Impact of order set design on urine culturing practices at an academic medical center emergency department
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Impact of order set design on urine culturing practices at an academic medical center emergency department
  • Published Date:

    January 20 2018

  • Source:
    BMJ Qual Saf. 27(8):587-592
  • Language:
Filetype[PDF-458.75 KB]

  • Alternative Title:
    BMJ Qual Saf
  • Description:
    Background Urinalysis and urine culture are commonly ordered tests in the emergency department (ED). We evaluated the impact of removal of order sets from the “frequently ordered test” in the computerized physician order entry system (CPOE) on urine testing practices. Methods We conducted a before (1 September to 20 October 2015) and after (21 October to 30 November 2015) study of ED patients. The intervention consisted of retaining “urinalysis with reflex to microscopy” as the only urine test in a highly-accessible list of frequently ordered tests in the CPOE system. All other urine tests required use of additional order screens via additional mouse clicks. The frequency of urine testing before and after the intervention was compared, adjusting for temporal trends. Results During the study period, 6499 (28.2%) of 22,948 ED patients had ≥ 1 urine test ordered. Urine testing rates for all ED patients decreased in the post-intervention period for urinalysis (291.5 pre- vs. 278.4 per 1000 ED visits post-intervention, p=0.03), urine microscopy (196.5 vs. 179.5, p=0.001) and urine culture (54.3 vs. 29.7, p <.001). When adjusted for temporal trends, the daily culture rate per 1000 ED visits decreased by 46.6% [−46.6%, 95% confidence interval (CI): −66.2, −15.6%], but urinalysis (0.4%, 95%CI: −30.1, 44.4%), microscopy (−6.5%, 95%CI: −36.0, 36.6%) and catheterized urine culture rates (17.9%, 95%CI: −16.9, 67.4) were unchanged. Conclusions A simple intervention of retaining only “urinalysis with reflex to microscopy’ and removing all other urine tests from the “frequently-ordered” window of the ED electronic order-set decreased urine cultures ordered by 46.6% after accounting for temporal trends. Given the injudicious use of antimicrobial therapy for asymptomatic bacteriuria, findings from our study suggest that proper design of electronic order sets plays a vital role in reducing excessive ordering of urine cultures.
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