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Original research
Impact of two-step urine culture ordering in the emergency department: a time series analysis
  1. Amanda Stagg1,
  2. Haydon Lutz2,
  3. Sakshi Kirpalaney2,
  4. John Justin Matelski3,
  5. Adam Kaufman1,
  6. Jerome Leis4,5,
  7. Janine McCready1,4,
  8. Jeff Powis1,4
  1. 1 Michael Garron Hospital, Toronto, Ontario, Canada
  2. 2 Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
  3. 3 Department of Internal Medicine, Toronto General Hospital, Toronto, Ontario, Canada
  4. 4 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  5. 5 University of Toronto, Center for Quality Improvement and Patient Safety, Toronto, Ontario, Canada
  1. Correspondence to Dr Jeff Powis, Michael Garron Hospital, Toronto, Ontario, Canada M4C 3E7; jpowi{at}tegh.on.ca

Abstract

Background Despite evidence against the use of antimicrobials for asymptomatic bacteriuria (ASB), they are frequently prescribed leading to unnecessary adverse events. Prior studies have shown that reducing unnecessary urine cultures (UCs) results in decreased antimicrobial utilisation for ASB. Emergency departments (EDs) submit the largest volume of UCs, yet efforts to limit overordering in this patient setting have had limited success.

Methods A new two-step model of care for urine collection, using a novel UC collection container, was implemented in the ED of a large community hospital. The collection system contains a preservative allowing UCs to be held at room temperature for up to 48 hours before processing. UCs were collected by front-line staff, but only processed in the microbiology lab if requested by ED physicians after clinical assessment.

Results Following implementation there was a decrease in the percentage of weekly ED visits associated with a processed UC (5.97% vs 4.68%, p<0.001), a decrease in the percentage of monthly ED visits requiring a callback for positive urine culture (1.84% to 1.12%, p<0.001) and a decrease in antimicrobial prescriptions for urinary indication among admitted patients (20.6% to 10.9%, p<0.01). There was a false omission rate of 1.35% (95% CI 0.7% to 2.2%), yet no identified cases of untreated urinary tract infection (UTI), or significant change in repeat ED visits or ED length of stay.

Conclusions Changing to two-step urine culture ordering in the ED resulted in a decrease in UCs processed, callbacks for positive results and antimicrobial use without evidence of untreated UTIs. This model of care has strong potential to improve the use of hospital resources while minimising detection and inappropriate treatment of ASB.

  • Emergency department
  • Quality improvement
  • Laboratory medicine

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjqs-2016-006250

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    Footnotes

    • Contributors All authors made substantial contribution to the project conception, study design, data analysis and drafting of the paper. All authors have approved this version of the paper for publication.

    • Funding This research received no specific grant from any funding agency, commercial or not-for-profit sectors. The UC system was paid for by hospital and no private funding was received. The company (BD) that manufactures this system did not have any role in the design of the study, the conduct of the study, the collection, management, analysis or interpretation of the data, or the preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    • Competing interests None declared.

    • Ethics approval Research ethics board.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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