Background, Rationale and Suggested Implementation Strategies
- Educate providers, including hospitalists, internal medicine, family medicine, emergency medicine physicians, residents, advanced practice professionals (APPs), and nursing staff regarding the diagnosis of ASB vs UTI.
- Educate patients and family members regarding the diagnosis of ASB vs UTI.
- Review ASB cases identified by HMS to direct high-yield intervention for recurrent problems.
- Evaluate and understand differences in provider groups (e.g., hospitalists, emergency department physicians). Target interventions to specific provider groups as necessary.
- Evaluate existing order sets to ensure preferred antibiotic options, doses, and durations are consistent with institutional UTI guidelines (including pre-operative order sets, ED admission sets, “commonly ordered test” lists).
- Utilize clinical decision support tools to discourage inappropriate urine culture testing in the absence of urinary symptoms, by requiring documentation of symptom(s) as indication for the test.
- Utilize checklists to discourage ordering of urine cultures in the absence of urinary symptoms by frontline clinical care team.
- Require documentation of dose and indication of antibiotics prescribed in the antibiotic order. Consider adding documentation of urinary symptom(s) necessitating treatment.
- Encourage documentation of dose, indication, and duration of antibiotics in the progress note.
- Encourage documentation of the total duration of antibiotics in discharge summary, potentially incorporating an area for antibiotic duration to be filled out in an automated discharge process.
- Provide audit and feedback directly to individual providers regarding their rates of testing and treatment for ASB.
- Consider performing urine cultures only when indicated (example: reflex culture only with positive urinalysis).
- Consider suppressing urine culture results by requiring providers to call the microbiology lab to request results (for non-catheterized patients).
- Create a protocol assessing for UTI in patients whose primary symptom is altered mental status (AMS).
- Consider implementing a diagnostic stewardship intervention. Examples include: removal of urine cultures from a) preoperative, b) emergency department, c) admission, or d) other order sets; addition or removal of reflex testing; hiding urine culture results in some settings; requiring physician order to run urine cultures in ED; two-step urine culture initiative to reduce urine cultures in ED; framing urine culture results in test reporting; AND/OR rejection of some urine culture samples (e.g., based on squamous cells)
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