Background: Urine culture testing should primarily be reserved for patients with clinical symptoms or other limited indications. Unfortunately, many admitted patients undergo unnecessary urine culture testing, leading to overdiagnosis and overtreatment of asymptomatic bacteriuria (ASB). Unnecessary antibiotic treatment for ASB does not improve outcomes and exposes patients to side effects. The negative implications may include increased cost, prolonged hospitalization, reporting of hospital-acquired infections, and decreased hospital reimbursement. In a prior study, we estimated that two-thirds of urine cultures collected in our general medical ward did not follow institutional guidelines.
Purpose: Our student-led quality improvement team aimed to reduce the rate of urine culture collection on general medicine floors by 20% within one year at a tertiary care center in New York City from July 2022 to June 2023.
Description: The QI team followed the Model for Improvement to develop, test, and implement change. After understanding the significant factors contributing to the problem, interventions were created by analyzing baseline data collected from chart review, staff surveys, faculty interviews, and crafting a Fishbone diagram. The primary intervention included modifying the electronic medical record (EMR) urine culture order by adding question prompts and instructions. In addition, front-line provider education was provided by highlighting the harms of inappropriate testing and promoting clinical algorithm use. Finally, nurses were instructed to question improper collections using an existing escalation process for other low-value tests. Given that our general medical floors have the same daily occupancy, the process measure used was the total number of urine cultures collected monthly. A run chart was created to assess performance (figure 1). The average monthly number of urine cultures collected was 30 in the pre-intervention period and 25 post-intervention, reflecting a 17% decrease in 12 months. A shift was noticed after the second PDSA cycle as interventions were refined.
Conclusions: While the project’s aim was not fully achieved, this project boasts numerous strengths as it draws inspiration from successful similar projects within the same institution, and its interventions demonstrate proven applicability. By leveraging existing communication and educational processes, it sidesteps the need for additional resources. Moreover, the project aligns seamlessly with the hospital medicine department’s goals, focusing on high-value care and waste reduction. Bolstering its success is a dedicated, motivated team of students committed to the project’s objectives. The main challenges during the study period included COVID-19 surges impacting regular workflow, nursing leadership changes on several floors, institutional restrictions on quick electronic medical records changes, and low attendance at some educational sessions. Understanding every institution’s environmental, cultural, and systemic practices is essential to adopting the most likely successful strategy. Although redundant, a continued methodological approach is necessary to realize and sustain this project.
