392 - The bag is not always bad: Implementing a two-step pathway for urine testing on the inpatient paediatric wards

Poster Number: 392
Publication Number: 392.243

Felicia Paluck, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada; Chandandeep Bal, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada; Laila Premji, The Hospital for Sick Children, Toronto, ON, Canada; Ting Ting Liu, The Hospital for Sick Children, North York, ON, Canada; Noel Wong, The Hospital for Sick Children, Toronto, ON, Canada; Beth D. Gamulka, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada

Background: Urinary tract infections (UTIs) are a common source of infection in young children. Best practice for diagnosing UTIs includes interpreting both a urinalysis and urine culture. Urine cultures require a sterile sample, and in non-toilet trained children these are obtained primarily through bladder catheterization. Bladder catheterizations are an invasive procedure and can be painful and time-consuming.
A two-step approach for urine collection starting with a urinalysis (UA) on a non-sterile sample, has previously been demonstrated to reduce unnecessary bladder catheterizations and urine cultures in young children 6-24 months of age with suspected UTIs.
Given the overwhelming strain on laboratory services during the COVID-19 pandemic, reducing unnecessary investigations is even more critical at this time.

Objective: Decrease the overall number of bladder catheterizations preformed and the number of unnecessary urine culture samples sent to the lab by implementing a two-step urine collection approach for children 6-24 months with suspected UTIs on the general paediatric inpatient wards.

Design/Methods: Baseline data was collected for all urine studies sent from the wards in 2020. A multi-disciplinary project team adapted a two-step pathway for collecting urine samples. This includes first completing a point-of-care urinalysis (UA) on a urine bag sample, and if positive, completing a bladder catheterization for UA and urine culture. Using the Model for Improvement and multiple PDSA cycles, the pathway was implemented on the paediatric wards. Education was done with nurses, residents and staff physicians regarding the initiative. Posters illustrating the new pathway were created and placed on the wards. Data collection continues monthly.

Results: Baseline data demonstrated a high rate of children having urinary catheter cultures despite a negative UA or no UA being performed prior (67%). After the pathway implementation, this rate has decreased to a mean of 30% (Figure 1). The number of Point of Care (POCT) UAs performed on the wards has also increased (to a mean of 88%), which means fewer samples being processed in the lab (Figure 2).Conclusion(s): Bladder catheterizations are often used to investigate UTIs in children but are invasive and not always necessary. A two-step approach can decrease the number of catheterizations performed on young children and will contribute to providing ongoing high-value, patient-centered care during a period where resource stewardship is pivotal.
Figure 1: Run chart displaying percent of urine cultures who had a negative UA or no UA prior
Figure 2: Run Chart displaying the percent of Urinalysis run as Point-of-Care-Testing.