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Healthcare worker attitudes on routine non-urological preoperative urine cultures: a qualitative assessment
Julia E Friberg Walhof1, Marin L Schweizer2,3, Kalpana Gupta4,5,6
1Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA.
Objective:
Many preoperative urine cultures are of low value and may even lead to patient harms. This study sought to understand practices around ordering preoperative urine cultures and prescribing antibiotic treatment.
Design:
Open-ended, semi-structured qualitative interviews.
Setting:
5 Veterans Affairs hospitals.
Participants:
Interviews with 14 surgeons (9 surgeons, 5 surgical leaders), 7 infectious disease physicians, 8 surgical advanced practice providers (APPs), 1 surgical nurse manager, 3 infectious disease pharmacists, 1 hospitalist, and 1 lab manager.
Methods:
We interviewed participants using a qualitative semi-structured interview guide. Collected data was coded inductively and with the Dual Process Model (DPM) using MAXQDA software. Data in the "Testing Decision-Making" code was further reviewed using the concept of perceived risk as a sensitizing concept.
Results:
We identified themes relating to surgeons' concerns about de-implementing preoperative urine cultures to detect asymptomatic bacteriuria (ASB) in patients undergoing non-urological procedures: (1) anxiety and uncertainty surrounding missing infection signs spanned surgical specialties, (2) there were perceived risks of negative consequences associated with omitting urine cultures and treatment prior to specific procedure sites and types, and additionally, (3) participants suggested potential routes for adjusting these perceived risks to facilitate de-implementation acceptance. Notably, participants suggested that leadership support and peer engagement could help improve surgeon buy-in.
Conclusions:
Concerns about perceived risks sometimes outweigh the evidence against routine preoperative urine cultures to detect ASB. Evidence from trusted peers may improve openness to de-implementing preoperative urine cultures.
Insights
Many surgeons worry about missing infections when not ordering preoperative urine cultures for asymptomatic bacteriuria (ASB), despite low evidence. Peer evidence and leadership support may aid de-implementation.
Area of Science:
- Medical Practice
- Infectious Disease
- Surgical Care
Background:
- Preoperative urine cultures for asymptomatic bacteriuria (ASB) are often low-value and can lead to patient harm.
- Understanding current practices and barriers to de-implementation is crucial.
Purpose of the Study:
- To explore the practices and decision-making processes surrounding preoperative urine cultures.
- To identify barriers and facilitators for de-implementing routine preoperative urine cultures.
Main Methods:
- Qualitative study utilizing semi-structured interviews.
- Conducted at 5 Veterans Affairs hospitals.
- Involved 35 participants including surgeons, infectious disease physicians, APPs, pharmacists, and hospital leadership.
Main Results:
- Surgeons expressed anxiety and uncertainty about omitting urine cultures, fearing missed infections.
- Perceived risks of negative consequences were associated with discontinuing cultures for specific procedures.
- Participants suggested leadership support and peer engagement as key to facilitating acceptance of de-implementation.
Conclusions:
- Concerns about perceived risks can override evidence against routine preoperative urine cultures for ASB.
- Trusted peer evidence and supportive leadership are vital for improving openness to de-implementing these tests.
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