title: Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria.
abstract: BACKGROUND
  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.
authors.affiliation: Houston Health Services Research and Development Center of Excellence, Michael E, DeBakey VA Medical Center, Houston, TX, USA.
authors.forename: Barbara W
authors.initials: BW
authors.lastname: Trautner
authors.forename: Rupal D
authors.initials: RD
authors.lastname: Bhimani
authors.forename: Amber B
authors.initials: AB
authors.lastname: Amspoker
authors.forename: Sylvia J
authors.initials: SJ
authors.lastname: Hysong
authors.forename: Armandina
authors.initials: A
authors.lastname: Garza
authors.forename: P Adam
authors.initials: PA
authors.lastname: Kelly
authors.forename: Velma L
authors.initials: VL
authors.lastname: Payne
authors.forename: Aanand D
authors.initials: AD
authors.lastname: Naik
mesh_terms: D000328:Adult; D000465:Algorithms; D001437:Bacteriuria / Q000175:diagnosis*; D055499:Catheter-Related Infections / Q000175:diagnosis* / Q000209:etiology; D002983:Clinical Competence; D003661:Decision Support Techniques; D003951:Diagnostic Errors / Q000517:prevention & control*; D005260:Female; D019983:Guideline Adherence; D006282:Health Personnel / Q000523:psychology* / Q000592:standards; D006801:Humans; D008297:Male; D015203:Reproducibility of Results; D014546:Urinary Catheterization / Q000009:adverse effects; D014552:Urinary Tract Infections / Q000175:diagnosis