Article Text
Abstract
Aims Urinalysis provides direction in diagnosis and treatment of patients in the emergency department (ED). Midstream urine (MSU) collection from female patients has a high contamination rate. Verbal instruction by nurses to patients reduces contamination but is inconsistent owing to lack of time and professional knowledge. This study aimed to determine if an alternative mode of instruction requiring minimal staff input may be effective.
Methods A pseudorandomised controlled trial was undertaken with 240 female patients for whom urinalysis was clinically required. No change was made to normal practice with regards to verbal instruction. Prior to collecting their sample the intervention cohort received illustrated instruction on how to collect a clean uncontaminated MSU sample. The control cohort received no illustrated instruction. Compared outcomes were rate of contamination on urinalysis, defined as 10 or more epithelial cells per high power field, and answers to a structured patient questionnaire.
Results Contamination rate was reduced from 40% to 25% by the intervention. According to patient survey responses, verbal collection instructions were seldom given and the actions of hand washing, cleaning with a towelette, and voiding then stopping were significantly higher in the intervention group. The illustrations were well received by over 95% of patients and were considered to be clear and effective especially for patients with reading difficulties and/or from a non-English speaking background.
Conclusions Illustrated urine collection instructions were well accepted by female ED patients, improved the rate of proper MSU collection and reduced the rate of urinalysis contamination in the ED.
- URINE
- GENITOURINARY PATHOLOGY
- METHODOLOGY
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Introduction
Urinary tract infections are reported to be the second most common infections1 affecting up to 15% of women in any given year2 and 50% of women during their lifetime.3 Urine is the most frequent sample presented to microbiology laboratories,4 and is probably the most common microbiology procedure where the specimen is self-collected by the patient.5
Urinalysis provides vital information in the clinical management of patients in the emergency department (ED). Contamination rates of urine samples are high especially in women.6 Sample contamination can lead to diagnostic ambiguity or incorrect diagnosis and inappropriate treatment. This in turn may lead to poorer patient outcomes, and increases the misuse of antibiotics and overall resistance.
The need to repeat samples incurs additional cost, prolongs time for diagnosis and treatment and can increase patient anxiety and time spent in the ED.7 ,8
Contamination of urine may not be completely avoidable; however the Q-Probe study5 concluded little progress had been made since a similar study a decade earlier.9
Contamination rates vary by institution, collection, storage and transport of samples and by definition of what constitutes a contaminated sample. Contamination has been defined variously including numbers of squamous cells visible by microscopy, mixed growth by culture or varying numbers of isolates in different concentrations of colony forming units.1 ,5 ,10
Background
Over 12 000 urine specimens originate from the adult ED at the study hospital annually. A review of the results of 2000 ED-sourced midstream urine (MSU) samples indicated contamination by squamous epithelial cells (≥10 cells per field) in 41.5% of samples from women and 5.4% of men.
One of the potential reasons for contamination is poor patient technique resulting in large part from inadequate instruction to the patient. The literature on communication processes between health professions and patients conclude that the likelihood of success in collection of medical samples increases with careful explanation.11–13
Written instructions are reported to complement verbal instructions;14 however there is a paucity of confirmatory research data. In fact a Cochrane Review of the medical literature12 reported that there were only two well controlled trials15 ,16 which compared instruction method in a medical context. Those trials occurred with patients at discharge and showed that combined verbal and written information appeared to improve knowledge and satisfaction.
With respect to urine collection, verbal instruction alone to patients has shown to be lacking on two fronts. First, two studies have shown that the knowledge of many nurses in urine collection technique was lacking and they require training or retraining in this technique.14 ,17 Second, the sustainability of the approach has been questioned. A recent Californian study evaluated a nursing MSU instruction protocol for the ED.18 The protocol which prescribed a series of verbal instructions to patients had immediate positive effect and increased steps such as hand washing over those patients not receiving instruction. However, despite widespread dissemination of information to the nurses, 40% of the time instructions were not given to patients. The authors concluded that ‘what really happens’ in an ED is that competing priorities resulted in the failure to deliver instruction. Those results were in agreement with the view of Lifshitz and Kramer19 who reported that instructing patients verbally on the MSU clean catch technique was time-consuming and was likely not to be sustainable.
