Reducing Unnecessary Urine Culture Testing with New EPIC Protocol
Some experts estimate that at least $200 billion is wasted each year on excessive medical testing and treatment. Amy Slenker, MD, Chair of the Test Utilization Committee, and Vice Chair of Quality and Patient Safety DOM at LVHN, set out to reduce expenditures in our hospital system in at least one area, and tackled a Quality Improvement project on “Reduction of Unnecessary Urine Culture Testing,” starting in 2016.
Urine cultures are best practices for diagnosing a urinary tract infection. However, data has revealed that 50 percent of urine cultures ordered in the hospital are for patients that did not have symptoms of UTI. Furthermore, most positive urine cultures occur in patients with a urinary catheter and are triggered by asymptomatic bacteriuria (ASB), which is common for catheterized patients. ASB is the presence of bacteria in the urine without clinical symptoms of infection, and treatment is unlikely to benefit to the patient.
“We found that these positive tests – derived from the presence of ASB and not based on the patient’s symptoms – were driving inappropriate and excessive prescribing of antibiotics,” says Dr. Slenker. “As we know, it’s imperative to reduce this excess. The most important take-away is: Culture the urine only when the indication is clear.”
To move toward a solution of reducing unnecessary urine testing, the team created an Inpatient Urine Culture Order in EPIC. Using this tool, providers have to answer three questions to request a urine culture: 1) Does the patient have a urinary catheter? 2) Does the patient have symptoms of a UTI, and 3) What are the patient’s symptoms? The clinical indications for ordering a urine culture are based on current Infectious Diseases Society of America (IDSA) guidelines. If the patient meets criteria for ordering a urine culture, the order would be processed as per usual. If the patient did not meet criteria for a urine culture, a Best Practice Advisory (BPA) would pop up with the following guidance: “Your patient does not meet the criteria for a urine culture, please remove the order.”
As a result of this simple procedure, the rate of urine cultures dropped by 25 percent. Other important educational measures were concurrently taken and from August 2016 to September 2017, LVH-17th Street, LVH-Muhlenberg, and LVH-Cedar Crest campuses saw a 60 percent drop in total urine culture ordering. The Urine Culture Order continues to be used throughout the hospitals at these three Lehigh Valley Health Network locations.