APPROPRIATENESS OF URINALYSIS ORDERS AMONG HEALTHCARE WORKERS AT A TERTIARY CARE HOSPITAL By JAMILAH TEJAN A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2019
Â© 2019 Jamilah Tejan
To my parents and brothers
4 ACKNOWLEDGMENTS I would like to express my appreciation and special thank s to my research mentor, Dr. Cindy Prins , as h er wisdom and guidance assisted me throughout my thesis project . Also, I would like to thank my supervisory committee member s, Dr. Lusine Yaghjyan and Dr. Nicole Iovine, for the insight provided to me for this project . In addition, I would like to thank the Infection Control Department at the University of Florida Health Shands Hospital for the internship opportunity and John D elano for assisting me with thesis data. Last, but not the least, I would like to thank my loved ones for their continuous support; Most notably, thank you to my parents and brothers for their lifelong guidance, encouragement, and love.
5 TABLE OF CONTENT S page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 6 LIST OF FIGURES ................................ ................................ ................................ .......... 7 LIST OF ABBREVIATIONS ................................ ................................ ............................. 8 ABSTRACT ................................ ................................ ................................ ..................... 9 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ ..... 10 2 MATERIALS AND METHODS ................................ ................................ ................. 13 3 RESULTS ................................ ................................ ................................ ................ 16 4 DISCUSSION ................................ ................................ ................................ .......... 23 5 CONCLUSION ................................ ................................ ................................ ........ 28 APPENDIX URINALYSIS ODERING CRITERIA INFECTION CONTROL DEPARTMENT, UNIVERSITY OF FLORIDA HEALTH SHANDS HOSPTIAL ................................ ................................ .......................... 29 LIST OF REFERNCES ... .30 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 34
6 LIST OF TABLES Table page 3 1 Results of Chart Review Categorization Patterns . ................................ .............. 1 7 3 2 Results of Chart Review Coinciding with Indications . ................................ ......... 18 3 3 Results of Chart R eview of Urinalysis Findings . ................................ ................. 20
7 LIST OF FIGURES Figure page 2 1 UF Health Shands Urinalysis Ordering Decision Tree ................................ ........ 13 3 1 Results of Order Categorization . ................................ ................................ ........ 16 3 2 Results of Chart Review Coinciding with Indications . ................................ ......... 19 3 3 Results of Chart Review of Urinalysis Findings ................................ .................. 21
8 LIST OF ABBREVIATIONS ASB CFU/mL HCW IDSA UA Asymptomatic Bacteriuria Colony forming units per milliliter Healthcare Workers Infectious Diseases Society of America Urinalysis UF UTI University of Florida Urinary Tract Infection
9 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science APPROPRIATENESS OF URINALYSIS ORDERS AMONG HEALTHCARE WORKERS AT A TERTIARY CARE HOSPITAL By Jamilah Tejan May 2019 Chair: Cindy Prins Major: Epidemiology Urinalysis (UA) is a commonly overused health service used to detect urinary tract infections (UTI). In efforts to reduce unnecessary UA, the University of Florida (UF) Health Shands Hospital recently implemented a UA ordering p rotocol aimed at assisting healthcare workers (HCW) in determining whether a UA is appropriate. The patterns, frequencies, and appropriateness of UA ordered by HCW at UF Health Shands in August of 2018 were analyzed. A total of 1147 UA orders were included in this study. The results of this study show that overall, the implemented UA ordering protocol is being used incorrectly among HCW in the UF Health Shands system. Further, when UA was ordered inappropriately, the UA was likely to result negative for a U TI. Further quality improvement studies are needed to understand the factors affecting adherence to UA ordering protocol among HCW; a more comprehensive understanding of these factors can potentially reduce unnecessary UA.
