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Patel UC, Ismail G, Suda KJ, Sabzwari R, Pacheco SM, Bhoopalam S. Evaluating the Impact of a Urinalysis to Reflex Culture Process Change in the Emergency Department at a Veterans Affairs Hospital. Fed Pract 2022; 39:76-81. [PMID: 35444388 PMCID: PMC9014942 DOI: 10.12788/fp.0221] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND Although automated urine cultures (UCs) following urinalysis (UA) are often used in emergency departments (EDs) to identify urinary tract infections (UTIs), results are often reported as no organism growth or the growth of clinically insignificant organisms, leading to the overdetection and overtreatment of asymptomatic bacteriuria (ASB). METHODS A process change was implemented at a US Department of Veterans Affairs medical center ED that automatically cancelled UCs if UAs had < 5 white blood cells per high-power field (WBC/HPF). An option for do not cancel (DNC) UC was available. Data were prospectively collected for 3 months postimplementation and included UA/UC results, presence of UTI symptoms, antibiotics prescribed, and health care utilization. RESULTS Postintervention, 684 UAs (37.2%) were evaluated from ED visits. Postintervention, of 255 UAs, 95 (37.3%) were negative with UC cancelled, 95 (37.3%) were positive with UC processed, 43 (16.9%) were ordered as DNC, and 22 (8.6%) were ordered without a UC. UC processing despite a negative UA significantly decreased from 100% preintervention to 38.6% postintervention (P < .001). Inappropriate prescribing of antibiotics for ASB was reduced from 10.2% preintervention to 1.9% postintervention (odds ratio = 0.17; P = .01). In patients with negative UA specimens, antibiotic prescribing decreased by 25.3% postintervention. No reports of outpatient, ED, or hospital visits for symptomatic UTI were found within 7 days of the initial UA postintervention. CONCLUSIONS The UA to reflex culture process change resulted in a significant reduction in processing of inappropriate UCs and unnecessary antibiotic use for ASB. There were no missed UTIs or other adverse patient outcomes.
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Affiliation(s)
- Ursula C Patel
- Edward Hines, Jr Veterans Affairs Hospital, Hines, Illinois
| | | | - Katie J Suda
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health Care System
- Department of Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | | | - Susan M Pacheco
- Edward Hines, Jr Veterans Affairs Hospital, Hines, Illinois
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
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Veillette JJ, Waters CD, Gelman SS, Hoopes L, Vargyas G, McKay A, Good T, Olson J, Vento TJ. Antibiotic prescribing for adult bacteriuria and pyuria in community hospital emergency departments. Am J Emerg Med 2020; 40:1-5. [PMID: 33326910 DOI: 10.1016/j.ajem.2020.11.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To describe emergency department (ED) antibiotic prescribing for urinary tract infections (UTIs) and asymptomatic bacteriuria (ASB) and to identify improvement opportunities. METHODS Patients treated for UTI in 16 community hospital EDs were reviewed to identify prescribing that was unnecessary (any treatment for ASB, duration >7 days for cystitis or >14 days for pyelonephritis) or suboptimal [ineffective antibiotics (nitrofurantoin/fosfomycin) or duration <7 days for pyelonephritis]. Duration criteria were based on recommendations for complicated UTI since criteria for uncomplicated UTI were not reviewed. 14-day repeat ED visits were evaluated. RESULTS Of 250,788 ED visits, UTI was diagnosed in 13,466 patients (5%), and 1427 of these (11%) were manually reviewed. 286/1427 [20%, 95% CI: 18-22%] met criteria for ASB and received 2068 unnecessary antibiotic days [mean (±SD) 7 (2) days]. Mean treatment duration was 7 (2) days for cystitis and 9 (2) days for pyelonephritis. Of 446 patients with cystitis, 128 (29%) were prescribed >7 days (total 396 unnecessary). Of 422 pyelonephritis patients, 0 (0%) were prescribed >14 days, 20 (5%) were prescribed <7 days, and 9 (2%) were given ineffective antibiotics. Overall, prescribing was unnecessary or suboptimal in 443/1427 [31%, 95% CI: 29-33%] resulting in 2464/11,192 (22%) unnecessary antibiotic days and 8 (0.5%) preventable ED visits. CONCLUSIONS Among reviewed patients, poor UTI prescribing in 16 EDs resulted in unnecessary antibiotic days and preventable readmissions. Key areas for improvement include non-treatment of ASB and shorter durations for cystitis.
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Affiliation(s)
- John J Veillette
- Infectious Diseases Telehealth Service, Intermountain Healthcare, Intermountain Medical Center, Murray, UT, USA; Department of Pharmacy, Intermountain Healthcare, Intermountain Medical Center, Murray, UT, USA.
| | - C Dustin Waters
- Department of Pharmacy, Intermountain Healthcare, McKay-Dee Hospital, Ogden, UT, USA
| | - Stephanie S Gelman
- Infectious Diseases Telehealth Service, Intermountain Healthcare, Intermountain Medical Center, Murray, UT, USA; Division of Infectious Diseases and Epidemiology, Intermountain Healthcare, Intermountain Medical Center, Murray, UT, USA
| | - Lisa Hoopes
- Department of Pharmacy, Intermountain Healthcare, Bear River Valley Hospital, Tremonton, UT, USA
| | - George Vargyas
- Utah Emergency Physicians, Intermountain Medical Center Emergency Department, Murray, UT, USA
| | - Alyssa McKay
- Department of Pharmacy, Intermountain Healthcare, American Fork Hospital, American Fork, UT, USA
| | - Tatiana Good
- Department of Pharmacy, Intermountain Healthcare, American Fork Hospital, American Fork, UT, USA
| | - Jared Olson
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, UT, USA; Division of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Todd J Vento
- Infectious Diseases Telehealth Service, Intermountain Healthcare, Intermountain Medical Center, Murray, UT, USA; Division of Infectious Diseases and Epidemiology, Intermountain Healthcare, Intermountain Medical Center, Murray, UT, USA
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