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Table 1. Urine Order Set Definitions During the Study Period Preintervention (January 2015–April 2016)
Test Name(s) Definition Test name(s)
UA Reflex to Microscopy WITH Culture
Urine Flex (Urine
Macroscopic UA Flex)
UA Flex C/S (Urine
Macroscopic UA Flex)a
UA Reflex UA W/Reflexed Microscopic
(UA Reflex)b
Urine Macro Urinalysis UA Macro UA Dip
Macroscopicc
UA Microscopy UA Microd
Urine culture, X (X=aerobic, fungal, mycobacterial)
Urine sediment examination only
UA Microscopy UA Micro
Urine culture, X (X= aerobic, fungal, mycobacterial)
Note. UA, urinalysis. aUrine Flex and Urine Flex C/S were the same orders with different names during the preintervention period; bUA Reflex and UA W/Reflexed were the same orders with different names during the preintervention period. cUrine Macro, Urinalysis, UA Macro and UA Dip Macroscopic were the same orders with different names during the study period. dUA Microscopy and UA Micro were the same orders with different names during the study period.
study period but did not have a urine culture ordered during their stay and patients who had their urine cultures obtained at an out- patient settings or the emergency department (ED) were excluded.
Intervention
A staged intervention was performed to clarify test names and to reduce the number of reflex urine cultures performed for nonspe- cific indications (eg, isolated proteinuria) by making changes to the urine reflex test panel at BJH (Table 1). This intervention was ini- tiated in the CPOE system on January 28, 2016. E-mail notification to providers with the new urine reflex tests was sent prior to ini- tiation. The inclusion of the new reflex tests in commonly used order sets within the CPOE system (eg, medical intensive care unit admission orders) was completed on April 19, 2016; therefore, April 2016 was used as the intervention month. January 2015 through April 2016 was the preintervention period and May 2016 through August 2017 was the postintervention period.
Data collection
Patient and laboratory data were abstracted from the hospital medical informatics database. Data included patient demographics (ie, age, race, and sex), laboratory test results (ie, urinalysis, micro- scopic exam and urine culture), and discharge disposition (ie, home, other facility, etc). For urine cultures with accompanying urinalysis or microscopy, the time between the urine culture and urinalysis and/or microscopy was calculated. Type of urine culture specimen was also noted (ie, clean catch, catheterized, or procedure related) as indicated by the ordering clinician.
For patients with multiple urine cultures during an admission, each sample was treated as an independent observation.
Definitions Urine cultures with growth of ≥100,000 colony-forming units (CFU)/mL for a clean-catch specimen and ≥10,000 CFU/mL for a catheterized specimen were considered positive results. Urine cultures that were negative for significant growth or contaminated were considered negative for this analysis. Leukocyte esterase ≥1 identified on urinalysis and >5 white blood cells per high-power field on urine microscopy were treated as abnormal and positive test results. We defined an isolated urine culture as a culture without an associated urinalysis and/or urine microscopy performed within 1 calendar day before or after the culture was performed. Catheter-associated urinary tract infection (CAUTI) surveillance was independently conducted by the hospital infection prevention department during the study period. A CAUTI was defined accord- ing to National Healthcare Safety Network definitions23 as a UTI where an indwelling urinary catheter was in place for >2calendar days on the date of event, with day of device placement being day 1, and an indwelling urinary catheter was in place on the date of event or the day before. If an indwelling urinary catheter was in place for >2 calendar days and then removed, theUTI criteriamust have been fully met on the day of discontinuation or the next day.
Cost assessment
Unit cost of a urine culture was obtained fromthe Medicare Clinical Laboratory Fee Schedule using national median Medicare payment
Urine sediment examination only
Perform urine dipstick. If positive for any protein >trace, blood, nitrite, or leukocyte esterase, then proceed to microscopy.
Macroscopic dipstick urinalysis only
UA Reflex to Microscopy WITHOUT Culture
Urine Macro Urinalysis UA Macro UA Dip Macroscopic
If urinalysis is positive for protein (>trace), blood, nitrites, OR leukocyte esterase, then microscopy will automatically be performed.
Macroscopic dipstick urinalysis only
Perform urine dipstick. If positive for any protein >trace, blood, nitrite, or leukocyte esterase, then proceed to microscopy and culture.
UA Reflex for Neutropenic Patients
Satish Munigala et al
Postintervention (May 2016–August 2017) Definition
If urinalysis is positive for nitrites OR leukocyte esterase, then microscopy and urine culture will automatically be performed.
If urinalysis is positive for protein (>trace), blood, nitrites, OR leukocyte esterase, then microscopy and urine culture will automatically be performed.
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