Quality Improvement Interventions and Implementation Strategies for Urine Culture Stewardship in the Acute Care Setting: Advances and Challenges

Abstract

Purpose ofReview-The goal of this article is to highlight how and why urinalyses and urine cultures are misused, review quality improvement interventions to optimize urine culture utilization, and highlight how to implement successful, sustainable interventions to improve urine culture practices in the acute care setting. Recent Findings-Quality improvement initiatives aimed at reducing inappropriate treatment of asymptomatic bacteriuria often focus on optimizing urine test utilization (i.e., urine culture stewardship). Urine culture stewardship interventions in acute care hospitals span the spectrum of quality improvement initiatives, ranging from strong systems-based interventions like suppression of urine culture results to weaker interventions that focus on clinician education alone. While most urine culture stewardship interventions have met with some success, overall results are mixed, and implementation strategies to improve sustainability are not well understood.Summary-Successful diagnostic stewardship interventions are based on an assessment of underlying key drivers and focus on multifaceted and complementary approaches. Individual intervention components have varying impacts on effectiveness, provider autonomy, and sustainability. The best urine culture stewardship strategies ultimately include both technical and socio-adaptive components with long-term, iterative feedback required for sustainability.

Optimizing reflex urine cultures: Using a population-specific approach to diagnostic stewardship

“…First, our prior work has shown that reflex urine cultures should not be used to diagnose UTIs but rather to reduce laboratory burden. 3,5,9 Discrete orderable tests for urinalysis, reflex urine cultures, and direct urine cultures should be created in the electronic medical record, and appropriate patient selection should be done in the ordering or preanalytic phase. Reflex urine cultures should be directed toward symptomatic patients, either through clinical decision support or by educating ordering clinicians.…”

“…Reflex urine cultures should be directed toward symptomatic patients, either through clinical decision support or by educating ordering clinicians. 9 To this effect, urinalysis parameters in a reflex urine culture should be based on their NPV. 5 Secondly, our data suggest that low-level pyuria (WBC ≥ 5) or trace leukocyte esterase may be adequate as single criterion in reflex urine culture algorithms if leveraged for its NPV to avoid unnecessary urine cultures.…”

“…Neonates or patients who are neutropenic, pregnant, or undergoing urologic procedures should be excluded from reflex testing protocols as these populations may either need treatment for asymptomatic bacteriuria (ASB) or may not display pyuria on urinalysis. 5,9 Last, laboratories should validate these findings on their own data to better optimize the local performance of reflex urine cultures. We recommend that institutions at least use include pyuria or leukocyte esterase (depending on availability of microscopic vs dipstick urinalysis) and nitrite when assessing the local performance of reflex urine cultures within their populations.…”

Beyond implementation: Uncovering the parallels between de-implementation and antimicrobial stewardship

“…For example, understanding that increase in urine tests is driven by inclusion of screening urinalysis orders (NPT theory) in admission or presurgical order sets allows de-implementation efforts to focus on removing these tests from admission or presurgical order sets. 18 …”

“…For example, understanding that increase in urine tests is driven by inclusion of screening urinalysis orders (NPT theory) in admission or presurgical order sets allows de-implementation efforts to focus on removing these tests from admission or presurgical order sets. 18 Multilevel factors affecting de-implementation Various frameworks and models have been used to describe factors that influence the pace and extent of the implementation of an innovation or intervention (eg, TDF and CFIR). 19 Although CFIR is primarily intended to identify potential factors that influence implementation, similar factors influence the pace and extent of de-implementation.…”