De-implementation of Unnecessary Pre-Operative Urine Testing

About This Grant

Significance to VA: Routine urine testing in surgical patients, either before or after surgery, is a low value practice and leads to overprescribing of antibiotics in the VA, which then leads to serious antibiotic-related side effects, such as Clostridioides difficile infections. Multiple national societies state that surgical patients without infectious symptoms should not have routine preoperative urine tests performed, and that not all fevers need urine testing to determine a cause, such as fever immediately in the postoperative state. Unfortunately, unnecessary urine testing occurs before 15-26% of VA surgeries overall, and before over 50% of certain high- risk VA operations. We have a track record of successfully implementing evidence-based practice guidelines about urine testing in VA settings. We hypothesize that implementation of our evidence-based intervention in the operative care line at 6 VA medical centers (VAMCs) will significantly decrease rates of urine testing and days of unnecessary antibiotics for surgical patients, both before and after operations. Our long-term objective is to improve Veteran care by ensuring that Veterans undergoing surgery receive only beneficial tests and treatments. Our work aligns with the [VA priority ‘Implement value-based care solutions’ and the core competency of Implementation Science by optimizing strategies to implement evidence-base practice.] This work also supports the Quintuple Aim and the Foundations for Evidence-based Policymaking Act. Innovation & Impact: Since 2013, we have been developing, testing, and disseminating an evidence-based intervention to reduce unnecessary urine testing, the “Kicking CAUTI” program. This intervention package includes a fast and frugal algorithm to help healthcare providers distinguish between UTI and bladder colonization, interactive teaching cases, case-based audit and feedback, and virtual learning collaboratives. This intervention boosts clinician autonomy, which is important to surgeons, but it has not yet been adapted for or tested in a surgical setting. Our intervention will decrease a low value practice and improve patient outcomes by preventing downstream consequences, such as antibiotic resistance and longer hospital stays. Specific Aims: Aim 1: Adapt our ‘Kicking CAUTI’ intervention to create a surgery-tailored intervention package informed by focus groups at six VA medical centers (VAMCs). Aim 2: Conduct a stepped wedge cluster randomized trial to evaluate the implementation and effectiveness of the tailored intervention package at six VAMCs. Aim 3: Evaluate the intervention in terms of [cost], acceptability, and barriers and facilitators to implementation. Methodology: We will conduct a hybrid type two effectiveness/implementation study. Our conceptual model is the Systems Engineering Initiative for Patient Safety (SEIPS) model. Aim 1: This work will be informed by focus groups with surgeons, nurses, and other operative care line personnel at six VAMCs. These stakeholders will help us tailor the Kicking CAUTI intervention to the surgical setting. Aim 2: We will conduct a stepped wedge cluster randomized trial. We will include patients undergoing surgery in these VAMCs, excluding certain types of surgery in which pre-operative urine testing is appropriate (urologic surgery). Clinical outcomes data including urinalysis, urine culture, days of antibiotics, will be extracted from Corporate Data Warehouse, in addition to surgical site infections, UTIs, length of stay and readmissions. Implementation measures will include adoption (time spent and cases discussed), penetration (providers reached), fidelity (use of intervention materials), [and dose]. Aim 3: Formative evaluations will occur through periodic reflections with local site champions and semi-structured interviews with key stakeholders at the six intervention sites. [The budget impact analysis will estimate the cost of implementing the intervention and direct healthcare costs saved by the intervention from the VA’s perspective.] Path to Translation/ Implementation: We will work with our operational partners (i.e., Antimicrobial Stewardship Task Force, National Surgery Office) to disseminate this intervention to other VAMCs.