A hospital-site controlled intervention using audit and feedback to implement guidelines concerning inappropriate treatment of catheter-associated asymptomatic bacteriuria

Abstract

Background: Catheter-associated urinary tract infection (CAUTI) is one of the most common hospital-acquired infections. However, many cases treated as hospital-acquired CAUTI are actually asymptomatic bacteriuria (ABU). Evidence-based guidelines recommend that providers neither screen for nor treat ABU in most catheterized patients, but there is a significant gap between these guidelines and clinical practice. Our objectives are (1) to evaluate the effectiveness of an audit and feedback intervention for increasing guideline-concordant care concerning catheter-associated ABU and (2) to measure improvements in healthcare providers' knowledge of and attitudes toward the practice guidelines associated with the intervention.

Methods/design: The study uses a controlled pre/post design to test an intervention using audit and feedback of healthcare providers to improve their compliance with ABU guidelines. The intervention and the control sites are two VA hospitals. For objective 1 we will review medical records to measure the clinical outcomes of inappropriate screening for and treatment of catheter-associated ABU. For objective 2 we will survey providers' knowledge and attitudes. Three phases of our protocol are proposed: the first 12-month phase will involve observation of the baseline incidence of inappropriate screening for and treatment of ABU at both sites. This surveillance for clinical outcomes will continue at both sites throughout the study. Phase 2 consists of 12 months of individualized audit and feedback at the intervention site and guidelines distribution at both sites. The third phase, also over 12 months, will provide unit-level feedback at the intervention site to assess sustainability. Healthcare providers at the intervention site during phase 2 and at both sites during phase 3 will complete pre/post surveys of awareness and familiarity (knowledge), as well as of acceptance and outcome expectancy (attitudes) regarding the relevant practice guidelines.

Discussion: Our proposal to bring clinical practice in line with published guidelines has significant potential to decrease overdiagnosis of CAUTI and associated inappropriate antibiotic use. Our study will also provide information about how to maximize effectiveness of audit and feedback to achieve guideline adherence in the inpatient setting.

Trial registration: NCT01052545.

Figure 1

conceptual model for treatment of asymptomatic bacteriuria (ABU) and patient health outcomes. Our conceptual model adapts and updates elements of the Cabana model of "Why don't physicians follow clinical practice guidelines?" to focus on the following barriers to guideline implementation: awareness and familiarity (knowledge), agreement and outcome expectancy (attitudes), and external barriers (behavior). The audit-feedback intervention will tackle 2 points in the chain of events that leads from a patient at risk to a patient who receives unnecessary antibiotics for ABU: the decision to order a urine culture (inappropriate screening) and the decision to treat a positive urine culture (inappropriate prescribing). We can measure the clinical outcomes after each of these points (objective 1), and at the same time we can measure changes in providers' awareness, familiarity, acceptance, and outcomes expectancy of ABU guidelines (objective 2). This conceptual model will help us determine which aspects of our implementation protocol are responsible for the observed changes in clinical outcomes.