Measuring Progress of Choosing Wisely Adam Sangster and Aidan Wilson

Introduction to Urine Dipsticks Background Wellington SCL Data Surveys Introduction to Urine Dipsticks Among the elderly there are harmless bacteria in the urine at rates of 15-30% among men and 25-50% among women. This is asymptomatic bacteriuria (ASB). Worldwide there is a high rate of testing with 47% of admissions to US hospitals having urinalysis ordered. In New Zealand, a 2014 audit found that in a secondary hospital ASB accounted for 43% of antibiotic courses received for UTI management.

Urine Testing in the Hospital Background Wellington SCL Data Surveys Urine Testing in the Hospital Hard to measure nonspecific signs and symptoms Misconceptions over common signs and symptoms Unnecessary tests (dipstick and urine culture) High false +’ve rate in elderly due to asymptomatic bacteriuria Antimicrobial resistance Unnecessary treatment Antibiotic associated colitis Other drug-specific side effects

Microbiology recommends Background Wellington SCL Data Surveys Microbiology recommends Don’t prescribe antimicrobials to treat asymptomatic bacteriuria in the elderly Don’t collect urine specimens for culture from adults who lack symptoms localizing to the urinary tract or fever unless they are pregnant or undergoing genitourinary instrumentation where mucosal bleeding is expected. Urology recommends

Choosing Wisely CCDHB Project Background Wellington SCL Data Surveys Choosing Wisely CCDHB Project Surveys Lab Data Investigate the level of staff knowledge of Urinary Tract Infection (UTI) testing guidelines, their attitudes towards UTI testing and treatment, and their practice in long-term care facilities (LTCFs) and Kenepuru hospital Test the hypothesis that use of dipsticks in the elderly drives increased requests for urine culture.

Choosing Wisely HVDHB Background Wellington SCL Data Surveys Dr Matthew Kelly and the Antimicrobial Stewardship team initiated project at Hutt Hospital to reduce inappropriate urine testing beginning in March 2016:

Wellington SCL Data

Aim Background Wellington SCL Data Surveys Hutt Valley DHB: Analysis of urine samples sent from HVDHB and processed by Wellington SCL from January 2015 to October 2017. CCDHB: Data on the number of urine cultures from sent from four wards at Kenepuru hospital associated with elderly care, January 2015 to October 2017, along with occupancy data for the same period. Purpose: Has there been a decrease in requests for urine culture over time and, for HVDHB, has there been a drop in number of diagnoses of urinary tract infections.

Limitations Background Wellington SCL Data Surveys Unable to link urine culture data to patient information. “Recognised uropathogen” includes both UTIs and asymptomatic bacteriuria. No total number of inpatients and outpatients at Hutt Hospital during the 2015-2017 period. Could not identify how much of each antibiotic was given to patients with UTIs. For Kenepuru: Removal of dipsticks not only possible cause of change Change in lab system March 2017

Wellington SCL Data Hutt Valley DHB

Inpatient vs Outpatient (HVDHB) Background Wellington SCL Data Surveys Inpatient vs Outpatient (HVDHB) Urine culture requests for inpatients saw a 26% decrease from 449 to 330 per month since intervention began. Data for outpatients actually saw a rise of 13% for the same period. Outpatients are the negative control for this project as the interventions were not targeted at these areas.

Quarterly Requests by Department (HVDHB) Background Wellington SCL Data Surveys Quarterly Requests by Department (HVDHB) ED and medicine both saw similar decreases in quarterly urine requests, both dropping almost 30% in the late-2016 and 2017 periods compared to 2015. Interventions not officially implemented in ED. However, Choosing Wisely has been promoted hospital-wide and all house officers were educated. The orthopaedic ward, where interventions were initially targeted towards, saw the biggest drop in urine culture requests, falling by almost 45%.

Quarterly Requests by Department (HVDHB) Background Wellington SCL Data Surveys Quarterly Requests by Department (HVDHB)

Diagnosis of UTIs at Hutt Hospital Background Wellington SCL Data Surveys Diagnosis of UTIs at Hutt Hospital ICD-10 and DRG codes for UTIs were retrieved from Medical Records at Hutt Hospital for the period January 2015 to October 2017. Before the intervention there were 163 primary and secondary diagnoses of UTIs per quarter which fell to 141 - a statistically significant decrease of 13%.

Wellington SCL Data Capital & Coast DHB

Number of Urines (Kenepuru) Rate Ratios Rate Before Dipsticks Removed 0.028 urines per patient day each month. Rate After Dipsticks Removed 0.020 urines per patient day per month Rate Ratio is 0.72 (95% CI 0.65 - 0.80) fewer urines per patient day each month after September 2016 (dipstick removal)

Benefits from removal of dipsticks Fewer urines to culture One less procedure for patients to undergo. Costs Reduction (money and time) Benefits from removal of dipsticks Harms Reduction Likely any urines not sent from patients who are dipstick positive but not convincing symptoms, more likely to be ASB. Fewer sticks in wards Key Points CCDHB on Lab Data Rates of urines requested statistically significant, clinical significance is unknown... Overall Removal likely to have had a positive impact In line with guidelines Likely to benefit elsewhere Harms of removing dipsticks Possibly some urines sent through that would’ve been ruled out.