10 CHAPTER 1 INTRODUCTION In the United States, about 30% of health services are overused and are associated with negative outcomes (Morgan et al., 2015). Medical overuse includes unnecessary or precarious diagnostic tests, potentially harmful medic ations, and healthcare settings of high costs (Morgan et al., 2015). One of the most commonly overused medical diagnostic tests, urinalysis (UA), is used to detect a urinary tract infection (UTI) (Dietz et al., 2016). UTIs are one of the most frequent infe ctions in patients (Sheerin, 2011; Pieretti, 2010 ) with approximately eight million UTIs occurring annually in the United States (Barber et al., 2013). Further, UTIs account for seven million annual clinic visits, costing over $1.6 billion (Sheerin, 2011). A UTI is an infection in the urinary tract syst em including the bladder, urethra, or kidneys (Sheerin 2011; Yarbough, 2018 ). UTIs develop when microbes enter the urinary tract provoking bacteria to evade urethral tissues, thus colonizing the urine (Foxman, 2014). Signs and symptoms of UTIs include urge ncy, frequency, dysuria, hematuria, suprapubic pressure, flank pain, and abdominal pain (Foxman 2014; Woodford & George 2009). Healthcare workers (HCW) have several urine sample ordering options that can be generally referred to as UA. The primary option i s a dipstick test, which is an inexpensive and rapid diagnostic method (Lammers et al. 2001; Rehmari 2004). In the case of a patient presenting signs and symptoms of a UTI and after a positive dipstick test, a urine culture may be performed to identify the pathogens causing the infection as well as the antimicrobial susceptibility of the pathogens (Wilson & Gaido, 2004). In some cases, HCW may order a urine culture in the absence of a dipstick test. Similar to a urine culture, an UA with reflex to culture m ay be ordered to identify infection causing
11 pathogens and their antimicrobial susceptibility (Jaeger et al. 2018). Urinalysis with reflex to culture aims to reduce negative urine cultures, therefore a dipstick test and urine culture are simultaneously orde red, but the urine culture is only subsequently performed in the case of a positive dipstick test (Jaeger et al. 2018). A patient has a UTI if they are symptomatic and have a positive UA, indicated by leukocyte esterase and/or elevated white blood cells an d/or nitrate levels (Barber et al., 2013; Lane & Takhar, 2011; Wilson & Gaido, 2004) and/or a bacterial presence of greater than 100,000 colony forming units per milliliter (10 5 CFU/mL) (Schmiemann et al. 2010). A positive UA in the absence of symptoms of a UTI indicates an asymptomatic bacteriuria (ASB) (Lane & Tekhar, 2011; Lin & Fajardo 2008; Yarbough 2018). Following randomized trials, guidelines developed by the Infectious Diseases Society of America (IDSA) recommend that ASB should not be treated as t reatment poses more harms than benefits, with the exception of pregnant women (Bates 2013; Foxman, 2014; Trautner & Gigoryan 2014; Nicolle et al. 2005). Despite these guidelines, patients continue to be treated for ASB. For example, a study involving hospi talized patients found that 50% of those with a urine culture detecting ASB received unnecessary treatment, despite the absence of signs/symptoms of a UTI (Leis et al., 2013). As the most prevalent rationale for antimicrobial use among older adults, improp er antibiotic use to treat UTIs generates amplification of multidrug resistant organisms (Rowe & Juthani Mehta, 2014). Overtreatment of ASB may also increase the likelihood of comorbid infections such as Clostridium difficile and contributes to extraneous healthcare costs (Jones et al . 2014; Trautner, Grigoryan 2014 ).
12 Urinalysis overuse and overtreatment of ASB may occur due to inadequate understanding of UA order protocols among HCW. In a study conducted by Drekonja et al. (2013), resident HCW were surve yed regarding their knowledge about urine testing (Drekonja et al., 2013); study findings indicated that overall, urine testing and management knowledge was low with an average of only 50% of questions answered correctly (Drekonja et al., 2013). Such circu mstances should be reduced as more prudent ordering of UA can lead to better management of resources and reduced costs (Jones et al., 2014). The Infection Control Department at University of Florida (UF) Health Shands implemented a protocol in May of 2018 (A PPENDIX ) intended to guide HCW in determining whether a UA is necessary. The protocol aims to decrease inappropriate ordering of UA in hopes of decreasing antimicrobial resistance, patient costs, and hospital costs. The purpose of this study is to deter mine the patterns and frequencies of UA ordering and to assess the appropriateness of the UA orders.
