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Impact of order set design on urine culturing practices at an academic medical centre emergency department
  1. Satish Munigala1,
  2. Ronald R Jackups Jr2,
  3. Robert F Poirier3,
  4. Stephen Y Liang1,
  5. Helen Wood4,
  6. S Reza Jafarzadeh5,
  7. David K Warren1
  1. 1 Department of Internal Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
  2. 2 Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, Missouri, USA
  3. 3 Emergency Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
  4. 4 Hospital Epidemiology and Infection Prevention, Barnes-Jewish Hospital, St. Louis, Missouri, USA
  5. 5 Clinical Epidemiology Research and Training Unit, Boston University, Boston, Massachusetts, USA
  1. Correspondence to Professor David K Warren, Department of Internal Medicine Washington University in St. Louis, St. Louis, Missouri, USA; dwarren{at}


Background Urinalysis and urine culture are commonly ordered tests in the emergency department (ED). We evaluated the impact of removal of order sets from the ‘frequently ordered test’ in the computerised physician order entry system (CPOE) on urine testing practices.

Methods We conducted a before (1 September to 20 October 2015) and after (21 October to 30 November 2015) study of ED patients. The intervention consisted of retaining ‘urinalysis with reflex to microscopy’ as the only urine test in a highly accessible list of frequently ordered tests in the CPOE system. All other urine tests required use of additional order screens via additional mouse clicks. The frequency of urine testing before and after the intervention was compared, adjusting for temporal trends.

Results During the study period, 6499 (28.2%) of 22 948 ED patients had ≥1 urine test ordered. Urine testing rates for all ED patients decreased in the post intervention period for urinalysis (291.5 pre intervention vs 278.4 per 1000 ED visits post intervention, P=0.03), urine microscopy (196.5vs179.5, P=0.001) and urine culture (54.3vs29.7, P<0.001). When adjusted for temporal trends, the daily culture rate per 1000 ED visits decreased by 46.6% (−46.6%, 95% CI −66.2% to –15.6%), but urinalysis (0.4%, 95% CI −30.1 to 44.4%), microscopy (−6.5%, 95% CI −36.0% to 36.6%) and catheterised urine culture rates (17.9%, 95% CI −16.9 to 67.4) were unchanged.

Conclusions A simple intervention of retaining only ‘urinalysis with reflex to microscopy’ and removing all other urine tests from the ‘frequently ordered’ window of the ED electronic order set decreased urine cultures ordered by 46.6% after accounting for temporal trends. Given the injudicious use of antimicrobial therapy for asymptomatic bacteriuria, findings from our study suggest that proper design of electronic order sets plays a vital role in reducing excessive ordering of urine cultures.

  • emergency department
  • infection control
  • trigger tools
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  • Contributors All authors made substantial contribution to the project conception, study design, data analysis and drafting of the paper. All authors have approved the final version of the paper for publication.

  • Funding This study was funded by Centers for Disease Control and Prevention Epicenters Program (grant no. 1 U54CK000482-01) to David K. Warren.

  • Competing interests None declared.

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

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