Hostname: page-component-586b7cd67f-dsjbd Total loading time: 0 Render date: 2024-11-28T08:05:20.273Z Has data issue: false hasContentIssue false
  • English
  • Français

Effect of changing urine testing orderables and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center

Published online by Cambridge University Press:  21 February 2019

Satish Munigala ,
Rebecca Rojek ,
Helen Wood ,
Melanie L. Yarbrough ,
Ronald R. Jackups Jr ,
Carey-Ann D. Burnham  and
David K. Warren Open the ORCID record for David K. Warren [Opens in a new window]
Satish Munigala
Affiliation:
Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
Rebecca Rojek
Affiliation:
Department of Hospital Epidemiology and Infection Prevention, Barnes-Jewish Hospital, St Louis, Missouri
Helen Wood
Affiliation:
Department of Hospital Epidemiology and Infection Prevention, Barnes-Jewish Hospital, St Louis, Missouri
Melanie L. Yarbrough
Affiliation:
Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
Ronald R. Jackups Jr
Affiliation:
Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
Carey-Ann D. Burnham
Affiliation:
Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
David K. Warren*
Affiliation:
Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
*
Author for correspondence: David K. Warren, Email: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

To evaluate the impact of changes to urine testing orderables in computerized physician order entry (CPOE) system on urine culturing practices.

Design:

Retrospective before-and-after study.

Setting:

A 1,250-bed academic tertiary-care referral center.

Patients:

Hospitalized adults who had ≥1 urine culture performed during their stay.

Intervention:

The intervention (implemented in April 2017) consisted of notifications to providers, changes to order sets, and inclusion of the new urine culture reflex tests in commonly used order sets. We compared the urine culture rates before the intervention (January 2015 to April 2016) and after the intervention (May 2016 to August 2017), adjusting for temporal trends.

Results:

During the study period, 18,954 inpatients (median age, 62 years; 68.8% white and 52.3% female) had 24,569 urine cultures ordered. Overall, 6,662 urine cultures (27%) were positive. The urine culturing rate decreased significantly in the postintervention period for any specimen type (38.1 per 1,000 patient days preintervention vs 20.9 per 1,000 patient days postintervention; P < .001), clean catch (30.0 vs 18.7; P < .001) and catheterized urine (7.8 vs 1.9; P < .001). Using an interrupted time series model, urine culture rates decreased for all specimen types (P < .05).

Conclusions:

