Date of Award

January 2024

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Louise-Marie Dembry


Urinalysis and urine cultures are important diagnostic tools for diagnosing urinary tract infections. Often urine cultures are ordered without appropriate clinical indications of infection attributable to the urinary tract. Inappropriate urine culture ordering can have significant downstream effects and contribute to the unnecessary use of antibiotics, increased prevalence of Clostridioides difficile infections and antibiotic resistance, as well as wasted resources. A quality improvement project was undertaken at the Veterans Affairs Connecticut Healthcare System (VACHS) to decrease the ordering of inappropriate urine cultures. A new, optional electronic medical record urine culture ordering note requiring documented indication for the test was implemented on August 23, 2023. Additionally, education sessions on urine culture ordering guidelines occurred periodically starting November 2023 with the bulk of the education taking place at the beginning of November 2023. Data on all inpatient VACHS urine culture orders from January 1, 2023, to February 9, 2024, were collected and reviewed for appropriateness. After review, analysis was performed on the pre-intervention and intervention data to determine if any changes in urine culture ordering practices occurred. There were 418 urine culture orders reviewed for this period with 292 included in the pre-intervention period and 126 in the intervention period. The analysis indicated no statistically significant change in ordering practices after the November 2023 education sessions (21.2% appropriate vs 25.3% appropriate, p=0.42). Demographic information of all urine culture orders demonstrated that the medicine clinical provider team was responsible for the majority (49%) of the VACHS’s urine culture ordering, regardless of appropriateness. Behavior change is an incredibly challenging area to target with diagnostic stewardship interventions. Due to this difficulty, the impact of these interventions is often insignificant. The VACHS intervention utilized a passive approach to diagnostic stewardship to start and would benefit from more active efforts. The next steps for this urine culture diagnostic stewardship initiative at VACHS consist of a mandatory ordering note to guide clinicians and continuing to reinforce appropriate urine culture ordering guidelines for providers through education. A mandatory ordering note should reduce the opportunity for inappropriate urine culture ordering and has previously been shown to be effective at VACHS for C. difficile testing.


This is an Open Access Thesis.

Open Access

This Article is Open Access