Urine test ordering—good and going for better

Says Dr. Murphy, “We’re trying to decrease the false-positive cultures, or rather patients who are incorrectly classified as having a urinary tract infection based purely on a culture.” Such improper classifications also have infection prevention surveillance implications, “because infection prevention uses the clinical information to determine whether it meets the CDC surveillance criteria for a catheter-associated urinary tract infection,” he says. “When coders are looking at this they may see the clinician documentation saying ‘we’ve got a positive urine culture, or a UTI,’ and then they abstract out of the chart, based upon clinician documentation, a diagnosis.” So cases of asymptomatic bacteriuria with a positive culture but no pyuria or symptoms, he says, may be incorrectly classified as UTIs by clinicians at the bedside and subsequently by administrative coders.

“If one looks at the CDC for frequency of urinary tract infections, that number is somewhat inflated by asymptomatic bacteriuria [cases],” he says. Discharge diagnoses in administrative data are similar. “So we’re trying to get to the root of that.”

At Barnes-Jewish Hospital in St. Louis, where a reflex urine culture algorithm was instituted in 2015, physicians are given a choice of three reflex orders, says Ronald Jackups Jr., MD, PhD, associate professor of pathology and immunology, Washington University School of Medicine, and associate chief medical information officer for laboratory informatics, BJC Healthcare. “The simplest one is a urinalysis reflex to microscopic, and that begins with a macroscopic urinalysis,” Dr. Jackups says. If it’s positive for one of four triggers—blood, leukocyte esterase, nitrates, or more than trace protein—it reflexes to a microscopic urinalysis. “And that is it,” he says. “It will not trigger a urine culture. And that is used by clinicians who want to do routine urinalysis testing but have no suspicion of a UTI because the patient’s asymptomatic.”

The second is a standard macroscopic urinalysis with reflex to microscopic and culture. It goes through the same steps as the first option, but “if the microscopic contains more than 10 white cells per microliter, it will trigger the culture,” he says. The third is for neutropenic patients. “It starts the same way, macro, and if that reflexes, it orders both the urinalysis microscopic and the urine culture, no matter what. It doesn’t look at the white count,” Dr. Jackups says. And they do allow urine culture to be ordered separately, with the expectation that it will be limited to the populations in which urinalysis is considered less capable of ruling out UTI—pediatric, urology, and pregnant patients.

Dr. Jackups and colleagues may soon eliminate the reflex order for neutropenic patients. “We found that a lot of clinical providers, including in oncology, are not using the urinalysis reflex specific for neutropenic patients, and we fear that’s simply communication or lack of awareness,” he says. Rather than put the onus on physicians to follow a different pathway for neutropenic patients, “we’re looking into the ability to combine the two reflexes into one.” The way this would work, he says, is they would build a new condition in the standard reflex order that would consider the patient’s most recent CBC. If the patient is neutropenic, the white count rule would then be ignored and the culture would be ordered. “So it would basically trigger more cultures in neutropenic patients than it is now.” The combined rule would eliminate the awareness problem for physicians, he says. “They don’t have to be aware as long as they know there’s one order to go to.”

Dr. Jackups and others reported a reduction in the number of urine cultures performed at Barnes-Jewish Hospital in 2018 and 2019 studies reported in CAP TODAY (https://tinyurl.com/22234xsb). “After COVID hit everything changed,” he says. But after the initial few months of the pandemic, urine culture rates stabilized at a lower rate than what they had seen pre-COVID, with rates slightly lower in 2021 and 2022 than in 2019. “I can’t say if all of that is due to COVID, but it seems we are now in a stable place post-pandemic.”

Laboratories that might move to adopt a reflex urine culture algorithm or otherwise attempt to reduce the number of urine cultures should expect a lot of trial and error, Dr. Jackups says. “Your first effort to improve the process could be surprisingly successful or a complete failure.” He advises incorporating stakeholders, “particularly the clinicians you’re going to be affecting, because if they’re not included, they can decide to not participate and continue to use orders in the old way.” And it’s critical throughout the process to monitor effects. “Because the effect can always surprise you, in either direction. So it is important to monitor and to change the process based on the new data you find.”

He advises, too, not to rely on order alerts. “They tend to be overridden a lot more because they tend to be aggressive” and to resemble the pop-ups seen on websites. “All those annoying pop-ups. And so it’s easy for providers to ignore them without seriously considering the language within them.” Other forms of clinical decision support have been more successful, in his view, “and that includes building reflexes and using order-entry questions to elicit information from providers and to give them a warning that doesn’t feel like a pop-up.”

Responses to order-entry questions can be required. “And because it’s not presented as a pop-up, clinicians may be more thoughtful and willing to provide a useful response.” With reflexes, “as long as the order name is clear, the provider doesn’t have to do anything else. They can order the reflex and then our rules within the lab will make what we feel are the best decisions for the test algorithm.”

A reflex algorithm would be built in the laboratory information system, and order-entry questions would be implemented in the EHR. “So partly it depends on which teams you have the easiest access to,” Dr. Jackups says. “But all things being equal, order-entry questions are usually fairly easy to implement,” whereas reflex algorithms are more complicated. “It does take a long time to build a reflex because you have to build all the rules and you have to validate them, both in a test environment and then in the live environment. But once they’re built, as long as you’re monitoring for surprises, it’s usually pretty stable after that.”

With order-entry questions, it’s important to monitor how physicians are responding, he says, and with such questions he usually includes the option to use free text. “Sometimes when the provider doesn’t like the answer options it’s helpful to hear what they think. It isn’t always what I expect or want to hear, but it’s often illuminating. And a good number of them are happy to provide text.”

For smaller hospitals with fewer IT resources, Dr. Jackups urges building relationships and becoming visible. “Number one, if you want your interests to be heard, you need to work with your clinicians. We need to stop thinking of the pathologist as the person who stays in the lab or stays in their office and signs out cases. We need to be more visible to the system.”

“If you can get buy-in from system leaders,” he continues, “they can help connect you with the information systems teams. And in the same way you want to be visible to the clinicians, you also want to be visible to your information system teams. You don’t want your request to feel like a demand coming from a faceless group.” Be engaged with the team, understand their work and the bandwidth they have, and be patient, he says, because in smaller hospitals in particular, the information systems teams tend to be overworked—though it’s true of all hospitals, he notes. Once a relationship has been established, “you can explain which initiatives are higher priorities than others and help them arrange their schedules as to which they want to focus on first.”

Support for reflex urine culture algorithms isn’t universal. “In some ways they miss the boat,” Dr. Howard-Anderson says. “They get at the low-hanging fruit—that urine cultures generally are not indicated if there is no pyuria.” But they don’t address the fact that for patients without UTI symptoms, there may be no need to order even the urinalysis. “So there’s still a lot of excessive ordering that it doesn’t target,” she says. “And one could argue that you should focus on education,” rather than put in place a reflex algorithm. Cutting out unnecessary testing completely, she says, is “the ideal world.”

“There are different beliefs about whether you should shoot for that ideal standard.”

Charna Albert is CAP TODAY associate contributing editor.