Asymptomatic Bacteriuria Guideline Implementation Study

Anticipated Impacts on Veterans' Healthcare: Urinary tract infection (UTI) is the single most
common hospital-acquired infection. However, the majority of cases of nosocomial
catheter-associated urinary tract infection (CAUTI) are really asymptomatic bacteriuria
(ABU). ABU is not a clinically significant condition, and treatment is unlikely to confer
benefit. Overtreatment of ABU is a quality, safety, and cost issue, particularly as
unnecessary antibiotics lead to emergence of resistant flora. The proposal to bring clinical
practice in line with published guidelines has significant potential to decrease CAUTI and
associated inappropriate antibiotic use in VA hospitals. The study will also provide
information about how to maximize effectiveness of audit-feedback to achieve guideline
adherence in the inpatient VA setting.

Project Background/Rationale: Evidence-based guidelines recommend that providers neither
screen for nor treat ABU in most catheterized patients. However, a significant gap between
these guidelines and clinical practice has been documented at the investigators' VA hospital
and throughout the world. Since many VA patients in both acute care settings and sub-acute
care settings, such as intermediate and long-term care, have a legitimate need for a urinary
catheter, the issue of overtreatment of catheter-associated ABU is an active problem for the
VA.

Project Objectives: The investigators hypothesize that implementing the existing
evidence-based guidelines about non-treatment of ABU will dramatically reduce the unnecessary
use of antibiotics to treat ABU and the incidence of incorrectly diagnosed CAUTI. The first
objective is to improve quality of care concerning ABU in terms of specific clinical outcomes
(inappropriate screening for and treatment of ABU) through implementation of an
audit-feedback strategy. The investigators also hypothesize that successful implementation of
an audit-feedback strategy will result in measurable changes in clinicians' knowledge and
attitudes concerning ABU practice guidelines. The second objective is to assess through
surveys the effect of the implementation on clinicians' guideline awareness, familiarity,
acceptance, and outcome expectancy.

Project Methods: The investigators' guidelines implementation strategy will employ
audit-feedback, applied as a post-prescription antimicrobial review based on established
guidelines. The study population for the clinical outcomes is all inpatients on certain wards
at the intervention site (Houston VA) and the control site (San Antonio VA). The
investigators' study population for the audit-feedback intervention and surveys is the health
care providers on these wards. The investigators propose a 3-year study. During the first
year the investigators will observe the baseline incidence of inappropriate screening for and
treatment of ABU at both sites. Blinded monitoring of clinical outcomes will continue during
the next 2 years of the study. During the second year, the investigators will distribute the
guidelines at both sites. Clinicians at the intervention site will receive individualized
feedback, either by telephone or in person, about whether their management of bacteriuria was
guideline-compliant. Unit-level feedback will also be provided. During the third year,
individualized feedback will cease, but unit-level feedback will continue as this constitutes
a sustainable intervention. Clinicians will complete pre/post surveys of awareness,
familiarity, acceptance, and outcome expectancy at the intervention site in year 2 and at
both sites in year 3. Differences in outcomes between the individualized intervention in year
2 and the group-level intervention in year 3 will help to determine the necessary intensity
of intervention for dissemination and implementation in other VA facilities.

Inclusion Criteria:

- For Objective 1 (Clinical Outcomes), all inpatients at the MEDVAMC or STVHCS on the
units of interest (medicine or ECL) during the 3 year period of the study will be
included in the chart review process.

- For Objective 2, modifying health care provider knowledge and behavior through
audit-feedback and surveys, the investigators will attempt to involve all health care
providers on rotation at the VA on the targeted wards during the study period.

- The audit-feedback intervention will be applied to the health care providers on the
targeted wards who make the decision to treat CAUTI.

Exclusion Criteria:

- For the chart review component, the investigators want to capture all available data
about the clinical outcomes during the study period.

- review the inpatient rosters on the wards of interest several times per week to
determine how many of the patients have urinary catheters, etc.

- survey as many health care providers as possible who rotate on the wards of
interest during the study period.

- the investigators anticipate that all health care providers who work at the VA
hospital will be competent to provide or refuse consent to participate.