BMC Med Inform Decis Mak - Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria.


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CKGROUND: Overtreatment of catheter-associated bacteriuria is a quality and safety problem, despite the availability of evidence-based guidelines. Little is known about how guidelines-based knowledge is integrated into clinicians' mental models for diagnosing catheter-associated urinary tract infection (CA-UTI). The objectives of this research were to better understand clinicians' mental models for CA-UTI, and to develop and validate an algorithm to improve diagnostic accuracy for CA-UTI.METHODS: We conducted two phases of this research project. In phase one, 10 clinicians assessed and diagnosed four patient cases of catheter associated bacteriuria (n= 40 total cases). We assessed the clinical cues used when diagnosing these cases to determine if the mental models were IDSA guideline compliant. In phase two, we developed a diagnostic algorithm derived from the IDSA guidelines. IDSA guideline authors and non-expert clinicians evaluated the algorithm for content and face validity. In order to determine if diagnostic accuracy improved using the algorithm, we had experts and non-experts diagnose 71 cases of bacteriuria.RESULTS: Only 21 (53%) diagnoses made by clinicians without the algorithm were guidelines-concordant with fair inter-rater reliability between clinicians (Fleiss' kappa = 0.35, 95% Confidence Intervals (CIs) = 0.21 and 0.50). Evidence suggests that clinicians' mental models are inappropriately constructed in that clinicians endorsed guidelines-discordant cues as influential in their decision-making: pyuria, systemic leukocytosis, organism type and number, weakness, and elderly or frail patient. Using the algorithm, inter-rater reliability between the expert and each non-expert was substantial (Cohen's kappa = 0.72, 95% CIs = 0.52 and 0.93 between the expert and non-expert #1 and 0.80, 95% CIs = 0.61 and 0.99 between the expert and non-expert #2).CONCLUSIONS: Diagnostic errors occur when clinicians' mental models for catheter-associated bacteriuria include cues that are guidelines-discordant for CA-UTI. The understanding we gained of clinicians' mental models, especially diagnostic errors, and the algorithm developed to address these errors will inform interventions to improve the accuracy and reliability of CA-UTI diagnoses.

Resumo Limpo

ckground overtreat catheterassoci bacteriuria qualiti safeti problem despit avail evidencebas guidelin littl known guidelinesbas knowledg integr clinician mental model diagnos catheterassoci urinari tract infect cauti object research better understand clinician mental model cauti develop valid algorithm improv diagnost accuraci cautimethod conduct two phase research project phase one clinician assess diagnos four patient case cathet associ bacteriuria n total case assess clinic cue use diagnos case determin mental model idsa guidelin compliant phase two develop diagnost algorithm deriv idsa guidelin idsa guidelin author nonexpert clinician evalu algorithm content face valid order determin diagnost accuraci improv use algorithm expert nonexpert diagnos case bacteriuriaresult diagnos made clinician without algorithm guidelinesconcord fair interrat reliabl clinician fleiss kappa confid interv cis evid suggest clinician mental model inappropri construct clinician endors guidelinesdiscord cue influenti decisionmak pyuria system leukocytosi organ type number weak elder frail patient use algorithm interrat reliabl expert nonexpert substanti cohen kappa cis expert nonexpert cis expert nonexpert conclus diagnost error occur clinician mental model catheterassoci bacteriuria includ cue guidelinesdiscord cauti understand gain clinician mental model especi diagnost error algorithm develop address error will inform intervent improv accuraci reliabl cauti diagnos

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