Description
Reduce antibiotic use by decreasing urine analysis orders for asymptomatic patients.
- Specific Policy change: We will no longer order UA on patients upon admission to swing bed from another facility
- Currently comparing data to see if the Workflow Charge of not testing every new swing bed admission for UTI has on how we actually practice. Number of UA cultures and Antibiotic for UTI prior to change will be compared to number of UA cultures and antibiotic for UTI after change.
- Goal is to see the numbers improve in terms of fewer UA’s being done which should result in lower ABX use.
- Note: Providers were already screening less for ASB prior to actual workflow sheet change as it was a topic of discussion for some time.
- Currently comparing data to see if the Workflow Charge of not testing every new swing bed admission for UTI has on how we actually practice. Number of UA cultures and Antibiotic for UTI prior to change will be compared to number of UA cultures and antibiotic for UTI after change.
- Education Campaign: We will no longer order UA on patients who are not symptomatic of UTI.
- Criteria to order UA will be educated upon
- Signs/Symptoms of UTI will be shared with nursing staff
- Debunk some historical assumptions. (Foul smelling urine does not = infections, Increased confusion in elderly does not equal UTI) Make well-known that 90% of patients over (certain age) will show bacteremia and will in fact be colonized and not infected.
- Length of ABX tx course for UTI
- Shorter length of treatment
- Catheter associated infection
- Always colonized, when to treat
- Criteria to order UA will be educated upon
Core Elements
Action
Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective.
Education
Educating clinicians about resistance and optimal prescribing.
Leadership Commitment
Dedicating necessary human, financial and information technology resources.
Tracking
Monitoring antibiotic prescribing and resistance patterns.
PDSA Cycles
Progress on PDSA Cycle 2
Reduce treatment of ASB by educating nurses, CNA’s and physicians to accurate symptoms of UTI.
Reports of foul smelling urine were observed during prior chart review to result in antibiotic use for ASB. Education upon accurate symptoms of UTI will reduce requests for UA in these patients. Population incidence of colonization in elderly patients should be focused on as well. Improved education will reduce unnecessary antibiotic use.
Nurse management, Physicians will be involved in this PDSA
Education ideas-will do research. We are small….so it would not be hard to add onto nurse education meetings, required competencies, but dont want to over-burden nurse staff. Physician education during med staff and direct communication.
EPIC option. UA order… can we prompt Urine culture by symptom identification?
Progress on PDSA Cycle 1
HDH will no longer automatically order a urine analysis for each patient when admitted to our Swing Bed program. We will identify fewer urinary tract infections due to ASB (Asymptomatic bacteriuria) and will reduce the use of antibiotics in this population. CNO, Infection Prevention Nurse, Pharmacy Director, Nursing Staff and all hospital physicians will be involved.
This change is to be implemented immediately. Med Staff approved the change on 7-15-2021. CNO to change policy. Nurse and Physician education to begin today and will be ongoing.
Resources needed are few. Change will result from education and reinforcement of appropriate process.
Data collected: Decrease in UTI diagnosis, decrease in antibiotic days
No policy existed in Policy manager for requiring UA’s upon SB admission. The Swing Bed Admission Worksheet managed by Swing Bed Coordinator was updated to reflect agreed upon practice of not conducting screening UA upon admit.
This change was made 7/21/21. Med Staff was made aware during meeting. Unknown if nurse training or any other communication was done.
Encounters for swing bed admissions were requested from Swing Bed Coordinator Mary Morgan. 26 patients were identified for the study. 13 patients prior to the change in Swing Bed Admission Worksheet and 13 patients after the change that removed UA screen order upon admission. Pharmacist reviewed charts of these admissions. Charts were reviewed for date of SB stay, UA lab done during stay, ABX use during stay, physician who ordering UA, and documentation for signs/symptoms of UTI observed. Results of study are reported only for UA completed upon admission to SB stay. Other UA orders for these patients were completed out of the admission time line during the stay and were not considered for this study.
Results: 2 out of 13 Swing bed encounters had a UA ordered upon admission prior to changing the Admission Worksheet. O out of 13 Swing bed encounters had a UA ordered upon admission after the change.
Change in practice was already pretty well accepted prior to changing the worksheet so I was surprised to see any difference in the two groups. N=26 was pretty small but chart review was arduous and time consuming. N was limited due to time/resource available
While reviewing these charts I was surprised to see nurse notes claiming foul smelling urine. Two of these documented observations resulted in UA order by physicians and antibiotics ordered for patient. These two patients statistically are likely to have bacteria in urine but were not symptomatic. Antibiotics use in these two patients was likely unnecessary. Provider/nurse/caretaker education could prevent this UA from being done.
Results of study to be presented to abx stewardship team, Med Staff and the Hospital board.
Pharmacist Jessica will begin this process with a report of Study.
Adapt– Asymptomatic Bacteriuria (ASB) Education for providers/nurses/CNA’s Observation of foul smelling urine is likely a common report that results in treatment of ASB. This education will impact all patients and not just the swing bed population.