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Appropriateness of Care Initiative: Antimicrobial Stewardship in Asymptomatic Bacteriuria

Identifying barriers and actionable opportunities for process improvement through facilitated co-creation workshops





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Project Partners

  • Appropriateness of Care: Asymptomatic Bacteriuria (Alberta Health Services)

  • University of Alberta Hospital


According to Choosing Wisely Canada, studies suggest that asymptomatic bacteriuria – i.e. excess bacteria in the urine that is not presenting any symptoms – in the elderly does not carry significant risk of morbidity if left untreated. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and show increased adverse antimicrobial effects. Potential adverse effects of antimicrobial treatment for asymptomatic bacteriuria include the development of bacterial resistance, adverse reactions to antibiotics and Clostridium difficile infection.

Secondary research has identified three root causes for the overutilization of urine testing:

  1. Belief that cloudy/smelly urine is indicative of a urinary tract infection (UTI)

  2. Belief that positive urinalysis or urine cultures are indicative of UTI

  3. Routine ordering of urinalysis and urine cultures is an accepted practice


This project was a partnership between the Physician Learning Program (PLP) and Alberta Health Services Appropriateness of Care: Asymptomatic Bacteriuria project to develop an algorithm for urinary infection testing. Three project objectives were identified:

  • Identify physician and nurse beliefs surrounding positive urine tests

  • Identify what processes physicians and nurses follow for ordering “routine” urine tests

  • Collect physician and nurse feedback on core messaging relating to a suite of clinical decision making and communication tools for appropriate urine testing

Project Summary

We held two co-creation workshops with physicians, nurses and other healthcare professionals at the University of Alberta Hospital. Each workshop incorporated three activities: process mapping, co-analysis of existing tools and co-designing new ideas for improvement.


Many barriers and areas for improvement were identified as a result of these workshops. The primary barrier to appropriate assessment identified was the time taken to receive results – particularly within the emergency department where time is considered a quality indicator.



This project demonstrated how the implementation of human-centred design principles can aid in the process of refining and incorporating decision support tools into practice.

Facilitated co-creation workshops prompted participants to reflect on their existing knowledge, perceptions, barriers and attitudes toward change – resulting in the identification of barriers and actionable opportunities for process improvement.

UTI Toolkit


As a result of feedback collected during the co-creation workshops, it became apparent that the algorithm in question needed to clearly communicate how the process could lead to safer outcomes.

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