13 CHAPTER 2 MATERIALS AND METHODS We conducted an analysis of UA ordering patterns among HCW at UF Health Shands Hospital, a 996 bed University affiliated teaching hospital in Gainesville, FL. All UA orders from August 1, 2018 through August 31, 2018 were included in the study except those ordered from outpatient clinics and those obtained from pediatric patients. O ur study was approved by the University of Florida Institutional Review Board. Figure 2 UA orderin g decision tree used to determine if UA is indicated. If the UA is indicated, the decision tree provides guidelines for further steps. Signs/Symptoms of UTI: (acute hematuria, dysuria, pyuria, suprapubic pain, costovertebral flank pain,frequency, urgency, discomfort) YES Order Urinalysis: Select indication for ordering based on patient's signs/symptoms Urinalysis Result: > Nitrates, Leukocyte Esterace/White Blood Cells > 10000 CFU/mL bacteria YES Treat patient for UTI NO Do not treat patient for UTI NO Do not order Urinalysis
14 Under the UF Health Shands UA ordering protocol (Figure 2 1), when HCW order a UA they are required to select the indication for the order. If the order indication does not fall under any of those listed in a dropdown section in the computer based order. The Infection Control Department receives a monthly document, through Clarity software, that li sts the type of UA, the department and/or service that ordered the UA, the indication for the order, the date of the order, and the urine sample collection date. The following information was collected from patient charts: demographics, comorbidities, indw elling urinary catheters, medical record number, dates, department/service that ordered the UA, and signs/symptoms of UTI (acute hematuria, dysuria, pyuria, suprapubic pain, costovertebral flank pain, frequency, urgency, discomfort), UA results, and medica tions. UA orders for the month of August were categorized in Microsoft Excel by type of UA, indication for UA, and other variables. Subcategories were created for those who zed as random or nonsensical answer was provided (i.e. random letters were entered as a means of bypassing the system). After categorizing the orders, 20 orders from each level of appropriateness were randomly selected for medical chart review. Patient medical charts were reviewed to
15 assess the proportion of order indications that coincided with the signs and symptoms liste randomly selected orders, the proportion of orders with positive UA results was deter mined. D ata Analysis. Data was coded and analyzed using Statistical Analysis software (SAS) version 9.4. Frequency tables were constructed to assess the proportion of concordant order indications and the proportion of orders with a positive resul t.
16 CHAPTER 3 RESULTS A total of 1147 orders were included in this study (Figure 3 1 ). Five hundred and twenty nine (529) (46%) order indications were solely selected from a dropdown menu whereas 618 (54%) were within the indication entered by the Physician. Among the 1147 orders, there were 576 Potentially Figure 3 1. Results of Order Categorization according to UA order appropriateness. UA Orders N = 1147 n= 529 (46%) n = 618 (54%) n = 47 (7.6%) Potentially n = 320 (51.8%) n = 251 (40.6%)
17 Table 3 1. Results of Chart Review Categorization Patterns Appropriateness of UA Total n (%) Appropriate Urinary frequency, urgency, or dysuria without indwelling catheter Part of sepsis workup where Urinary source is suspected, or source is unclear/ unknown New onset of delirium/AMS with no other suspected cause or explanation Unexplained suprapubic or flank pain Appropriate Dysuria Flank pain Hematuria Potentially Appropriate UA/UTI Positive UA Required/Per Protocol Inappropriate Random/nonsensical Leukocytosis Fever 159 (30%) 75 (14%) 66 (12%) 40 (8%) 12 (26%) 7 (15%) 5 (11%) 93 (29%) 57 (18%) 18 (6%) 42 (17%) 21 (8%) 12 (5%) Frequencies of the most common UA order indications within each level of appropriateness. Table 3 1 shows patterns of the most frequent indications within each level of urinary frequency, urgency or dysuria without an indwelling urinary catheter (30%, n=159), followed by sep sis workup where a urinary source is suspected or the source is unclear (14%, n=75). The third most frequent indication was a new onset of delirium/AMS with no other suspected cause or explanation (12%, n=66). Further, majority were listed as having dysuria (26%,
18 Potentially ), or required/per protocol (6%, n=18). The most entries (17%, n=42), leukocytosis (8%, n=21), and fever (5%, n=12). Within each of the four categories (Non other, Other App ropriate, Other Potentially appropriate, and Other Inappropriate), 20 charts were selected at random for review of whether signs and symptoms that coincided with possible UTI were charted. Table 3 2. Results of Chart Review Coinciding with Indications Ap propriateness of UA Total n (%) Appropriate 10 (50%) Appropriate Potentially Appropriate 16 (80%) 17 (85%) Inappropriate 17 (85%) chart according to level of order appropriateness.
19 Figure 3 2. Frequencies of UA order indications concurring with the signs/symptom s rt according to level of order appropriateness.
20 Table 3 2 and Figure 3 2 show the proportion of UA orders that we reviewed that coincided with the signs and symptoms listed in the patient medical charts based on listed in the UA ordering system concurred with the signs and symptoms listed in the patient medical charts, indicating that UA orders were appropri listed in the UA ordering system concurred with the signs and symptoms listed in the orders, 16 (80%) had documented symptoms of possible UTI in the medical record that concurred with indications listed in orders, 17 (85%) of indications listed in the UA ordering system concurred with thos e listed in the patient orders, 17 (85%) of indications listed in the UA ordering system concurred with the inappropriate signs and symptoms of a UTI that we re listed in the patient charts in which a UA should not have been ordered in these cases. Table 3 3. Results of Chart Review of Urinalysis Findings Appropriateness of UA Positive n (%) Appropriate 10 (50%) Appropriate Potentially Appropriate Inappropriate 5 (25%) 7 (35%) 3 (15%) Frequencies of positive UA results according to level of order appropriateness.
