Assignment Prompt & Instructions
Peter
Approved PICOT Question:
Among healthcare providers in an adult primary care clinic (P), how does implementation of the Infectious Diseases Society of America clinical practice guideline for asymptomatic bacteriuria through provider education, a clinical decision-making algorithm, and audit and feedback (I), compared with current practice (C), affect provider adherence to guideline recommendations and the rate of inappropriate antibiotic treatment for asymptomatic bacteriuria (O) over eight weeks (T)?
Week One objectives
Objective #1
The major objective for the week one was to begin the DNP project as outlined in the approved implementation plan that had been approved by Solution IRB and establish a consistent manner in which the IDSA guidelines for asymptomatic bacteriuria (ASB) would be applied. The week was to ensure that all participating providers understood the purpose of the DNP project, understood the distinction between ASB and urinary tract infections, and understood the conditions, if any, to screen or treat patients with ASB.
In addition to establishing this understanding among providers, another objective was to introduce the clinical decision-making algorithm developed as part of this DNP project so that providers could utilize it when evaluating adult patients whose laboratory results indicate abnormal urinalysis or urine cultures. This algorithm emphasizes assessing urinary and systemic symptoms prior to obtaining a urine culture and/or providing antibiotic treatments. This is consistent with the IDSA guideline recommending screening and treating ASB primarily in pregnant women and those undergoing endoscopic urological procedures resulting in mucosal trauma (Nicolle et al., 2021).
Additionally, objectives included administering the pre-implementation provider knowledge survey; confirming the process to identify clinical encounters; beginning the audit-and-feedback tracking system; and verifying that the DNP project activities did not disrupt normal patient care. Since this DNP project evaluated provider behaviors rather than recruited patients as participants, there were no direct patient recruitment or informed consent activities performed. Confidentiality and utilization of de-identified aggregate information continued to remain priorities throughout the week.
Activities completed during the week
The first week involved meeting with the project preceptor and clinic leadership to validate the implementation schedule; confirm provider schedules; and clarify roles. Meeting with the preceptor and clinic leaders helped the project team confirm that the education, data collection, and feedback activities aligned with the approved DNP project protocol. Prior to collecting data, the workflow for identifying encounters that included suspected urinary tract infection; positive urine culture; or potential ASB was reviewed.
Staff education session
An education session for staff was held during a scheduled time frame that was selected to minimize disruptions to ongoing patient care. The educational content reviewed the definition of ASB, common reasons for excessive urine testing, populations where treatment is typically discouraged, and the limited instances where screening and treatment are warranted. Older adults; patients diagnosed with diabetes; and individuals experiencing chronic urinary issues were specifically addressed since each population may have an increased prevalence of bacteriuria without symptomatic urinary tract infection. The educational session emphasized that pyuria (cloudy urine), malodor urine, or a positive urine culture result alone does not constitute a symptomatic urinary tract infection.
Providers were distributed the IDSA-based decision algorithm and instructed on its application during clinical decision-making. Educational material reviewed potential negative effects of excessive antibiotic use, such as adverse medication side effect(s); c. Difficile diarrhea, antibiotic resistance, additional diagnostic tests, and avoidable financial expenditures were all noted. Providers were urged to document symptoms that support a urinary tract infection diagnosis prior to initiating antibiotic treatment.
After the educational session was concluded, participating providers completed the pre-implementation provider knowledge survey. The surveys were coded with project-specific codes to assure provider confidentiality. I reviewed the returned surveys for completeness but reported no provider-specific scores to clinic leadership. Results will be compared with the post-implementation provider knowledge survey that was completed after the eight-week study.
Audit tracker initiated
Initial audits of clinical records were also begun during week one. An audit tracker was developed to document whether urinary symptoms were recorded, whether a urine culture was ordered due to clinical indications, whether antibiotics were prescribed, and whether decisions related to either symptomatically infected vs. asymptomatic bacteriuria were in accordance with project algorithms. Initially, it was planned to review 20 charts per week until a minimum of 100 charts were audited. However, due to delays in developing an efficient auditing process, fewer than expected numbers of charts were initially audited.
A multi-site stewardship evaluation found that various approaches exist for interventions designed to address ASB (Amenta et al., 2023). The authors noted that these approaches can include educational components, audit and feedback, and implementation support; however, they also noted that sustaining these types of interventions requires consideration of resource implications. Therefore, I tracked time required to identify cases, review documentation, track data, prepare provider feedback, and communicate with my DNP mentor, preceptor, and professor about the study's initiation and start-up.
