Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings

Abstract

BackgroundInappropriate ordering and acquisition of urine cultures leads to unnecessary treatment of asymptomatic bacteriuria (ASB). Treatment of ASB contributes to antimicrobial resistance particularly among hospital-acquired organisms. Our objective was to investigate urine culture ordering and collection practices among nurses to identify key system-level and human factor barriers and facilitators that affect optimal ordering and collection practices.MethodsWe conducted two focus groups, one with ED nurses and the other with ICU nurses. Questions were developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. We used iterative categorization (directed content analysis followed by summative content analysis) to code and analyze the data both deductively (using SEIPS domains) and inductively (emerging themes).ResultsFactors affecting optimal urine ordering and collection included barriers at the person, process, and task levels. For ED nurses, barriers included patient factors, physician communication, reflex culture protocols, the electronic health record, urinary symptoms, and ED throughput. For ICU nurses, barriers included physician notification of urinalysis results, personal protective equipment, collection technique, patient body habitus, and Foley catheter issues.ConclusionsWe identified multiple potential process barriers to nurse adherence with evidence-based recommendations for ordering and collecting urine cultures in the ICU and ED. A systems approach to identifying barriers and facilitators can be useful to design interventions for improving urine ordering and collection practices.

Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department

“…Likewise, prior studies of ASB in hospitalized patients have found urine testing results, both the UA and UC, to be associated with treatment by clinicians [ 2 , 18 , 19 ]. Both internal medicine physicians and ED nurses have been found to have knowledge gaps regarding the interpretation of UAs and UTI diagnosis [ 24–27 ]. The misinterpretation of UAs (ie, a positive UA equates with a UTI) has been highlighted as a target for decreasing inappropriate ASB treatment [ 2 , 18 , 19 , 28 , 29 ].…”

“…Although the UA has a high negative predictive value and is useful in ruling out a UTI, it is not indicative of a UTI in the absence of symptoms. Qualitative studies have identified that this is poorly understand and that a “positive UA” is incorrectly cited as the reason for sending a UC, diagnosing UTI, and initiating antibiotics [ 24 , 30 ].…”

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

“…Recently, Hartley et al (4) replicated these interventions in hospitalist-based service in three different hospitals and observed a 24% reduction in ASB treatment 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 two-step urine culture ordering in the emergency department (22). Although there are several of these upstream interventions in eliminating unnecessary ordering and downstream interventions in reducing treatment of asymptomatic bacteriuria, there is limited knowledge on the role of CPOE in reducing the burden of unnecessary ordering in inpatient setting.…”

Electronic Health Record–Assisted Reflex Urine Culture Testing Improves Emergency Department Diagnostic Efficiency

“…1-4 Prior work suggests that many urine cultures performed in the ED have limited utility based on frequent culture contamination, because patient presentations do not suggest acute urinary infections, and poor correlation with formal UA results. 5 Risks to patients include adverse medication reactions, development of Clostridioides difficile infection, or incident multidrug-resistant organism infection. 2…”

“…2 Previous investigations into urine culture ordering practices by ED and intensive care unit nurses suggest that educational interventions may result in early success that lacks sustained improvement as a result of limited optimization of the electronic health record (EHR), resistance to urine reflex culture protocols, and ED throughput concerns. 5 Accordingly, the study team sought to design a quality improvement intervention to overcome both technical challenges as well as human factor barriers to implementation. Furthermore, prior work has demonstrated reductions in urine culture utilization without examining the risk of undertesting or the effect of utilization reduction on diagnostic yield.…”