A Diagnostic Stewardship Success: Implementing a Urine Culture Reflex Policy in the Emergency Department of a Large Safety-Net Hospital.

Background: Urinalyses and urine cultures (UCs) are frequently ordered simultaneously in emergency departments (EDs) to increase efficiency and decrease triaging times. However, this often comes at the cost of overdiagnosis and overtreatment of urinary tract infections. Our study examines the rates of UC orders and hospital savings after implementation of a reflex UC system in a large safety-net county hospital ED. Differences in rates of antibiotic use are also described. Methods: The electronic medical records of eligible patients were analyzed before and after implementation of a reflex UC ordering system, and rates of UC processing were documented to estimate savings to the hospital and the healthcare payer. As a secondary analysis, 7 days of medical records both before and after intervention were reviewed to describe absolute rates of antibiotic prescribing and adverse events attributed to antibiotics. Results: Data analysis of 9 months after initiation of a reflex UC protocol revealed a decrease in the average of monthly cultures processed by 20.3%, resulting in a hospital cost savings of $425 000 with savings to the healthcare payer on the order of $5 650 000 in prevented cultures alone. Secondary analysis revealed a small but not statistically significant decrease in the number of antibiotics prescribed after intervention (from 40.76% to 38.11%) with similar rates of adverse effects. Conclusions: Implementation of a reflex UC protocol in the ED of a large safety-net hospital resulted in a decrease of the number of cultures being processed, leading to substantial healthcare savings, which is particularly important in a resource-limited setting. While the implementation of the protocol resulted in cost savings due to diagnostic stewardship, the impact of such a protocol on antibiotic stewardship requires further study.