Working Together to Improve Patient Safety: 'To Screen or Not to Screen' in Suspect Urinary Tract Infections

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Health & Medicine

Published on March 7, 2014

Author: bcpsqc



This presentation was delivered in session F1 of Quality Forum 2014 by:

Anita Kwong
Director, Laboratory Quality and Process Improvement
Lower Mainland Pathology and Laboratory Medicine

To Screen Or Not To Screen In Suspect Urinary Tract Infections BCPSQC Quality Forum 2014 Session F1 February 28, 2014 Vancouver General Hospital Laboratory VCH Regional Laboratory Medicine Lower Mainland (LM) Laboratories Anita Kwong, Director, Quality and Process Improvement, LM Laboratories 1

Project Team Multi – Discipline Collaboration VGH Medical Biochemistry Dr. Morris Pudek, Adelina Lim, Karen Ng, Alisha Thompson, Biochemistry technologists VGH Medical Microbiology Dr. Diane Roscoe, Charlene Porter, Jackie O’Connell, Microbiology technologists VCH Operations Richard Walker Sharon Stapleton LM / VCH Labs Quality Team Sara Garcha (up to Oct 2013) Anita Kwong Data Analysis • Team Members Jason Pal (up to Dec 2013) Disclosure: No project team members has affiliation (financial or otherwise) with a commercial organization that is related to this presentation 2

VCH Regional Laboratories Vancouver General Hospital VCH Regional Laboratories: – Include 11 sites – VGH – One of the largest diagnostic laboratories in Western Canada – Referral centre for other VCH Laboratories – Referral centre for special tests across the province

Who We Are Laboratory Physicians, Medical Technologists and Medical Laboratory Assistants working in: • • • • • • • Medical Biochemistry Hematopathology Medical Microbiology Transfusion Medicine Anatomical Pathology Cytology Cytogenetics and Molecular Genetics • Transplant Immunology

Patients We Serve at VGH Laboratory Partial list of samples / procedures Per day Blood collections (lab staff procedures only) 900 Chemistry samples 1,800 Chemistry urine samples for urinalysis 140 Microbiology samples 1,100 Microbiology urine samples for culture 185 5

Urinary Tract Infections (UTI) • 1 in 3 women will experience UTI by age 24 • Female lifetime probability of UTI is >50% • UTI most common bacterial infection for both hospitalized and community patients • Major healthcare cost driver: • VCH: UTI is the most common Hospital-Acquired Infection (HAI), 18,900 cases over 4 years, $16.3m in costs (Raschka, S. 2012. Health Economic Evaluation of Quality and Patient Safety Within an Organization, Quality Forum 2012.) • Diagnosis and Management algorithm • Gold standard for bacterial cause of UTI = culture

Urinalysis • If laboratory testing is required, perform urinalysis dipstick first: • May be automated • Costs ~$0.30 • Results ready in 2 minutes • If dipstick positive → microscopy for cellular elements • • • • • • Microscopy is labour intensive Costs ~$5 (labour) Results ready in 1-2 hours At VGH, of 140 urinalysis requests per day, 30% require microscopy exam Outpatients UTI laboratory protocol: – dipstick leukocyte and/or nitrite positive → urine culture Inpatients: – Urinalysis and urine culture are independent orders 7

Urine Cultures • Urine cultures for bacterial cause of suspect UTI • • • • Labour intensive Costs ~$5 to $40 per culture Results ready in 1 to 2 days At VGH, 185 urines are processed for cultures per day • Many patients are treated with antibiotics without culture results being known • Many UTIs are diagnosed without the supporting information of a urinalysis 8

New Technology • Current technology: – Dipstick, microscopy, urine cultures • New technology: • Flow cytometry uses scattered light which reflects the size and volume of each cellular element, e.g. WBC, RBC, and bacteria. • Fluorescent stains specifically targets mitochondrial and nuclear DNA of these cells. • Cellular elements are counted and quantitative values are available in minutes. 9

New Approach to UTI Diagnosis Automated Urinalysis + Fluorescent Flow Cytometry (FFC) = Rapid and powerful tool to screen urine samples for absence / presence of UTI

Cross Discipline Collaboration • Evaluation of Fluorescent Flow Cytomery (FFC) at VGH laboratory • September 18 to October 18, 2013 • Urine samples (n=432) were tested for: • Urinalysis & FFC on instrument A • Urinalysis & FFC on instrument B • Urine cultures – read at 24 hours and 48 hours 11

Study Findings * Using urine culture results as gold standard: • FFC threshold was identified to correlate to negative cultures • Sensitivity 90% • Specificity 74% • Applying the FFC threshold in this study: • Of 430 urine samples, 257 (60%) would not have been cultured using FFC negative bacteria count cutoff (Both instruments A and B yielded similar results) 12

Correlating Results Biochemistry Microbiology 430 urine samples in FFC study 185 urine samples for culture per day 60% would not have been cultured 40% no growth 19% no significant growth FFC negative Results in 5 minutes No growth or no significant growth Results in 1 to 2 days Cost of urinalysis and FFC $1.50 (excluding capital cost) Cost savings for not processing no growth urines: ~$135K per year Reference: US study reduced unnecessary urine cultures by 55% Gieson, Greeno, Thompson et al, 2013. Clin Biochem.

Surrogate Marker for No Growth Urine Culture Results Available in <1 hour • Patient Safety Benefits: • Avoids unnecessary antibiotic treatment • Potential reduction of side effects related to antimicrobial therapy • Systems Benefits: • Reduces healthcare costs • Reduces laboratory operations cost • Promotes team building across laboratory disciplines

Next Steps • Validate findings with identified patient groups • Validate findings with samples specifically ordered for urine cultures • Laboratory workflow re-design across Biochemistry and Microbiology • Collaborate with clinical partners to change practice of laboratory UTI diagnosis

Thank You! Questions

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