Lead/Presenter: Kalpana Gupta,
COIN - Bedford/Boston
All Authors: Gupta K (Boston VAHCS, Boston University School of Medicine), Hartmann CW (Center for Healthcare Organization Implementation Research & Boston University School of Public Health), Schweizer ML (Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System)
Performing urinalyses and cultures in asymptomatic patients is one of the most common reasons for inappropriate antibiotic use. However, de-implementing this practice has been difficult, especially for clinical scenarios deemed to be high risk for infectious complications, such as in patients with delirium or those undergoing orthopedic implant surgery
Using the dual process theory QUERI framework "Developing De-Implementation Strategies Based on Un-Learning and Substitution," an educational intervention citing new guidelines and providing a pneumonic "ABCs of ASB" was created and delivered to providers to encourage performance of evidence based prevention actions in place of low-value urine screening and treating of asymptomatic patients. Clinical providers and staff (MD, RN, APRN, trainees) in 3 different levels of care (acute inpatient, long term, and outpatient) took part in the education. Participants were asked to voluntarily answer a web-based anonymous pre and post survey to assess the intervention's influence on provider behavior.
Responses from 279 unique providers were collected. For scenario #1 (patient with delirium and a positive urine culture and no other infectious symptoms), the option to give antibiotics was reduced by 45% pre to 4% post, p < 0.01 (Chi-square). For scenario #2 (patient having knee replacement and positive preoperative urine culture, no other symptoms) the option to give antibiotics was reduced by the same magnitude (~50%) but a lower absolute number (67% pre and 33% post), p < 0.01. Changes in predicted behavior were similar across levels of care.
Substituting evidence based practices in place of low value practices is an appealing framework for influencing provider behavior. Our work demonstrates that education can successfully reduce the intention to use antibiotics for asymptomatic patients with positive urine cultures.
De-implementing this low value action through site specific education has the potential to reduce adverse events, antibiotic resistance and re-focus efforts on more beneficial care activities.