Several other studies have compared instruction method within the context of urine collection with mixed results. In the research laboratory environment there was no statistical difference between written and verbal instruction.20 Other studies support this view.19 ,21 In contrast provision of written and/or verbal instructions has some success in reducing contamination in several other studies7 ,20 ,21 including samples collected from EDs where written instructions were distributed to patients.5
The conclusion from these studies is that verbal communication while effective is not sustainable and the effectiveness of written instruction is not absolute. A more effective method which will work in the ED environment is needed.
At the study hospital instructions for collection of MSU are only provided verbally. No specific training of nursing and medical staff is provided; instead reliance is given on the experience and communication skills of the nurses or doctors. Preliminary observational research complemented by conversations with nursing and medical staff indicated that verbal instruction to patients was inconsistent in frequency and content.
Recognising that in reality this was unlikely to change, this study was designed to assess whether illustrations depicting the step-by-step process for collecting a urine sample would be effective in decreasing the contamination rate in female ED patients. Instructions were provided for an MSU sample as this is the most frequently used patient-collected method whereby the first portion of urine which has the highest rate of contamination is voided.
Design
A pseudorandomised control trial undertaken with 240 female patients, comparing pathology results and answers to a structured questionnaire between those patients provided with an illustrated instruction (figure 1) and those with no instruction.
Participants
Participants were 18 years and over who presented to the ED, and because of their presenting symptoms suggestive of infection (eg, flank pain, painful urination, fever) were clinically required to provide a clean catch MSU sample for diagnostic purposes. Patients who were unable to provide the sample in this way and provided a sample via other methods such as indwelling urinary catheter and suprapubic catheter were excluded.
Participants were alternately provided with an envelope containing either the illustrated instruction (figure 1; Illustration group=I) or a piece of paper advising them to return their sample to the nurse (No illustration group=NI). Both envelopes contained a non-alcohol based towelette. In order to mimic the usual situation as closely as possible the nurses were not provided with any additional instruction other than to give the envelope at the same time as the sample container. Nurses were therefore free to give verbal instruction as per their normal practice.
After patients had returned their sample to the nurse they were approached by one of two investigators (CJ or LK) and both groups consented to complete an investigator-administered questionnaire.
As per standard procedure the urine sample was sent to the pathology department for analysis which included the quantification of epithelial cells. A high number of epithelial cells is indicative of contamination of the sample with cells from the distal urethra and/or perineum. This is frequently associated with false-positive urine culture results, as these epithelial cells can carry large numbers of bacteria. For the purposes of this study contamination was defined simply as the presence of 10 or more squamous epithelial cells per high power field as a surrogate of bacterial of contamination.
Questionnaire
The questionnaire contained questions requiring either answer of yes/no or a response on a Likert-type scale. The questions determined (A) memory of any verbal instructions given by the nurse, and (B) the process by which they collected their sample. Skip logic was applied such that if the response to Q1 “Did the nurse tell you how to collect your sample?” was ‘No’ then Questions 2–5 on recall of what was said were omitted. Questions 7–11 were only administered to those patients who received the illustrated instructions. After completion of the questionnaire the NI group participants were given a copy of the illustrations and both groups were provided with the opportunity to offer comment on them.
Ethics approval
The study received approval from the ethics committees of the hospital and university.
Statistical analysis
Statistical analysis was performed using two-proportion z test for proportions and χ2 test for categorical variables.
Results
Table 1 presents the pathology results. Based on epithelial cells of ≥10 group I had fewer contaminated samples (25%) than did the NI group (40%). There was no difference in the contamination rate regardless of whether they received verbal instruction from the nurse.
In the I group there were 16 UTIs reported based on culture results. Of these five were qualified as ‘possible UTI’ owing to the sample being contaminated with epithelial cells. In the NI group the figures were 15 and 8, respectively.
In response to the question “if you had received this instruction sheet would it have been clearer to you as to how to give the sample” 91 of the 120 NI participants said ‘Yes’.
