The Diagnosis and Treatment of Adult Urinary Tract Infections in the Emergency Department.

Emergency medicine has been called the art of "making complicated clinical decisions with limited information." This description is particularly relevant in the case of diagnosis and treatment of urinary tract infections (UTIs). Although common, UTIs are often challenging to diagnose given the presence of non-specific signs and symptoms and over-reliance on laboratory findings. This review provides an interdisciplinary interpretation of the primary literature and practice guidelines, with a focus on diagnostic and antimicrobial stewardship in the emergency department.

'Medical Clearance' of Patients With Acute Mental Health Needs in the Emergency Department: A Literature Review and Practice Recommendations.

INTRODUCTION: Emergency departments have seen increasing numbers of patients presenting with acute mental illness. Currently, there is not a standard for assessing the medical stability of these patients prior to transfer to inpatient psychiatric services, which causes unnecessary delays in patient care. OBJECTIVE: Provide a literature review and multidisciplinary expert consensus recommendations to simplify and expedite the medical evaluation of patients requiring admission to inpatient psychiatric facilities. METHODS: A task force with representation from emergency physicians (Wisconsin Chapter of the American College of Emergency Physicians) and psychiatrists (Wisconsin Psychiatric Association) met to create this position statement. The members reviewed clinical practice guidelines and primary literature sources to develop evidence-based recommendations. RESULTS: Five categories of recommendations were developed: (1) A detailed history and physical exam should constitute the minimum necessary information required for most medical assessments. (2) Clinical information should guide further diagnostic testing; therefore, receiving facility blanket requirements for routine testing should be abandoned. (3) Emergency physicians should understand the limited medical capabilities of institutes of mental disease. Obtaining reasonable diagnostic testing that is not available at these facilities may be appropriate, though this should not delay patient transfer. (4) Structured medical evaluation algorithms should be used to enhance the uniformity of medical assessments for these patients. This task force recommends the Wisconsin SMART Form. (5) Emergency physicians and psychiatrists should communicate more regularly without intermediaries, both at the clinical encounter and beyond. CONCLUSION: The recommendations in this paper are endorsed by the Wisconsin Chapter of the American College of Emergency Physicians and the Wisconsin Psychiatric Association, which strongly urge affected medical providers to adopt them into routine practice.

Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings.

Background: Inappropriate ordering and acquisition of urine cultures leads to unnecessary treatment of asymptomatic bacteriuria (ASB). Treatment of ASB contributes to antimicrobial resistance particularly among hospital-acquired organisms. Our objective was to investigate urine culture ordering and collection practices among nurses to identify key system-level and human factor barriers and facilitators that affect optimal ordering and collection practices. Methods: We conducted two focus groups, one with ED nurses and the other with ICU nurses. Questions were developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. We used iterative categorization (directed content analysis followed by summative content analysis) to code and analyze the data both deductively (using SEIPS domains) and inductively (emerging themes). Results: Factors affecting optimal urine ordering and collection included barriers at the person, process, and task levels. For ED nurses, barriers included patient factors, physician communication, reflex culture protocols, the electronic health record, urinary symptoms, and ED throughput. For ICU nurses, barriers included physician notification of urinalysis results, personal protective equipment, collection technique, patient body habitus, and Foley catheter issues. Conclusions: We identified multiple potential process barriers to nurse adherence with evidence-based recommendations for ordering and collecting urine cultures in the ICU and ED. A systems approach to identifying barriers and facilitators can be useful to design interventions for improving urine ordering and collection practices.