1. Measuring Progress of Choosing Wisely
Adam Sangster and Aidan Wilson

2. 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.

3. 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

4. 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

5. 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.

6. 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:

7. Wellington SCL Data

8. 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.

9. 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 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

10. Wellington SCL Data Hutt Valley DHB

11. 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.

12. 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%.

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

14. 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 a statistically significant decrease of 13%.

15. Wellington SCL Data Capital & Coast DHB

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

17. 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.

18. Staff Surveys

19. 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.

20. 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.

21. 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.

22. 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 ( )
48.6 ( )
Burning sensation during urination
95.8 ( )
43.1 ( )
Fever
87.5 ( )
23.6 ( )
Frequent urination
83.3 ( )
Smelly urine
13.9 ( )
Cloudy Urine
76.4 ( )
5.6 ( )
Abnormal dipstick result
26.4 ( )
Recent fall in elderly patient
59.7 ( )
Blood in urine
55.6 ( )
6.9 ( )
Supraubic tenderness
2.8 ( )

23. 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.

24. 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 ( )
63.5 ( )
1.6 ( )
3.2 ( )
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 ( )
11.1 ( )
14.3 ( )
9.5 ( )

25. 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% ( )
59.7% ( )
Agree
40.5% ( )
30.6% (
Neutral
10.8% ( )
4.2 ( )
Disagree
2.7% ( )
2.8% ( )
Strongly disagree
1.4% (

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

27. 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.

28. Thank you for your attention… Questions?