Staff Surveys

Purpose of Questionnaires Background Wellington SCL Data Surveys Purpose of Questionnaires Nurses: Focuses on their current knowledge, attitudes and behaviours surrounding urine testing of patients. House Officers: Series of clinical scenarios to gauge current practice behaviours around urine testing and antibiotic prescribing.

Limitations Background Wellington SCL Data Surveys Small sample sizes. 14 (out of 36) house officers and 37 nurses completed the survey at Hutt Hospital. No differences were statistically significant. At HVDHB, only 1 qualitative interview was able to be conducted. Surveys are of a quantitative nature only.

UTI Signs and Symptoms (HVDHB) Background Wellington SCL Data Surveys UTI Signs and Symptoms (HVDHB) 67.6% of nurses incorrectly believe that an abnormal urine dipstick result is indication of UTI. 35.1% of nurses are not aware that suprapubic tenderness is associated with UTIs. 86.5% of nurses will take a urinalysis for a patient who has experienced increasing confusion.

UTI Signs and Symptoms (CCDHB) Background Wellington SCL Data Surveys UTI Signs and Symptoms (CCDHB) Sign or Symptom Percentage Surveyed Nurses Describing it as “Significant” (%) Percentage of Surveyed Nurses who Would Rank it as one of the “Two Most Significant” (%) Increasing confusion 97.2 (90.3 - 99.7) 48.6 (36.7 - 60.7) Burning sensation during urination 95.8 (88.3 - 99.1) 43.1 (31.4 - 55.3) Fever 87.5 (77.6 - 94.1) 23.6 (14.4 - 35.1) Frequent urination 83.3 (72.7 - 91.1) Smelly urine 13.9 (6.9 - 24.1) Cloudy Urine 76.4 (64.9 - 85.6) 5.6 (1.5 - 13.6) Abnormal dipstick result 26.4 (16.7 - 38.1) Recent fall in elderly patient 59.7 (47.5 - 71.1) Blood in urine 55.6 (43.4 - 67.3) 6.9 (2.3 - 15.5) Supraubic tenderness 2.8 (0.3 - 9.7)

Nurse Management of Patients (HVDHB) Background Wellington SCL Data Surveys Nurse Management of Patients (HVDHB) 59.5% of nurses would only send urine sample to lab if the dipstick is abnormal, even if there is suspected UTI. Only 29.7% would send urine to the lab.

Nurse Management of Patients (CCDHB) A majority of nurses would use the dipstick to ‘rule out’ UTI, a common practice. However when given a patient presenting with very vague symptoms, but positive leukocytes they said policy would recommend immediate treatment. This presentation could easily could have been ASB. Proportion of LTCF Nurses, % Clinical Vignette Yes No Unsure No Answer If an elderly patient showed clinical signs and symptoms of UTI and a dipstick test was negative (−) for leukocytes. Would your facility’s protocol recommend immediate antibiotic treatment for UTI? 31.7 (20.6 - 44.7) 63.5 (50.4 - 75.3) 1.6 (0.0 - 8.5) 3.2 (0.4 - 11.0) If an elderly patient with dementia was more confused than normal and a dipstick was (+++) for leukocytes. Would your facility’s protocol recommend immediate antibiotic treatment for a UTI? 65.1 (52.0 - 76.7) 11.1 (4.6 - 21.6) 14.3 (6.7 - 25.4) 9.5 (3.6 - 19.6)

Perception of Urine Test Harm Background Wellington SCL Data Surveys Perception of Urine Test Harm Responses to the question: “I believe that urine tests are safe and present no harm or risk to the patient”. Near universal agreement that urine tests cannot cause harm, contrary to Choosing Wisely principles. Hutt Valley DHB CCDHB Strongly agree 43.2% (27.1 - 60.5) 59.7% (47.5 - 71.1) Agree 40.5% (24.8 - 57.9) 30.6% (20.2 - 42.5 Neutral 10.8% (3 - 25.4) 4.2 (0.9 - 11.7) Disagree 2.7% (0.1 - 14.2) 2.8% (0.3 - 9.7) Strongly disagree 1.4% (0.0 - 7.5

Knowledge of Choosing Wisely Background Wellington SCL Data Surveys Knowledge of Choosing Wisely Nurses: House Officers:

A special thank you to the Council of Medical Colleges, New Zealand for sponsoring this project by providing the educational grant. Their facilitation of Choosing Wisely in New Zealand is crucial to improving healthcare for both health professionals and patients across the country.

Thank you for your attention… Questions?