiotic prescribing and the behavior in healthcare institutions, my focus is really on the social and cultural dynamics that shape decision making and sort of taking it from it's not just an issue of what's happening in individual minds, it's it's an issue of what's happening at the group level.
• 5:39
  SPEAKER_00: And I think that when someone's thinking about a problem, whether it's the overuse of a particular type of antibiotic or the overuse of a laboratory test or some infection prevention behavior that's not being consistently done, that the sociologic approach requires us to think about all the possible drivers beyond just knowledge and technical factors and to get into cultural norms and relational issues and really understanding the drivers of why clinicians are doing what they do.
• 6:10
  SPEAKER_00: And sometimes that involves talking to them or uncovering what they believe, for example, about a blood culture, what they believe it will do, and really understanding where they're at and what they think so that you can tailor your intervention strategies appropriately.
• 6:24
  SPEAKER_00: And I think that with something like a laboratory test, there are multiple different levers of this that are really emotional.
• 6:31
  SPEAKER_00: It might have to do with the mitigation of fear and risk around a patient's sick, I don't know what's going on, I need to do something.
• 6:38
  SPEAKER_00: And the act of doing a culture is doing something.
• 6:42
  SPEAKER_00: It may also have to do with, well, I've always done it this way, or my attendings have always done it this way, and that it becomes sort of this normative behavior that has been always happening that remains unquestioned, that it's something that people just do, and needing to sort of find a way to disrupt those norms and those habits through a variety of different approaches.
• 7:03
  SPEAKER_00: And so I think that once those drivers are uncovered, then the individual who's really trying to improve blood culturing practices at their institution can tailor their interventions appropriately based on whatever the driver is.
• 7:17
  SPEAKER_00: So that's sort of how a sociologist would think about it.
• 7:21
  SPEAKER_02: You know, and I think that so much of what you've just hit on, Julie, is so reminiscent of the discussions and issues that we've had with antibiotic stewardship.
• 7:31
  SPEAKER_02: And it's so interesting to see this now kind of moving over into lab stewardship.
• 7:37
  SPEAKER_02: You know, and I think that that's probably kind of the next wave that we're going to see for a lot of these programs.
• 7:42
  SPEAKER_02: And, you know, as someone who's been playing in the antibiotic stewardship world now for going on 20 years, it is so fascinating to me to sit and listen to you talk about these things because it's something I'm not smart enough, I think, to probably have put my finger on.
• 7:57
  SPEAKER_02: But listening to you describe all of this, the similarities between what we do in antibiotic stewardship and I think how we're going to have to handle this in lab stewardship is so strikingly similar.
• 8:09
  SPEAKER_02: And I think that it's going to take both the structural issues being addressed.
• 8:15
  SPEAKER_02: You touched on, I think, so beautifully the order set piece.
• 8:18
  SPEAKER_02: You know, that is one of the things that we have found both from an antibiotic side as well as from a laboratory utilization side, is that you can make such huge changes by just changing what you show in some of the electronic medical records or in some of the order sets that are out there.
• 8:36
  SPEAKER_02: And so I really envision a lot of our structural or procedural changes for lab stewardship as having huge overlap with what we've done in antibiotic stewardship.
• 8:49
  SPEAKER_02: And I guess, you know, my question for you as someone who would love to try to implement more of the behavior change side of this is where do you see or do you see differences at all between the things that we do in antibiotic stewardship and the things that we would do in trying to roll out kind of this blood culture stewardship program?
• 9:08
  SPEAKER_00: Well, Jim, that's an excellent question.
• 9:10
  SPEAKER_00: And I think that it is very important to harmonize because the decision to use an antibiotic, the decision to order a blood culture, the decision to put on a gown going into a patient's room who's on isolation, those decisions are all they have different drivers, but I think there's a similar conceptual framework that we can use to figure out why are people not doing what's optimal.
• 9:36
  SPEAKER_00: And so I absolutely agree with you that the behavioral approaches that we might take in stewardship absolutely can apply to improving the use of diagnostics tests and should, that the individuals who, whether it's it's a stewardship team or someone else in the institution who wants to take this project on, should have some harmony between the way that they're approaching understanding what the issue is and improving upon it.
• 10:01
  SPEAKER_00: And I think that, you know, you talked about order sets, and I absolutely agree that we need to have a combination of electronic supports and sort of the way we display information to clinicians to make the choice architecture to help them do the right thing.
