EXECUTIVE SUMMARY

Recent data suggest many patients without symptoms of a urinary tract infection (UTI) are tested for the condition in the ED, with some likely to be receiving antibiotics unnecessarily. Investigators report urine testing in the ED is associated with longer stays.

  • Of more than 16,000 patients who presented with chest pain at two academic EDs between 2015 and 2019, 19% underwent urine tests, even though only 0.01% would be expected to have UTIs from an epidemiological standpoint. Slightly more than 10% of patients who underwent urine tests received antibiotics to treat UTI.
  • Regarding patients who presented with abdominal pain, researchers reported 75% received urine tests, and 17% of these patients received prescriptions for antibiotics to treat UTI.
  • A separate study revealed a nurse-driven intervention can help curb unnecessary urine cultures and associated antibiotic use. Although the study was conducted on an inpatient unit, investigators report it could work just as well in the ED.

There is anecdotal evidence suggesting too many patients were undergoing urine tests to rule out urinary tract infections (UTIs), receiving unnecessary antibiotics, and enduring excessive waits in EDs.

To put these suspicions to the test, researchers conducted a retrospective cohort study on patients discharged from two academic EDs between 2015 and 2019. They divided patients into groups, based on the chief complaint, excluding patients who were placed in observation, received a psychiatric consultation, received a diagnosis of alcohol intoxication, or whose length of stay (LOS) exceeded nine hours.

Of the more than 16,000 patients presenting with chest pain, 19% underwent urine tests, even though only 0.01% would be expected to have UTIs from an epidemiological standpoint. For the 3,146 patients who underwent urine tests, slightly more than 10% received prescriptions for antibiotics to treat UTIs. As a comparison, just 1.4% of patients who did not receive urine tests received the antibiotics.

Regarding patients who presented to the ED with abdominal pain, the researchers reported 75% received urine tests, 17% of whom received prescriptions for antibiotics to treat UTIs. Additionally, 78% of women older than age 65 years who presented with weakness, an altered mental state, or confusion underwent urine tests. Twenty-seven percent received UTI antibiotics.

Focus on Symptoms

Investigators presented these preliminary findings in October 2020 during the virtual annual meeting of the American College of Emergency Physicians. Researchers plan to explore more details in patient charts to determine, among other things, whether the patients who received urine tests and antibiotics were experiencing any symptoms of UTI.

Still, these early findings indicate a possible pattern of excessive urine testing in the ED, leading to unnecessary antibiotic prescriptions and potential harm.

“Oftentimes, physicians are taught that a urine culture is the gold standard [for the diagnosis of UTI], but that is not the case,” observes Richard Childers, an emergency physician at the University of California San Diego (UCSD) Medical Center who led this research team. “If [the patient] is not having symptoms, [a positive urinalysis] just doesn’t matter. You can’t benefit [from antibiotics] if you are not having symptoms of UTI.”

Excessive urine testing may not just adversely affect antibiotic stewardship. In a separate analysis, UCSD researchers studied the LOS of all patients who were discharged from the ED during the 2015-2019 study period. Patients who underwent urine tests remained in the ED for an average of 78 minutes longer than others. When examining all patients who underwent lab tests, those who underwent urine tests spent an average of 21 minutes longer in the ED than others.

Provide Education

What is driving the widespread use of urine tests to rule out UTIs in patients who present without symptoms? Childers suspects the answer may be related to the desire to establish an explanation for whatever symptoms have prompted patients to seek care.

Childers notes he and colleagues often see patients who present with “vague abdominal pain” that is hard to explain away. “That is oftentimes not satisfying for the patient ... we have a desire to find a definitive answer to explain things. A UTI is definitely attractive as an explanation because then we can say that [we have] an antibiotic to give that will fix it.”

Childers stresses emergency physicians care about patient flow. Considering the effect of excessive urine testing on LOS in the ED, he is optimistic physicians can be persuaded to make improvements. Perhaps leaders can provide more education, coupled with reassurances that changing will not be accompanied by more administrative busy work.

“Maybe that will be a lower bar to meet to change their behavior than asking them to do extra work,” Childers offers.

