1. Promoting Adherence to Best Practice Urine Reflex to Culture Testing
Maykel Alonso BA, BSN-RN, CPH . Patient Improvement Theme- Patient Safety
CNL Role
Problem
Methods
Results
A single center study by Epstein et al. (2016) used a reflex urine culture protocol that prompted the laboratory staff to perform a UA followed by a urine culture if pyuria was present using pyuria WBC >10/HPF as a trigger to order a urine culture. This improvement project occurred in a hospital laboratory microsystem that uses >5/HPF as a criterion for pyuria. A problem exists with referring physicians who lack awareness of the CDC protocol and best practice for urine reflex to culture testing. An educational intervention was introduced to improve adherence to best practice.
Unnecessary urine culture testing can lead to the reduction of unnecessary culture testing and potential overtreatment in asymptomatic patients with antimicrobials.
To ensure that the number of urine cultures triggered by the new urine reflex to culture testing protocol meets clinical indications.
To educate 25 referring physicians to adhere to the Centers for Disease Control (CDC) protocol and best practices related to urine reflex to culture testing.
Consensus was obtained among 25 referring physicians to pilot the new protocol and improve communication and collaboration between the micro laboratory microsystem.
Created and pilot tested a Reflex to Culture Testing Data Collection Tool for prospective tracking and monitoring of UTI.
Developed and pilot tested a pocket sized reminder for Urine Reflex to Culture Testing Updated Workflow Criteria
Member of the Profession: Collaborate with healthcare professionals from multiple disciplines to plan, implement, and evaluate an improvement opportunity (AACN, 2013).
Educator: Utilizes a micro-laboratory pocket guide to outline the new process. The CNL Infection Control Nurse and the laboratory team will utilize a pocket guide for handoff across multiple shifts to assist with introducing the new criteria (pyuria >10/HPF) at the microsystem level, fostering a learning environment between MDs and lab.
Using Failure Mode Effects Analysis (FMEA) the urine reflex to culture starts with the collection process at the facility, it is then processed by the micro laboratory, and a reflex to culture is performed if urinalysis meets WBC>10/HPF. If a result is >10/HPF urine testing can lead to antimicrobial use.
Criteria for Urine Reflex to Culture Testing Flowchart
Goals
PICOT
Limitations
Patient and Problem: Asymptomatic UTI patients with bacteriuria (WBC>5 HPF) whose reflex culture yielded to the presence of a microorganism and antimicrobial.
Intervention: Over a 2-weeks period, educate referring physicians to adhere to the Centers for Disease Control (CDC) protocol, which delineates the clinical manifestation of SUTI, and to recommend best practices related to urine reflex to culture testing using pyuria > 10 HPF.
Comparison: Use the collected data after updating pyuria criteria to later determine physician adherence to the Centers for Disease Control (CDC) protocol. Baseline data between January 2017 and December 2017 represented that 10% of 200 urine samples from asymptomatic patients with UAs (negative leukocyte esterase and a WBC count <5/HPF) yielded the presence of a possible microorganism, necessitating further evaluation and antimicrobial treatment on asymptomatic patients
Outcome: 25 physicians were educated using a flowchart that defines the new UTI clinical criteria and outlines the new pyuria criteria (>10HPF) testing on UTI asymptomatic patients.
Timeframe: Education-4-weeks; pilot flowchart-2 weeks.
UTI has a large amount of codes assigned by the International Classification of Diseases, Tenth Edition (ICD-10), which could potentially make the gathering of data difficult and inaccurate.
Obtaining ICD-10 codes from the MD office or coding department can lead to human error and incorrect UTI coding.
SUTI is well defined in the literature. Accurately measuring the incidence of UTI in the Trauma community is challenging because of the characteristics and clinical manifestations of UTI in this trauma population. A large volume of patients will not be able to complaint of the presence of flank pain, dysuria, urgency, or frequency, especially if they are intubated or have neurological impairment.
Specific Aim: Over a 2-week period, 25 referring physicians will be educated about the current CDC protocol that recommends urine reflex to culture testing when pyuria (WBC >10/HPF) is present on patients who meet Symptomatic Urinary Tract Infection (UTI) criteria.
Setting: 264-bed acute care, trauma II-designated facility located in Northern California- San Jose which provides full service care to a community which is primarily underserved.
Tools
Selected References
Centers for Disease Control and Prevention. (2018). Urinary tract infection (catheter associated urinary tract infection [CAUTI] and non-catheter-associated urinary tract infection [UTI]) and other urinary system infection (USI) events. In National Healthcare Safety Network (NHSN) patient safety component manual (Ch. 7). Retrieved from
Redwood, R. & Knobloch, M. (2018). Reducing unnecessary culturing: A systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings. Antimicrobial Resistance and Infection Control, 7:4. DOI /s
Misconceptions regarding UTI
In the absence of symptoms—dark or foul-smelling urine and change in Foley catheter urine appearance, are not indications of an UTI (Redwood et. al, 2018).
Urine Reflex to Culture Testing Updated Workflow Criteria
(pocket card)
Leukocyte Esterase
Nitrite
Bacteria
WBC
POS
NEG
Small to Large
NEG – Many
>10/HPF
MOD – Many .
Acknowledgements
Theoretical Framework-Lewin's Three-Step Model for Change
I would like to thank Prof. Cathy Coleman, for her guidance and support. Her encouragement and guidance have helped me accomplish a Master Degree in the Nursing –Clinical Nursing Leadership program at University of San Francisco.
Special gratitude goes to my colleague and classmate
Ginger Miramontes for her dual commitment to my completion of the educational program.
Thank you to facility’s Quality Department, Microbiology Department and the clinicians for providing the resources needed, which allowed me to undertake this research.
MDs awareness of current practice for urine reflex to culture testing using a WBC level of >5 HPF
Freeze
Introduce new best practice for urine reflex to culture testing using a WBC level of >10 HPF
Unfreeze
Lab and MDs will adapt to the new process and track lab testing and UTIs over 6 months.
Note: POS= Positive, NEG= Negative, MOD= Moderate
Author updated internal data from facility's Micro Laboratory Guide. General Specimen Collection Information (July 15, 2018).