• 10:16
  SPEAKER_00: But sometimes we even notice in other examples that clinicians ignore order sets, they work around them, they get what they want, which to me indicates that they don't really fully believe in the principles of stewardship, whether it's an antibiotic or the use of a diagnostic test.
• 10:32
  SPEAKER_00: And so to make really big impact and a lot of change, I think you need to work on multiple levers of this.
• 10:38
  SPEAKER_00: And I think that in the case of stewardship and in terms of antibiotics and diagnostic tests, that there are a number of different key behavior change strategies that we can use.
• 10:49
  SPEAKER_00: So the first would be leveraging data on performance to foster transparency and accountability.
• 10:55
  SPEAKER_00: So that essentially means reporting to the clinicians on how many blood cultures they use.
• 11:00
  SPEAKER_00: You can compare them to their colleagues, and you can have some measure of how much of it is in excess.
• 11:07
  SPEAKER_00: And I think that using data as a behavioral change agent is really, really important.
• 11:12
  SPEAKER_00: So that's one.
• 11:14
  SPEAKER_00: The second behavioral change strategy, I would say, is to identify a change agent ambassador to sort of promote the cause of stewardship in a more grassroots or advocacy fashion.
• 11:25
  SPEAKER_00: And I like to think about this as sort of a ground up instead of top-down.
• 11:29
  SPEAKER_00: And a lot of our patient safety and even stewardship, it's sort of people who are far removed from the unit, who are coming to the unit and saying, you need to do things this way.
• 11:39
  SPEAKER_00: And there's less of a partnership maybe than there could be.
• 11:42
  SPEAKER_00: And a lot of times an us versus them dynamic emerges.
• 11:46
  SPEAKER_00: And I think it's really important to try to partner with somebody who is of the group that you're trying to change the behavior.
• 11:53
  SPEAKER_00: The third piece is to think about when you are promoting or communicating the need for diagnostic stewardship, is to answer the question of the clinician whose behavior you're trying to change is what's in it for them.
• 12:05
  SPEAKER_00: And I think the framing of the issue is crucially important.
• 12:08
  SPEAKER_00: And so, although, for example, costs might be a reason why diagnostic stewardship should occur, we know from other examples that clinicians don't respond well to cost restriction.
• 12:20
  SPEAKER_00: And that's something that can cause them to lose attention and cause the issue to lose credibility.
• 12:25
  SPEAKER_00: And so I think we need to think about how do we present the problem of diagnostic overuse to these clinicians.
• 12:31
  SPEAKER_00: And I also think the fourth piece is thinking about fostering a culture of commitment to doing better.
• 12:37
  SPEAKER_00: So encouraging multiple types of individuals and people to say that this is something we care about and we're committed to doing in that.
• 12:46
  SPEAKER_00: And that can be through public displays of commitment, that can be through a leader saying this is a priority for our organization, but it's about making a public statement that this is a value that we're trying to work towards and we all care about it.
• 13:01
  SPEAKER_00: And I think that those are some strategies that we can think about in terms of changing behavior around these kinds of issues.
• 13:08
  SPEAKER_02: Yeah, again, I think so much of that sounds so familiar.
• 13:12
  SPEAKER_02: And I think the frustrating thing for so many of us is that it it sounds amazing and then and then the implementation piece always becomes so challenging.
• 13:21
  SPEAKER_02: And you know, the piece with blood cultures, I think, is as you kind of alluded to, I think that one of the challenges that we bump into routinely is the perception that it there's really no harm in doing them.
• 13:35
  SPEAKER_02: And again, I feel like that is so analogous to the mindset that we've had to overcome with antibiotics, where far too often the perception has been that antibiotics can only help, they can't really hurt.
• 13:48
  SPEAKER_02: And so again, I think that there's not a single healthcare provider I've ever met who looks to go to work on a given day and says, I want to do a bad job today, or I want to do something that doesn't optimize patient care, or I want to jack up the care, or the costs of the care to my patients.
• 14:03
  SPEAKER_02: I don't think you're ever going to find a provider who's looking to do that.
• 14:06
  SPEAKER_02: And I think that again, the the pieces that we on the stewardship side need to think about, in addition to all of the behavioral change stuff, which Julie has laid out so nicely, is again the pieces surrounding where blood cultures are of high value and where they have been shown to be really of kind of questionable clinical value.
• 14:28
  SPEAKER_02: And I think the piece that really resonates very loudly with me from what Julie has been talking about is again the importance of being able to generate data to show providers and to be able to show where perhaps behaviors are outside of what would be expected from their peers or from comparable other institutions.
