Does Requiring Provider Attestation for Positive Urinary Tract Infection Symptoms Improve Urine Culture Diagnostic Stewardship?

Urinary tract infection (UTI) is primarily a clinical diagnosis requiring a syndromic approach. However, urine studies are often ordered reflexively without formal assessments for UTI symptoms in an Emergency Department (ED). Here, we investigated if requiring provider attestation for positive UTI symptoms reduced inappropriate urine study orders in the ED.

This is a single health system, retrospective chart review of 24,847 urinalysis (UA) and urine culture (UCx) orders at our 3 EDs over 08/2022 – 08/2023. An electronic medical record (EMR)-based intervention was implemented on 02/21/2023, requiring UA with reflex to UCx orders to accompany attestation for positive UTI symptoms. We conducted a chief-complaint (CC) based adjudication for urine study order appropriateness over 6-months pre- and 6-months post- implementation. Two raters independently binned CC into 17 categories. Disagreement was resolved by a third rater. Data was excluded from further analysis when there was a disagreement between all three raters. Orders were considered appropriate if CC conformed to IDSA guidelines on UTI symptoms.

Pre- and post- implementation, the number of appropriate UA orders were 988 and 863, and UCx orders were 538 and 473. The rate of culture positivity was similar (55.8% vs 56.0%). Interestingly, the rate of culture positivity was the highest when CC specifically mentioned “UTI,” “pyelonephritis,” or “kidney infection” (62.3 %). While we did not observe a large change in UA orders for central nervous system workup (167 vs 155), the reduction was pronounced for traumatic workup (162 vs 76).

For select medical indications, we did not observe a large change in urine order patterns after requiring provider attestations for UTI symptoms. This could be due to click fatigue, a well-documented phenomenon for EMR-based interventions. Further, nursing-driven order sets likely contribute to our observation. Our CC based appropriateness adjudications likely missed cases where subsequent history and exam were consistent with classic presentation for UTI. Diagnostic stewardship in an ED continues to be an important task balancing expedient comprehensive workup in critically ill population and ED throughput.