All participants were offered the opportunity to make additional comments. Of the 123 who did so 65 referred specifically to the clarity and effectiveness of the illustrations with phrases such as ‘instructions were good’, ‘they made it clearer’, ‘pretty thorough’, ‘well detailed’, ‘very helpful’. Examples of other comments are
“Beneficial in waiting room as more discrete way of giving MSU instructions”;
“That’'s brilliant, easier to understand”;
“Verbal instructions are rushed with many people in the room. Written is much more helpful”.
Six participants noted that the illustrations would be useful for people who had difficulty reading or for those who are from a non-English speaking background.
“Pictures [will be] good for non-English speaking people or those with poor eyesight”.
“Information sheet must be given automatically to non-English speaking people”
However 10 patients had negative feedback of the illustrations.
“Too graphic”;
“Verbal instructions should be enough”;
“The detail in the instructions are a little over the top”.
Responses to the questionnaire (table 2) indicated that almost half of the patients did not receive any verbal instruction from the nurses. More NI patients than I recollected being told to wash their hands but fewer to void their first urine into the toilet.
Steps the subjects recalled performing during sample collection are presented in table 3. Of six steps queried, three were reported to be performed statistically more often by the I group.
There were no differences in the rate between NI subjects who recalled receiving verbal instructions and those who did not.
While all the intervention patients received instruction of what to do with the towelette, some control group patients reported that they had used the towelette to wipe their hands or the toilet seat. The effect of the towelette was shown to be non-significant when it was removed for the last 40 of the NI group.
Discussion
There is only one prior study evaluating instructions for urine collection in an ED environment and it was a verbal intervention.18 The authors showed that adherence to a new protocol for provision of verbal instruction was unsustainable and identified a need for pragmatic ED studies on the impact of urine collection instructions. These conclusions are an endorsement of our study to determine a practical approach to improve sample collection.
It is clear that verbal instruction cannot be relied upon. In our own department only a little over half of the patients recalled receiving verbal instruction. Interestingly, while only 50% of the intervention group stated that they received verbal instruction 61% of the control group did so. This latter figure is exactly the same as that reported previously.18 It is possible that some intervention participants forgot about the verbal instruction after receipt of the illustrations. Factors affecting this may be related to the workload of nurses, however there also may be reticence in describing the process in a public area.5
The value of using a towelette was questioned with no difference seen in any parameters to those patients in the NI group who used the towelette for its intended purpose. A small or negligible effect of perineal cleaning has also been seen in other studies21 ,22 with parting of the labia reported to be a more important step.18
We used squamous epithelial cells from the skin surface or from the outer urethra as a surrogate marker for contamination and demonstrated a reduction in the intervention group. Another measure of contamination may have provided different results, however our data are consistent with a previous study showing that written instructions resulted in lower urine contamination in ED patients.5
Disposable, patient-held devices, designed to automatically obtain a midstream collection, are on the market, but it is unclear whether such devices reduce contamination, particularly in a clinical real world setting.6 ,10 Furthermore they are relatively expensive and unlikely to be adopted soon for use in our public health system.
Overall the study demonstrated that these low-cost illustrations were effective. It is noted however that some, albeit a very low, proportion of patients found the graphic illustrations distasteful. We concede that this is a small, unavoidable consequence of such illustrations.
Conclusion
In an ED setting, where nurse verbal urine collection instructions often were not recalled, simple illustrated instructions improved patient performance of MSU collection steps and reduced urine contamination.
Take home messages
The time-poor and busy environment of the emergency department creates challenges to ensure patient-collected urine samples are contaminant-free.
Verbal and written interventions are either unsustainable or provide barriers to many patients.
Illustrated instructions are an inexpensive, easily applied and acceptable method of providing information to patients in the emergency setting to reduce contamination rate of midstream urine samples.
Acknowledgments
The authors thank Dr Joan Faoagali and Angela Payne for supporting this study and David Toohey for drawing the illustrations.
References
Footnotes
Handling editor Slade Jensen
Contributors All of the named authors contributed to the design of the study, data collection and analysis. RE drafted this article, which was then commented on by the other authors.
Funding This study received funding from the Queensland Emergency Medicine Research Foundation grant number EMSS-12-183.
Competing interests None declared.
Patient consent Obtained.
Ethics approval Metro South HREC.
Provenance and peer review Not commissioned; externally peer reviewed.