• 14:47
  SPEAKER_02: And I think that we've all experienced the challenges of trying to get these types of data out of our EMRs, et cetera, for our antibiotic stewardship programs.
• 14:58
  SPEAKER_02: And I think that fortunately this seems to be a little bit easier to do with some of the lab information systems.
• 15:05
  SPEAKER_02: Because again, I really foresee this being kind of the next step or an extension of a lot of our antibiotic stewardship programs that are already in place.
• 15:14
  SPEAKER_02: And so I think that this is going to hopefully incentivize something that we should have been doing all along, which is making sure that Clinical Micro is really involved day in, day out in the frontline functioning of our antibiotic stewardship programs.
• 15:28
  SPEAKER_02: Because again, I think contamination rates, blood culture, use by indications, by units, you know, a lot of these data are going to be extremely critical to us in order to one, demonstrate to providers what's going on, but two, to really kind of show them the need for or areas where there could be improvement.
• 15:48
  SPEAKER_02: And again, I think involving, you know, nursing staff, et cetera, a lot of this multidisciplinary effort that again, I heard Julie allude to so nicely, as far as kind of building teamwork and presence in those units in those areas, uh, I think will be absolutely massive as we have seen with regards to antibiotic stewardship.
• 16:06
  SPEAKER_02: And then again, I think that while your clinicians don't necessarily respond to dollars all the time, your C-suite always does.
• 16:14
  SPEAKER_02: Being able to show what the cost of a contaminated blood culture results in, I think will really resonate with that group and will help with the development of support from those areas.
• 16:27
  SPEAKER_02: And I think that this is not an either-or type situation.
• 16:31
  SPEAKER_02: I think that you need the structural changes, but to underestimate the behavioral change piece here, I think would be to unlearn everything that we have painstakingly learned in antibiotic stewardship over the last 10 to 15 years.
• 16:44
  SPEAKER_02: And we really should not be repeating the same mistakes multiple times here.
• 16:48
  SPEAKER_00: I mean, I completely agree.
• 16:50
  SPEAKER_00: And I and I think that, you know, this issue of finding a way to get this issue to be seen as important amongst your leaders, amongst your clinicians, is really the first step in changing behavior because these clinicians and these hospital administrators, they're dealing with many, many different priorities every day.
• 17:10
  SPEAKER_00: And and how can you get your issue to be something that they care about and they see as important?
• 17:16
  SPEAKER_00: I think it's exactly as you said, it's finding the framing and the lever that's going to make them sit up and take notice.
• 17:22
  SPEAKER_00: And we've learned that that's got to be the case with antibiotics, especially where the downstream consequences are harder to sort of apprehend in the moment.
• 17:30
  SPEAKER_00: So I think exactly what you said is is where we need to go with this.
• 17:34
  SPEAKER_02: It's a blessing and a curse, but one of the things in antibiotic stewardship is you can always point at C diff as you like a downside of the excess antibiotic use.
• 17:43
  SPEAKER_02: It's it's a little more tricky to come up with the downside of that extra blood culture, right?
• 17:48
  SPEAKER_02: And so I think that again, finding the levers that you can pull with the different areas is really, I think, going to be maybe a little bit different than what we're used to, but I think the overarching framework remains extremely similar, you know, and so a lot of those lessons will hopefully carry forward into this.
• 18:07
  SPEAKER_00: Absolutely.
• 18:08
  SPEAKER_02: All right, so Julie, thank you so much for educating me immensely today and again giving me further ammunition to kind of move forward and improve my ability to hopefully do uh behavior change, not just on lab stewardship, but also in stewardship.
• 18:23
  SPEAKER_02: And you know, I would like to really again encourage our audience to look at what's going on in your institution surrounding blood cultures because I think you'll be unpleasantly surprised when you turn that rock over as to what crawls, because most places are using a lot of blood cultures in maybe not the most optimal way.
• 18:41
  SPEAKER_00: Thank you, Jim, and thank you to Shay for inviting me to speak about this.
• 18:45
  SPEAKER_00: I feel very fortunate as a social scientist to be able to have discussions with people who are very smart and on the ball like Jim in these kinds of settings.
• 18:54
  SPEAKER_00: And I think I would leave the audience with just a message to remember that healthcare institutions are populated by people working together on sick people, and that the dynamics of the social world that are happening everywhere outside the walls of the hospital apply to the inside of the hospital as well.
• 19:10
  SPEAKER_00: And that anytime we try to introduce a change into practice, that we need to think about the human element in order to achieve the success that we would like.