De-implementation of Unnecessary Pre-Operative Urine Testing
openNIH
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.