Enlist Nurses

Another potential pathway to improvement is through a nurse-driven intervention. This approach proved effective in a pilot program at the Johns Hopkins Hospital in Baltimore.1

“We know that one of the major drivers of inappropriate antibiotic use is UTIs,” explains Valeria Fabre, MD, lead investigator. “There is what we call asymptomatic bacteriuria, which basically means that people can have bacteria in the urine without having a UTI ... if you [perform a urine culture] on a patient who does not have symptoms of a UTI, you may find bacteria. Once you see that bacteria in the urine, it is very hard for most clinicians not to treat that.”

Considering this tendency to treat even asymptomatic patients based on the results of the urine culture, Fabre and colleagues developed an intervention focused on avoiding urine cultures in most patients without any symptoms of a UTI.

Historically, antibiotic stewardship or diagnostic stewardship-focused interventions are tailored to ordering providers or pharmacists, leaving nurses out. In their model, Fabre and colleagues included nurses, part of a larger initiative focused on involving nurses in antimicrobial stewardship.

Nurses learned the principles of diagnostic stewardship. A nurse champion drove the project, serving as a liaison between 37 nurses who worked on the unit and the antibiotic stewardship program. The team implemented an algorithm to guide nurses in their discussions with hospitalists when they believed a urine culture may not be needed.2

During the intervention period, Fabre would visit the unit once a week and examine some patient examples from that week or that day with the nurses. “We would review cases retrospectively or, if they were cases that were pending, we would [focus on] increasing their comfort level in using the algorithm and making these determinations, says Fabre, associate medical director of the antimicrobial stewardship program and an associate hospital epidemiologist at the Johns Hopkins Hospital.

By using this approach, the mean urine culture rate per 100 patient days declined from 2.30 to 1.52. This compares to the urine culture rate increasing from 2.17 to 3.10 when the intervention was not in place.

Nurture Collaboration

For nurses to comfortably take up these issues with the treating provider, Fabre says the culture must be collaborative. Fortunately, that was the case in the unit where the intervention was implemented and studied. “The unit has to embrace that open communication,” Fabre says. “In most places, there is a lot of effort to [facilitate] those types of conversations, it is OK to question your colleagues.”

A Situation-Background-Assessment-Recommendation (SBAR) tool is available to help clinicians communicate more effectively and succinctly.3 “Many times, depending on how you say something, you will have a different impact on the other person’s response,” Fabre notes.

Unit leadership support is critical to the success of this approach. “If you don’t have that support, then the intervention cannot happen, at least in this format,” Fabre cautions.

The unit where the pilot program took place still uses the intervention with the ongoing support of a nurse champion. Investigators also have disseminated the algorithm to other units. “You can’t just drop the algorithm and expect people to use it,” says Fabre, who provides extra education to those other units.

Fabre sees no reason why the nurse-driven intervention could not be used effectively in the ED. When someone in the ED orders urine cultures for patients with no UTI symptoms, and those patients are admitted later, it is left up to the inpatient providers to make treatment decisions.

“They will see that the patient had a urine culture [and] conclude there must have been a reason. If the urine culture is positive, they will treat the patient,” Fabre observes. “From the get-go, the urine culture was highly likely not needed. That leads to so much inappropriate antibiotic prescribing.”

It can be difficult to change behavior, particularly in instances where providers are not rewarded for doing the right thing. Fabre advises champions of this effort to focus on patient safety. Provide examples of patients who were harmed because they received inappropriate antibiotic treatment. “People react to that,” Fabre says.

Additional tips and tools used to implement a range of nurse-driven antimicrobial stewardship interventions at the Johns Hopkins Hospital are available at this link.

REFERENCES

  1. Fabre V, Pleiss A, Klein E, et al. A pilot study to evaluate the impact of a nurse-driven urine culture diagnostic stewardship intervention on urine cultures in the acute care setting. Jt Comm J Qual Patient Saf 2020;46:650-655.
  2. Johns Hopkins Medicine. Algorithm for inpatients with or without a urethral catheter.
  3. Johns Hopkins Medicine. Nurses take antibiotic stewardship action.