Our intervention of changes to order sets and inclusion of the new urine culture reflex tests resulted in a 45% reduction in the urine cultures ordered. CPOE system format plays a vital role in reducing the burden of unnecessary urine cultures and should be implemented in combination with other efforts.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 40 , Issue 3 , March 2019 , pp. 281 - 286
Copyright
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved. 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Trautner, BW. Asymptomatic bacteriuria: when the treatment is worse than the disease. Nat Rev Urol 2011;9:85–93.CrossRefGoogle ScholarPubMed
McMaster-Baxter, NL, Musher, DM. Clostridium difficile: recent epidemiologic findings and advances in therapy. Pharmacotherapy 2007;27:1029–1039.CrossRefGoogle ScholarPubMed
Saint, S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control 2000;28:68–75.CrossRefGoogle ScholarPubMed
Hartley, SE, Kuhn, L, Valley, S, et al. Evaluating a hospitalist-based intervention to decrease unnecessary antimicrobial use in patients with asymptomatic bacteriuria. Infect Control Hosp Epidemiol 2016;37:1044–1051.CrossRefGoogle ScholarPubMed
Cope, M, Cevallos, ME, Cadle, RM, Darouiche, RO, Musher, DM, Trautner, BW. Inappropriate treatment of catheter-associated asymptomatic bacteriuria in a tertiary care hospital. Clin Infect Dis 2009;48:1182–1188.CrossRefGoogle Scholar
Pavese, P, Saurel, N, Labarere, J, et al. Does an educational session with an infectious diseases physician reduce the use of inappropriate antibiotic therapy for inpatients with positive urine culture results? A controlled before-and-after study. Infect Control Hosp Epidemiol 2009;30:596–599.CrossRefGoogle ScholarPubMed
Kelley, D, Aaronson, P, Poon, E, McCarter, YS, Bato, B, Jankowski, CA. Evaluation of an antimicrobial stewardship approach to minimize overuse of antibiotics in patients with asymptomatic bacteriuria. Infect Control Hosp Epidemiol 2014;35:193–195.CrossRefGoogle ScholarPubMed
Yin, P, Kiss, A, Leis, JA. Urinalysis orders among patients admitted to the general medicine service. JAMA Intern Med 2015;175:1711–1713.CrossRefGoogle ScholarPubMed
Hartley, S, Valley, S, Kuhn, L, et al. Overtreatment of asymptomatic bacteriuria: identifying targets for improvement. Infect Control Hosp Epidemiol 2015;36:470–473.CrossRefGoogle Scholar
Grein, JD, Kahn, KL, Eells, SJ, et al. Treatment for positive urine cultures in hospitalized adults: a survey of prevalence and risk factors in three medical centers. Infect Control Hosp Epidemiol 2016;37:319–326.CrossRefGoogle Scholar
Trautner, BW, Bhimani, RD, Amspoker, AB, et al. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak 2013;13:48.CrossRefGoogle ScholarPubMed
Linares, LA, Thornton, DJ, Strymish, J, Baker, E, Gupta, K. Electronic memorandum decreases unnecessary antimicrobial use for asymptomatic bacteriuria and culture-negative pyuria. Infect Control Hosp Epidemiol 2011;32:644–648.10.1086/660764CrossRefGoogle ScholarPubMed
Trautner, BW, Grigoryan, L, Petersen, NJ, et al. Effectiveness of an antimicrobial stewardship approach for urinary catheter-associated asymptomatic bacteriuria. JAMA Intern Med 2015;175:1120–1127.CrossRefGoogle ScholarPubMed
Gupta, K, Hooton, TM, Naber, KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52:e103–e120.CrossRefGoogle Scholar
Nicolle, LE, Bradley, S, Colgan, R, Rice, JC, Schaeffer, A, Hooton, TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643–654.10.1086/427507CrossRefGoogle Scholar
Nicolle, LE. Asymptomatic bacteriuria: review and discussion of the IDSA guidelines. Int J Antimicrob Agents 2006;28(suppl 1):S42–S48.CrossRefGoogle ScholarPubMed
Choosing Wisely: an initiative of the ABIM Foundation. 2015. http://www.choosingwisely.org/doctor-patient-lists/infectious-diseases-society-of-america/. Accessed March 3, 2018.Google Scholar
Bonnal, C, Baune, B, Mion, M, et al. Bacteriuria in a geriatric hospital: impact of an antibiotic improvement program. J Am Med Dir Assoc 2008;9:605–609.CrossRefGoogle Scholar
Chowdhury, F, Sarkar, K, Branche, A, et al. Preventing the inappropriate treatment of asymptomatic bacteriuria at a community teaching hospital. J Community Hosp Intern Med Perspect 2012;2:(pii)17814.10.3402/jchimp.v2i2.17814CrossRefGoogle Scholar
Leis, JA, Palmay, L, Elligsen, M, Walker, SA, Lee, C, Daneman, N. Lessons from audit and feedback of hospitalized patients with bacteriuria. Am J Infect Control 2014;42:1136–1137.CrossRefGoogle ScholarPubMed
Jones, CW, Culbreath, KD, Mehrotra, A, Gilligan, PH. Reflect urine culture cancellation in the emergency department. J Emerg Med 2014;46:71–76.CrossRefGoogle ScholarPubMed
Stagg, A, Lutz, H, Kirpalaney, S, et al. Impact of two-step urine culture ordering in the emergency department: a time series analysis. BMJ Qual Saf 2018;27:140–147.CrossRefGoogle ScholarPubMed
Catheter-associated urinary tract infection (CAUTI) event. National Health Safety Network Patient Safety Manual; 2018. Centers for Disease Control and Prevention website. https://www.cdc.gov/nhsn/pdfs/validation/2018/pcsmanual_2018-508.pdf. Published 2018. Accessed March 8, 2018.Google Scholar
Clinical laboratory fee schedule, 2017. Centers for Medicare and Medicaid Services website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files-Items/17CLAB.html?DLPage=1&DLEntries=100&DLSort=2&DLSortDir=descending. Updated January 2017. Accessed December 2018.Google Scholar
Tomford, JW, Hershey, CO. The i.v. therapy team: impact on patient care and costs of hospitalization. NITA 1985;8:387–389.Google ScholarPubMed
Gupta, K, Hooton, TM, Naber, KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52:e103–e120.CrossRefGoogle Scholar
Forsman, RW. Why is the laboratory an afterthought for managed care organizations? Clin Chem 1996;42:813–816.Google Scholar
Trautner, BW, Petersen, NJ, Hysong, SJ, Horwitz, D, Kelly, PA, Naik, AD. Overtreatment of asymptomatic bacteriuria: identifying provider barriers to evidence-based care. Am J Infect Control 2014;42:653–658.CrossRefGoogle ScholarPubMed
Leis, JA, Rebick, GW, Daneman, N, et al. Reducing antimicrobial therapy for asymptomatic bacteriuria among noncatheterized inpatients: a proof-of-concept study. Clin Infect Dis 2014;58:980–983.CrossRefGoogle ScholarPubMed
Irfan, N, Brooks, A, Mithoowani, S, Celetti, SJ, Main, C, Mertz, D. A controlled quasi-experimental study of an educational intervention to reduce the unnecessary use of antimicrobials for asymptomatic bacteriuria. PLoS One 2015;10:e0132071.CrossRefGoogle ScholarPubMed
Redwood, R, Knobloch, MJ, Pellegrini, DC, Ziegler, MJ, Pulia, M, Safdar, N. Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings. Antimicrob Resist Infect Control 2018;7:4.CrossRefGoogle ScholarPubMed
Carlson, AL, Munigala, S, Russo, AJ, et al. Inpatient urine cultures are frequently performed without urinalysis or microscopy: findings from a large academic medical center. Infect Control Hosp Epidemiol 2017;38:455–460.CrossRefGoogle ScholarPubMed
Information regarding the final CY 2018 private payor rate-based clinical laboratory fee schedule (CLFS) payment rates. Centers for Medicare and Medicaid website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/CY2018-CLFS-HCPCS-Median-Calculations.pdf. Published 2018. Accessed December 2018.Google Scholar
Munigala, S, Jackups, RR Jr, Poirier, RF, et al. Impact of order set design on urine culturing practices at an academic medical centre emergency department. BMJ Qual Saf 2018;27:587–592.CrossRefGoogle ScholarPubMed
Chen, M, Eintracht, S, MacNamara, E. Successful protocol for eliminating excessive urine microscopies: quality improvement and cost savings with physician support. Clin Biochem 2017;50:88–93.CrossRefGoogle ScholarPubMed