Positive outcomes from week one
There were many positive aspects from week one of this study. Perhaps most positively influenced was the level of interest displayed by the providers relative to participation in both the education session and discussing challenges associated with distinguishing between ASB and symptomatic urinary tract infection. Clinically relevant questions were asked by providers, and some providers described scenarios in which diagnostic ambiguity often occurs. This enthusiasm indicated that this DNP project addresses a well-documented clinical practice issue rather than proposing a new practice that providers feel has little relevance to their workday.
Another positive outcome from week one was receiving support from both the preceptor and clinic administration. Both assisted with facilitating scheduling for education sessions, distributing educational materials, clarifying data collection processes, and validating consistency of decision algorithms being utilized by clinicians during patient encounters.
Auditing tool testing was also helpful.
Testing the audit tool during week one was also helpful. For the most part, all variables required for tracking purposes could be located within clinical documentation and tracking data, with the audit tool providing a structured means of identifying whether management decisions were consistent with guideline recommendations. There were no confidentiality or safety breaches experienced during this process.
Unexpected Events during Week One
Perhaps the most unforeseen event from week one was that not all providers attending the initial educational session were present due to patient care obligations and conflicting schedules. While most providers were able to attend, lack of attendance by several staff members necessitated conducting a brief makeup session.
Additionally, variability existed in how providers documented urinary symptoms. Documentation varied from detailed assessments of symptoms to very vague descriptions of symptoms. This variability may complicate the determination of whether antibiotic treatment decisions were appropriate solely based upon documentation of urinary symptoms. In order to avoid assuming answers, cases lacking sufficient documentation will be categorized using predetermined criteria from this DNP project. Additionally, cases requiring further explanation will be clarified with the preceptor.
Time required to complete initial chart reviews was greater than expected.
Completing the initial chart reviews took longer than I had estimated. This delay was partially due to becoming familiar with the locations of relevant information within the electronic medical record.
No changes made to approved study outcomes or data collection variables
Since no changes were made to study outcomes or data collection variables, no additional revisions will be needed during subsequent weeks.
Adjustments needed for week two
For week two, I will conduct a brief follow-up educational session for providers unable to attend the initial educational session. I will also distribute identical standardized educational materials to ensure all participating providers receive similar information.
Brief reminders regarding documenting presence or absence of localized genitourinary symptoms and systemic signs of infection prior to ordering cultures or prescribing antibiotics will be added to weekly feedback. I will also review usage of the audit tracker with the preceptor to ensure uniform interpretations are applied when encountering incomplete documentation.
To increase efficiency, I will designate blocks of time to complete chart reviews rather than completing them sporadically throughout the working day. Feedback will remain supportive and non-punitive. Focus will remain on patterns of practice rather than individual performance. These changes should help maintain data accuracy while maintaining provider involvement.
Practicum Hours
I anticipate spending **12 hours** at the practicum site this week. These hours will consist of presenting educational materials, meeting with the preceptor and clinic administrators regarding the project timeline, distributing decision algorithms, assisting providers as needed, reviewing documentation for inclusion in the audit tracker, and implementing the audit-and-feedback tracking process.
A total of **18 practicum hours** will be reported in my practicum log. These hours include the 12 hours completed at the practicum site, as well as 6 additional hours spent meeting with the DNP mentor, preceptor, professor, or Associate Dean; reviewing the evidence base; preparing educational materials; analyzing project activities; and completing required reports and documentation.
Overall, week one served as a solid basis for this eight-week study. Engagement from providers, administrative support, and successful establishment of both education and audit processes were key successes achieved in week one. Scheduling and documentation inconsistencies encountered unexpectedly during the week one was minor and offered valuable insight for improving processes implemented in week two.
References
Amenta, e. M., Grigoryan, l., Rajan, s. S., Khawcharoenporn, t., Harbarth, s., trautner, B. W., & Goetz, m. B. (2023). Quantifying the implementation and cost of a multisite antibiotic stewardship intervention for asymptomatic bacteriuria. Antimicrobial Stewardship & Healthcare Epidemiology, 3(1), e115. Https://doi.org/10.1017/ash.2023.198
Nicolle, l. E., Gupta, k., Bradley, s. F., Colgan, r., DeMuri, g. P., Drekonja, d., Eckert, l. O., geerlings, s. E., köves, b., Hooton, t. M., Juthani-Mehta, m., Knight, s. L., saint, s., Schaeffer, a. J., trautner, b. W., Wullt, b., & siemieniuk, r. (2019). Clinical practice guideline for the management of asymptomatic bacteriuria: 2021 update by the Infectious Diseases Society of America. Clinical infectious diseases , 68(10): e83–e110. Https://doi.org/10.1093/cid/ciy1121