A fast and frugal algorithm to strengthen diagnosis and treatment decisions for catheter-associated bacteriuria.
A fast and frugal algorithm to strengthen diagnosis and treatment decisions for catheter-associated bacteriuria.
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DOI：
10.1371/journal.pone.0174415
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发表时间：
2017
期刊：
影响因子：
3.7
通讯作者：
Trautner BW
中科院分区：
文献类型：
--
作者：
Naik AD;Skelton F;Amspoker AB;Glasgow RA;Trautner BW
管理导管相关性尿路感染（CITTI）和无症状细菌（ASB）的指南在常规护理中的转化率很低，部分原因是认知诊断错误。本研究确定了与传统的教育方法相比，实施快速和节俭的算法后，是否可以提高PITTI和ASB诊断和治疗的准确性。一个干预前后的同期比较网站，涉及美国两个地区退伍军人事务系统的住院和长期护理病房。参与者包括216名内科住院医师和16名初级保健临床医生。干预临床医生接受了快速和节俭算法的培训。对比研究中心的临床医生接受了指南教育。在类似的三个月，干预前和干预后的时期，诊断和治疗的准确性与标准标准进行了评估。在每个研究中心比较两个时期的灵敏度、特异性和似然比。对196例实施前和117例实施后的菌尿管理进行了评价。实施后，干预参与者中菌尿管理的准确性显著高于对照点（干预：阳性似然比（LR+）= 8.5，特异性= 0.89，95%置信区间（CI）= 0.78 - 1.00;比较：LR+ = 4.62，特异性（95%CI）= 0.79（0.63 - 0.95）。此外，干预部位的改善具有统计学显著性（实施前：LR+ = 2.1，特异性（95%CI）= 0.60（0.50 - 0.71）;实施后：LR+ = 8.5，特异性（95%CI）= 0.89（0.78 - 1.00）。在两个研究中心，从实施前到实施后，负LR的改善相似：[干预研究中心= 0.28至0.08;比较研究中心= 0.13至0.04]。在干预部位，ASB的不适当管理从32例（40%）明显下降到3例（11%）。一个快速和节俭的算法，提高了诊断和治疗的准确性，为ESTTI和减少不适当的治疗ASB。快速和节俭的算法，重新调整诊断直觉和治疗规范，可以提高证据转化为实践。
Guidelines for managing catheter-associated urinary tract infection (CAUTI) and asymptomatic bacteria (ASB) are poorly translated into routine care due in part to cognitive diagnostic errors. This study determines if the accuracy for CAUTI and ASB diagnosis and treatment improves after implementation of a fast and frugal algorithm compared with traditional education methods. A pre and post-intervention with contemporaneous comparison site involving inpatient and long term care wards at two regional Veterans Affairs Systems in United States. Participants included 216 internal medicine residents and 16 primary care clinicians. Intervention clinicians received training with a fast and frugal algorithm. Comparison site clinicians received guidelines education. Diagnosis and treatment accuracy compared with a criterion standard was assessed during similar three-month, pre- and post-intervention periods. Sensitivity, specificity, and likelihood ratios were compared for both periods at each site. Bacteriuria management was evaluated against criterion standard in 196 cases pre-implementation and 117 cases post-implementation. Accuracy of bacteriuria management among intervention participants was significantly higher, post-implementation, than those at the comparison site (Intervention: positive likelihood ratio (LR+) = 8.5, specificity = 0.89, 95% confidence interval (CI) = 0.78−1.00; comparison: LR+ = 4.62, specificity (95%CI) = 0.79 (0.63−0.95). Further, improvements at the intervention site were statistically significant (pre-implementation: LR+ = 2.1, specificity (95%CI) = 0.60 (0.50−0.71); post-implementation: LR+ = 8.5, specificity (95%CI) = 0.89 (0.78−1.00). At both sites, there were similar improvements in negative LR from pre- to post-implementation: [Intervention site = 0.28 to 0.08; comparison site = 0.13 to 0.04]. Inappropriate management of ASB declined markedly from 32 (40%) to 3 (11%) cases at the intervention site. A fast and frugal algorithm improves diagnosis and treatment accuracy for CAUTI and reduces inappropriate treatment of ASB. Fast and frugal algorithms that realign diagnostic intuitions and treatment norms can enhance translation of evidence into practice.