Introduction of a New Protocol to Limit the Number of Cancelled Elective Orthopaedic Operations Due to Asymptomatic Bacteriuria

Abstract

Background Asymptomatic bacteriuria (ASB) poses a significant diagnostic dilemma for medical professionals. Current hospital screening protocol determines the likelihood of a positive diagnosis of a urinary tract infection (UTI) based on the results of a bedside urinalysis. ASB, defined as a positive urine culture in the absence of symptoms, can contribute to unnecessary cancellations, poor utilisation of theatre time, and delayed patient care. We present a two-cycle audit proposing a new pathway to addressing ASB in patients awaiting elective orthopaedic surgery, aiming to optimise surgical yield. Our objectives are to identify areas for improvement in our departmental practices with respect to asymptomatic bacteria compared to the published literature. We propose a new protocol targeted to improve our current practices to minimise patient cancellations and optimise theatre utilisation. Methodology A total of 78 patients who had an elective orthopaedic procedure cancelled at a large district general hospital offering tertiary orthopaedic services, between two study periods spanning March 2018 to April 2019 and May 2019 to March 2020, were identified from electronic hospital records and theatre management systems. Demographics, procedure details, and reasons for cancellations, including the result of urinalysis and the presence of UTI symptoms were assessed. Our pathway was introduced after the first study period and, subsequently, re-audited to assess adherence to the new protocol and its effect on cancellations. Results We identified 78 patients, with a 50:50 male:female split and an average age of 63 (range = 9-90). Of the 33 patients in the first cohort, seven (21.2%) were cancelled due to UTI risk based on positive urinalysis. Of these seven cancellations, one (14.3%) patient reported symptoms of a UTI. The second cohort comprised 45 patients, two (4.4%) of whom were cancelled due to UTI risk based on symptom questionnaire results. These two symptomatic patients along with another two asymptomatic patients (8.8% in total) were found to have positive urinalyses; however, the two asymptomatic patients had their operations cancelled for unrelated reasons. Conclusions The study has shown that previously of all patients awaiting elective orthopaedic operations who had their procedures cancelled, 85.7% were cancelled due to ASB. After the introduction of a new protocol focussing on symptoms rather than urinalysis, we estimate that the number of cancelled elective orthopaedic operations has reduced by 71.4%, thereby greatly improving the utilisation of theatre time.

Keywords: asymptomatic bacteriuria (asbu); elective orthopaedic surgery; quality assessment in healthcare of urinary tract infections; surgical site infection (ssi); urinalysis testing.