1830. Avoiding Routine Urinalysis (UA) and Improving Urine Culture (UC) Utilization: An Antibiotic Stewardship Imperative in Geriatric Psychiatry and Emergency Medicine (EM)
Session: Poster Abstract Session: Antimicrobial Stewardship: Non-hospital Settings
Saturday, October 6, 2018
Room: S Poster Hall
Posters
  • ID Week Poster 2018.pdf (1.2 MB)
  • Background: A prior investigation alerted us to a common practice of obtaining UAs and UCs for admission to our geriatric psychiatry unit (GPU). These findings compelled us to assess antibiotic use (AU) on our 22-bed unit at Cambridge Health Alliance, Everett, a community-based teaching hospital, from 02/01/16-01/31/17. Among 427 patients, 115 (27%) received an antibiotic. Urinary tract infection (UTI) was the most common diagnosis (53%); however, only 12 patients (20%) met diagnostic criteria. Contaminated (CT) specimens and asymptomatic bacteriuria (ASB) were more prevalent (26% and 22%, respectively). UC orders were not triggered by symptoms.

    Methods: We evaluated the impact of education to the GPU (8/14/17), removing a requirement for UA (9/6/17) which was communicated to EM leadership, and clinical decision support (CDS) during computerized order entry for UC (10/1/17) on UA and UC utilization. AU appropriateness was determined for patients who received at least four doses of an antibiotic for UTI. Pre- (discharge 7/3/17-8/14/17) and post-intervention (admitted after 10/1/17 and discharged prior to 1/17/18) periods were compared.

    Results:

    There were non-significant (NS) decreases in UAs and UCs and a NS increase in UAs among asymptomatic patients, largely ordered by EM providers. There was a 23% decrease in unjustified AU for UTI (NS). CT specimens and ASB were far more common than UTIs.

    Pre-Intervention Period

    Post-Intervention Period

    P value

    Number of patients

    48

    109

    UAs ordered

    38 (79.2%)

    79 (72.5%)

    0.74

    UAs in asymptomatic patients

    19 (50%)

    50 (63.3%)

    0.49

    Urine cultures

    15 (31.3%)

    25 (22.9%)

    0.41

    Unjustified antibiotic Rx UTI

    4 (8.3%)

    7 (6.4%)

    0.68

    Contaminated

    6 (40%)

    12 (48%)

    0.78

    ASB

    4 (26.7%)

    6 (24%)

    0.88

    UTI

    1 (6.7%)

    2 (8%)

    0.93

    Conclusion:

    Education, removal of the UA requirement for medical clearance and CDS were minimally effective in improving UA and UC utilization and reducing inappropriate antibiotic therapy. Efforts are undermined by a requirement for UA by other psychiatric units in our referral network. We intend to collaborate with medical directors in our psychiatry network to expand this improvement work, provide more robust education to our EM providers and implement a UA with reflex to UC for > 10 WBC/hpf.

    Lou Ann Bruno-Murtha, DO1,2, Reiko Emtman, MD2,3 and Amanda Barner, PharmD4, (1)Medicine, Cambridge Health Alliance, Cambridge, MA, (2)Harvard Medical School, Cambridge, MA, (3)Psychiatry, Cambridge Health Alliance, Cambridge, MA, (4)Pharmacy, Cambridge Health Alliance, Cambridge, MA

    Disclosures:

    L. A. Bruno-Murtha, None

    R. Emtman, None

    A. Barner, None

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