21 Figure 3 3. Frequencies of positive UA results and truly appropriately ordered UA according to level of order appropriateness. Table 3 3 shows the proportion of orders that we chart reviewed that resulted in a positive UA, indicative of a potential UTI or an ASB. Figure 3 3 shows the proportion of orders that we chart reviewed that resulted in a positive UA, indicative of a potential UTI or an ASB, and the proportion of orders that legitimately had signs and symptoms of a UTI in the medical chart among those that resulted in a positive UA, indicative of a of UA were positive, indicative of a potential UTI or an ASB, of which 70% (n=7) of the positive UA legitimately had signs and symptoms of a UTI in the medical chart. Among indicative of a potential UTI or an ASB, of which all of the UTI positive cultures legitimately had signs and symptoms of a UTI listed in the indicative of a potential UTI of which 86% (n=6) of the positive UA legitimately had signs and symptoms of a UTI in the medical chart. Lastly, that we chart reviewed, 15% (n=3) had a positive UA although none had legitimate
22 signs and symptoms if a UTI listed in the medical chart indicating an ASB detection in these samples.
23 CHAPTER 4 DISCUSSION UTIs are one of t he most common types of infection that are often treated with antibiotics (Colgan, 2006). In 2014, the Centers for Disease Control and Prevention (CDC) reported that in at least 39% of cases, UTI treatment in hospitals could have been prevented (Fridkin et al., 2014). Considering that UA is often excessively ordered to test patients for UTIs (Yin, 2015), we explor e d a protocol intended to reduce unnecessary UA ordering, which could potentially prevent unnecessary treatment. Our study suggests that the proto col is being used incorrectly in our healthcare appropriateness, although more chart review may be needed to confirm these findings. For a few reasons, our findings prop ose that HCW may perceive the protocol as a necessary hurdle to ordering a UA rather than utilizing the protocol as an apparatus for indications received in this category were already listed in the dropdown menu. Thus, HCW could have simply selected the order the indication. This may indicate that HCW are attempting to rapidly order the UA as opposed to adequately reading and following protocol guidelines. Next, based on both many HCW are simply bypassing the system . Rather than providing the legitimate clinical indication for the UA among potentially appropriate orders, the majority input rders, a considerable number of HCW used the
24 protocol incorrectly and entered random or nonsensical text as the order indication such The results of this study indicate a need to provide individual feedb ack to those utilizing the protocol incorrectly to increase individual accountability. Data from a qualitative study would be helpful in determining the reasons why HCW are not using the system correctly. One possibility may be that HCW were instructed to order a UA without having received a justification for the order, leading to unclear or illegitimate for the order, suggesting the HCW was unaware of the indication for th e order. In several cases order indications were listed as leukocytosis or fever. Leukocytosis and/or fever are often incorrectly viewed as clinical indications of a UTI. For example, (2008) retrospective cohort study found no association between UTI and independent or simultaneous fever and/or leukocytosis (Golob et al., 2008). Taking this into consideration, it is important for HCW to understand that fever or leukocytosis are not cli nical signs of a UTI, and UAs should not be ordered for such indications. As a method of determining whether HCW are using the protocol correctly or are finding means of bypassing the system, we examined whether the indications listed by HCW matched those documented in a random selection of patient charts. Among UAs only 50% of order i ndications coincided with the signs and symptoms listed in the patient charts, which suggests that HCW may have selected any indication besides
25 indicating that that half of the patients in our random sample did not have clinical UTI signs and symptoms. Taking these findings into account, we conclude that HCW are generally using the protocol correctly when listing the indication for the order. Although most of the indicatio ns did coincide, this does not mean that the indication was appropriate. a UTI. These findings differ from some in the literature, which propose that patients often a have a s lightly increased probability of having a UTI based upon signs and symptoms alone (Bent & Saint 2003). Some researchers suggest that 25% 30% of women with UTI symptoms have a negative urine culture explained by the bacterial threshold in their urine sampl e (De Backer et al., 2008; Naber et al., 2008). Further, an observational study was conducted comparing quantitative polymerase chain reaction (PCR) for Escherichia coli and Staphylococcus saprophyticus between women with symptoms of uncomplicated UTI and women without symptoms of UTI (Heytens et al., 2017). Results from the study suggest that most women with characteristic urinary complaints and a negative urine culture are in fact infected with E. coli . (Heytens et al., 2017). Heytens and colleagues (2017 ) support management of cases suggesting that when a woman presents typical uncomplicated UTI signs and symptoms (without indications of potential sexually transmitted infections), a UTI diagnosis and empirical treatment are acceptable based on guidelines (Gupta et al. 2017; Heytens et al. 2017; Knottnerus et al. 2013; Little et al. 2010; Naber et al. 2008). Such findings may be a factor in the low rate of positive UAs
