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Satish Munigala et al
P=.871; 1.25 per 1,000 catheter days preintervention vs 1.27 per 1,000 catheter days postintervention; P=.899) (Table 3).
Effect of intervention on laboratory costs
Our intervention resulted in a $6,490 reduction in the mean monthly laboratory cost during the postintervention period, with an estimated total cost savings of $103,345 for inpatient urine cul- ture laboratory costs in the postintervention period ($236,190 pre- intervention vs $132,345 in the postintervention period).
Discussion
Fig. 1. Urine culture rate by specimen type. *P value for clean-catch and catheterized cultures. Note. The preintervention period was January 2015 to April 2016 and the postintervention period was May 2016 to August 2017.
46.5%; P =.012), and were routinely discharged home (66.6% vs 63.9%; P < .001) compared to the postintervention period.
Urine culture characteristics
A total of 24,569 urine cultures were ordered (during 18,954 admissions at the rate of 29.4 cultures per 1,000 patient days; median, 1 urine culture per admission) during the study period. Of these, 70.7% had an associated urinalysis and 70.4% had an associated microscopy (25.4% of urine cultures were deemed to be isolated). Overall, 6,642 urine cultures (27%) were positive. The proportion of positive urine cultures increased in the postin- tervention period (25.5% preintervention vs 29.7% postinterven- tion; P < .001), whereas the proportion of isolated urine cultures decreased (26.0% preintervention vs 24.2% postinterven- tion; P=.002) (Table 3).
Urine culture rates by specimen type
Urine culture decreased by 45.1% in the postintervention period (38.1 per 1,000 patient days preintervention vs 20.9 per 1,000 patient days postintervention; P < .001) (Table 3). This decrease was observed for clean catch (30.0 per 1,000 patient days preinter- vention vs 18.7 per 1,000 patient days postintervention; P < .001) and catheterized urine cultures (7.8 per 1,000 patient days prein- tervention vs 1.9 per 1,000 patient days postintervention; P<.001), whereas procedure-related urine cultures remained stable at 0.3 per 1,000 patient days (Fig. 1). When adjusted for impact of the intervention using an inter-
rupted time series model, urine culture rates decreased signifi- cantly for overall (P < .001), catheterized (P < .001), and isolated cultures (P=.027), respectively (Fig. 2).
Catheter associated urinary tract infections (CAUTI)
Overall, 250 CAUTIs were identified during the study period (0.30 per 1000 patient days); however, after the intervention there was no significant change in the CAUTI rates (0.30 per 1,000 patient days preintervention vs 0.30 per 1,000 patient days postintervention;
In this retrospective study, we observed a 45.1% unadjusted decrease in the rate of inpatient urine cultures performed because of changes to electronic orders in the computer physician order entry system. The reduction in the urine culture rate was most marked for the catheterized (75.6%) compared to a clean-catch specimens (37.8%). We also noticed a 16.4% increase in the pro- portion of positive urine cultures and a 6.9% decrease in the proportion of isolated urine cultures obtained. Overall, our inter- vention resulted in an estimated reduction of $103,845 in lab- oratory charges to patients. Unnecessary ordering of urine cultures and inappropriate anti-
microbial use for asymptomatic bacteriuria remain common among clinicians.13,15–17,25–27 Lack of familiarity with the recom- mendations, excessive testing in patients with comorbidities, and certain practice patterns among physicians are some of the common factors driving this clinical practice.9,28 Moreover, a urine culture result is often difficult for clinicians to ignore and drives antimicrobial therapy regardless of symptoms.29 Several prior efforts to prevent treatment of asymptomatic bac-
teriuria have included educational sessions,6,30 pocket cards with diagnostic algorithms with audit and feedback for training clini- cians,13 and antimicrobial stewardship efforts. Recently, Hartley et al4 replicated these interventions in hospitalist-based service in 3 different hospitals and observed a 24% reduction in ASB treat- ment rates, resulting in fewer days of antimicrobial therapy. Other recent interventions have included focus groups interviews for identifying factors that affect nurse initiated urine culture ordering and collection practices,31 reflex urine culture cancellation,21 and 2-step urine culture ordering in the emergency department.22 Although several of these upstream interventions are aimed toward eliminating unnecessary ordering and downstream interventions are aimed toward reducing treatment of asymptomatic bacteriuria, knowledge on the role of CPOE in reducing the burden of unnec- essary ordering in the inpatient setting is limited. Because of our intervention, we also noticed a significant
increase in the proportion of urine cultures that were positive during the postintervention period. This finding may indicate increased clarity of reflex algorithm test names and a change in the behavior of ordering clinicians (eg, urine cultures are more likely to be ordered in patients with a higher pretest probability). The postintervention period had a significantly higher proportion of positive urine cultures with an associated abnormal or positive urinalysis (1,896 of 2,621 [72.3%] vs 2,442 of 4,021 [60.7%]; P<.001) and a significantly lower proportion of positive urine cul- ture results with an associated negative urinalysis (122 of 2,621 [4.7%] vs 479 of 4,021 [11.9%]; P < .001). These findings suggests that a chance of an important UTI having been missed due to the decreased rate of urine culture following the intervention was less unlikely. Although we noticed a significant but small (6.9%) decrease in the isolated urine culture and substantial decrease
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