Infection Control & Hospital Epidemiology (2019), 40, 281–286 doi:10.1017/ice.2018.356
Original Article
Effect of changing urine testing orderables and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center
Satish Munigala MBBS, MPH1, Rebecca Rojek MPH2, Helen Wood RN, MA, CIC2, Melanie L. Yarbrough PhD3,
Ronald R. Jackups Jr MD, PhD3, Carey-Ann D. Burnham PhD3 and David K. Warren MD, MPH1 1Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, 2Department of Hospital Epidemiology and Infection Prevention, Barnes-Jewish Hospital, St Louis, Missouri and 3Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
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.Wecompared 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.CPOEsystem format plays a vital role in reducing the burden of unnecessary urine cultures and should be implemented in combination with other efforts.
(Received 21 September 2018; accepted 11 December 2018)
Urinalysis and urine culture are commonly ordered tests among hospitalized patients suspected of urinary tract infection (UTI). However, these tests are often ordered for patients without clinical suspicion of UTI, leading to unnecessary testing and increased hos- pital costs.1–3 Positive urine cultures are amajor driver for antibiotic treatment.4–11 Several studies have reported that the treatment of asymptomatic bacteriuria (ASB) does not affect patient outcomes and leads to unnecessary antibiotic use, increasing the prevalence of antibiotic-resistant organisms and Clostridium difficile infec- tion.12–14 Despite Infectious Disease Society of America and other professional societies’ recommendations to avoid antibiotic prescrip- tions for asymptomatic bacteriuria,14–17 its treatment is still common.
Author for correspondence: David K. Warren, Email:
dwarren@wustl.edu Cite this article: Munigala S, et al. (2019). Effect of changing urine testing orderables
and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center. Infection Control & Hospital Epidemiology, 40: 281–286,
https://doi.org/ 10.1017/ice.2018.356
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved. Previous interventions to prevent unnecessary urine testing
have included provider education, use of pocket cards, antimicro- bial stewardship efforts, reflex urine culture cancellation and 2-step urine culture ordering.6,7,12,13,18–22 However, data on the effect of changes in electronic order sets and its role on inpatient urine test- ing practices are limited. In this study, we evaluated the impact of changes to the in-
patient urine orders in a computer physician order entry (CPOE) system on the urine culturing practices of a large urban, academic medical center.
Methods Setting
This retrospective before-and-after study included patients admitted to Barnes-Jewish Hospital (BJH), a 1,250-bed teaching hospital, from January 1, 2015, to August 31, 2017, who had≥1 urine culture ordered during their stay. Patients who were admitted during the
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