Table 3.
Illustrative Participant Quotes by Intervention Component
| Proposed Intervention | Illustrative Quotes |
|---|---|
| Urine culture indications | “Yes… I think [having the template] would [improve diagnosis]. I think it would, if they have to mark off the appropriate indications of why you’re doing this, just like the appropriate indications of why you’re inserting a catheter, it makes them think twice, or ‘am I just doing the urine culture because, you know, I want to pan-culture everything? Or am I doing it specifically for the urine? Am I looking for something that’s actually going to be there rather than just culturing.’”—Site 1, infection preventionist & nurse manager |
| Documenting presence of urinary catheter | “I like having the separate comment for the catheter, just because sometimes in the VA system, it’s hard to find that information in the chart. At least, I have found that sometimes I’ll be doing a chart search and it’s not even there. And then I have to find out from the team, like verbally, that the patient has a catheter. So, I do think that part is helpful.”—Site 1, antimicrobial stewardship pharmacist |
| Nudge to not culture in the absence of symptoms | “… I get a lot of [patients and families] that call in and it’s just like, ‘You know, the color’s off, can we check his urine?’ And I will typically acquiesce to doing a urinalysis, but I won’t necessarily do a culture right off the bat. Because we have to maintain a therapeutic relationship, too. And if I’m coming across like I’m blowing off their concern … I appreciate the fact that [the nudge is] there, ‘cause it gives us something to say to them, you know, ‘that color alone is not a great indicator.’”—Site 3, ambulatory care physician |
| Conditional urine culturing | Assenting viewpoint |
| “I think for a majority of the facility, if we just had one standardization [threshold for urine culture], like the [Delphi-agreed upon] algorithm … I think that would simplify the process. You know, there’s always going to be those case-by-case basis, if a physician is looking for something and maybe they have cultured everything else and they want to go ahead and culture the urine for whatever reason, even though it doesn’t meet that criteria, there may be a case-by-case basis for that. But I think, facility-wide, I think this would be a better process. It’s more straightforward. Simplistic. If there’s nothing there, like there’s no WBC count in your urine, then we really shouldn’t be processing it to culture.”—Site 1, infection preventionist | |
| Dissenting viewpoint | |
| “The art and the science of medicine is for the physician or the nurse practitioner to take the data and make a decision. Rather than for us to take, well, we just didn’t do a culture ‘cause the UA was pretty bland … So it really becomes down to who’s the gatekeeper? Who makes the decisions? And I’m not a fan of waiting for UA in order to do the culture. And I’m not sure I ever will be a fan because this is a much more complicated area that we can have one simple rule and it’s [going to work] for everything.”—Site 2, microbiology laboratory director | |
| Cascade reporting | Assenting viewpoint |
| “It’s kind of a brilliant idea, because I think a lot of times when we’re going to start antibiotics, we kind of look at this list and not having, you know, meropenem on there probably makes it less likely that that’s the antibiotic that someone would choose. I guess the only thing I would want to make sure is that the like, full susceptibilities were checked, so that if needed, that information could be gathered.”—Site 2, inpatient physician | |
| Dissenting viewpoint | |
| “I will tell you, the limited agents reported, it makes sense, but I definitely get into situations where, especially people who have a million different allergies, or maybe they have a UTI plus something else, and so it makes it harder to pick. … Sometimes, having more options is sometimes helpful.”—Site 3, surgeon | |
| Selective reporting | “I think the literature, albeit limited, is pretty compelling that selective reporting can be helpful to steering people towards appropriate choices. … I have no problem with selective reporting. I think you have to do a little education component, even though it says there, you know, like sometimes they don’t realize that it’s not a full set, so they don’t even know to call, or anything.”—Site 3, emergency department physician |
| Report nudges | “It’s hard, ‘cause more text means that there’s more to read or more to skip … But I think, sometimes having this information in the results is actually kind of comforting, that you can—You’re kind of getting support in not necessarily treating a positive urine culture.”—Site 2, long-term care physician |