The Use of Clinical Decision Support in Reducing Diagnosis of and Treatment of Asymptomatic Bacteriuria
Clinical decision support (CDS) embedded within the electronic health record (EHR) is a potential antibiotic stewardship strategy for hospitalized patients. Reduction in urine testing and treating asymptomatic bacteriuria (ASB) is an important strategy to promote antibiotic stewardship. We created an intervention focused on reducing urine testing for asymptomatic patients at a large tertiary care center. The objective of this study was to design an intervention to reduce unnecessary urinalysis and urine culture (UC) orders as well as the treatment of ASB. We performed a quasiexperimental study among adult inpatients at a single academic institution. We implemented a bundled intervention, including information broadcast in newsletters, hospital-wide screensavers, and passive CDS messages in the EHR. We investigated the impact of this strategy on urinalysis, UC orders, and on the treatment of ASB by using an interrupted time series analysis. Our intervention led to reduced UC order as well as reduced antibiotic orders in response to urinalysis orders and UC results. This easily implementable bundle may play an important role as an antibiotic stewardship strategy.
© 2017 Society of Hospital Medicine
Reducing the treatment of asymptomatic bacteriuria (ASB), or isolation of bacteria from a urine specimen in a patient without urinary tract infection (UTI) symptoms, is a key goal of antibiotic stewardship programs.1 Treatment of ASB has been associated with the emergence of resistant organisms and subsequent UTI risk among women with recurrent UTI.2,3 The Infectious Diseases Society of America and the American Board of Internal Medicine Foundation’s Choosing Wisely campaign recommend against treating ASB, with the exception of pregnant patients and urogenital surgical patients.1,4
Obtaining urinalyses and urine cultures (UC) in asymptomatic patients may contribute to the unnecessary treatment of ASB. In a study of hospitalized patients, 62% received urinalysis testing, even though 82% of these patients did not have UTI symptoms.5 Of the patients found to have ASB, 30% were given antibiotics.5 Therefore, interventions aimed at reducing urine testing may reduce ASB treatment.
Electronic passive clinical decision support (CDS) alerts and electronic education may be effective interventions to reduce urine testing.6 While CDS tools are recommended in antibiotic stewardship guidelines,7 they have led to only modest improvements in appropriate antibiotic prescribing and are typically bundled with time-intensive educational interventions.8 Furthermore, most in-hospital interventions to decrease ASB treatment have focused on intensive care units (ICUs).9 We hypothesized that CDS and electronic education would decrease (1) urinalysis and UC ordering and (2) antibiotic orders for urinalyses and UCs in hospitalized adult patients.
METHODS
Population
We conducted a prospective time series analysis (preintervention: September 2014 to June 2015; postintervention: September 2015 to June 2016) at a large tertiary medical center. All hospitalized patients ≥18 years old were eligible except those admitted to services requiring specialized ASB management (eg, leukemia and lymphoma, solid organ transplant, and obstetrics).1 The study was declared quality improvement by the Johns Hopkins Institutional Review Board.
Intervention
In August 2015, we implemented a multifaceted intervention that included provider education and passive electronic CDS (supplementary Appendix 1 and supplementary Appendix 2). Materials were disseminated through hospital-wide computer workstation screensavers and a 1-page e-mailed newsletter to department of medicine clinicians. The CDS tool included simple informational messages recommending against urine testing without symptoms and against treating ASB; these messages accompanied electronic health record (EHR; Allscripts Sunrise Clinical Manager, Chicago, IL) orders for urinalysis, UC, and antibiotics commonly used within our institution to treat UTI (cefazolin, cephalexin, ceftriaxone, trimethoprim-sulfamethoxazole, nitrofurantoin, and ciprofloxacin). The information was displayed automatically when orders for these tests and antibiotics were selected; provider acknowledgment was not required to proceed.
Data Collection
The services within our hospital are geographically located. We collected orders for urinalysis, UC, and the associated antibiotics for all units except those housing patients excluded from our study. As the CDS tool appeared only in the inpatient EHR, only postadmission orders were included, excluding emergency department orders. For admissions with multiple urinalyses, urinalysis orders placed ≥72 hours apart were eligible. Only antibiotics ordered for ≥24 hours were included, excluding on-call and 1-time antibiotic orders.
Our approach to data collection attempted to model a clinician’s decision-making pathway from (1) ordering a urinalysis, to (2) ordering a UC in response to a urinalysis result, to (3) ordering antibiotics in response to a urinalysis or UC result. We focused on order placement rather than results to prioritize avoiding testing in asymptomatic patients, as our institution does not require positive urinalyses for UC testing (reflex testing). Urinalyses resulted within 1 to 2 hours, allowing for clinicians to quickly order UCs after urinalysis result review. Urinalysis and UC orders per monthly admissions were defined as (1) urinalyses, (2) UCs, (3) simultaneous urinalysis and UC (within 1 hour of each other), and (4) UCs ordered 1 to 24 hours after urinalysis. We also analyzed the following antibiotic orders per monthly admissions: (1) simultaneous urinalysis and antibiotic orders, (2) antibiotics ordered 1 to 24 hours after urinalysis order, and (3) antibiotics ordered within 24 hours of the UC result.