26 res earch is needed to determine if signs and symptoms are truly predictive of a UTI. resulted positive for a UTI. We anticipated this low rate of positive results considering that the patients did not have clinical signs and symptoms of a UTI. Our findings are consistent with the literature showing that patients who do not have signs and symptoms of UTI most likely do not have a UTI. Furthermore, in order to reduce cost and inappropria te treatment, UA should not be performed on asymptomatic patients (Jaeger et al., 2018). positive for a UTI. These findings were expected as we assumed that both appropriate a nd inappropriate orders were included in this category of orders. When we further explored our results by evaluating if patients were on antimicrobials that may have impacted the UA result, our findings were nonsignificant. The patients who were on antimi crobials that could have possibly affected the results had both negative and positive samples, rather than a more frequent result. Therefore, antimicrobials may have disguised the actual UA results. Strengths/Limitations . The large sample size and wide range of patient ages in our study improves the reliability and validity of our study. Another strength to our study is generalizability to other hospitals and numerous medic al units within each hospital. However, there were several limitations to our study. We could not properly assess if the HCW had appropriate justifications for ordering the UA. Therefore, there may have
27 been misclassification bias due to misinterpretatio ns of physician indications. Another limitation to our study is that patients may have had signs and symptoms that were not document indication reflected the true clini cal situation. In addition, considering that we conducted a pilot study, the size of our randomly selected UA orders reduces the power of our study ; a larger sample size is necessary in order to more adequately UA ordering patterns among HCW. Lastly, the s tudy findings derive from one month of data, therefore it is possible that HCW are currently using the ordering system differently.
28 CHAPTER 5 CONCLUSION Our study showed that, overall, HCW were not appropriately following hospital protocol when ordering UA. Further, when UAs are inappropriately ordered, the UA will most likely result as negative for a UTI. Supplementary quality improvement studies are needed to test protocol implementations in order to decrease rates of unnecessary UA orderi ng. These projects should prioritize educating HCW who order UA and should provide feedback in order to increase adherence to UA guidelines for the best interest of patients; doing so will reduce unnecessary UA orders, antimicrobial treatment, and expenses . Future studies should assess the frequency of ASB when HCW adhere to the UA order protocol. This may provide a more comprehensive understanding as to whether appropriate UA ordering decreases the risk of unnecessary ASB treatment.
29 APPENDIX U RINALYSIS ORDERING CRITERIA INFECTION CONTROL DEPARTMENT, UNIVERSITY OF FLORIDA HEALTH SHANDS HOSPITAL 1. Urinary frequency, urgency or dysuria without indwelling urinary catheter 2. Fever of unclear/unknown origin in a patient with limited ab ility to communicate symptoms 3. New onset of hematuria 4. Spinal cord injury patient with new or worsening spasticity, autonomic hyperreflexia, malaise, lethargy, or sense of ease 5. Unexplained suprapubic or flank pain 6. Fever and kn own urinary tract obstruction 7. Part of sepsis workup where urinary source is suspected, or source is unclear/unknown 8. Fever after urologic procedure/surgery 9. New onset of delirium/AMS with no other suspected cause or explanation 10. Screening for asymptomatic bacteriuria in one of the following patient populations: pregnant patients, prior to a urologic procedure/surgery or neutropenic patient 11. Fever in a pregnant patient 12. Fever in a kidney transplant recipient 13. Ped iatric population: Fever without a source in a patient < 3 months or Fever of unknown origin in any age 14. Neutropenic fever 15. Other (Specify)
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34 BIOGRAPHICAL SKETCH Jamilah Tejan attended Mercer University where received her Bachelor of Arts in g lobal h ealth s tudies with a minor in Spanish Language. Jamilah was also a four year Division 1 student athlete during her undergraduate years. Jamilah interned at the Infection Control Department of UF Health Shands Hospital. In the future, Jamilah plans on earning her PhD in Public Health and owning a non profit organization.