Reducing infant catheterization in the emergency department through clean-catch urine collection

Amanda E Mulcrone, Manas Parikh, Fahd A Ahmad, Amanda E Mulcrone, Manas Parikh, Fahd A Ahmad

Abstract

Objective: Our emergency department (ED) traditionally relied on urethral catheterization to obtain urine cultures when evaluating infants for urinary tract infections (UTIs). Catheterization is associated with adverse effects, and recent studies have demonstrated clean-catch urine methods can be successfully used to obtain urine cultures. We pursued a quality improvement (QI) initiative aimed at decreasing the frequency of urethral catheterizations in our ED by using an established clean-catch technique to obtain infant urine cultures.

Methods: We implemented a clean-catch urine collection method, which we entitled "Bladder Massage," for infants 0-6 months of age needing a urine culture in our ED. Exclusions included critical illness, known urologic abnormality, or prior UTI diagnosis. Our primary interventions were educational initiatives. We retrospectively collected data regarding the use of bladder massage. Our balancing measure was the contamination rate of urine cultures obtained via bladder massage technique compared to catheterization.

Results: In our first-year post-implementation, we identified 334 eligible patients. Bladder massage was attempted on 136/334 (40.7%) eligible infants, with 87/136 (64%) successful attempts, thus avoiding catheterization in 26.1% of patients. Our baseline contamination rate from catheterization was 8/488 (1.6%), compared to 10/87 (12%) using bladder massage (P < 0.001), with 9/10 contaminants from female patients.

Conclusion: We successfully introduced a method for clean-catch urine cultures in our pediatric ED, averting the need for urethral catheterization in many well-appearing infants. Ongoing efforts must focus on reduction of contamination in females, increased technique usage, and electronic health record changes to facilitate documentation to continue method use.

© 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.

Figures

FIGURE 1
FIGURE 1
Implementing bladder massage—highlighting the total opportunities, attempts, and successes by month. This graph also demonstrates the cumulative catheterization reduction rate of infants requiring urine culture collection over the course of our initiative. The initiative began February 15, 2018* and ended February 14, 2019**
FIGURE 2
FIGURE 2
Run chart of proportion of eligible patients with successful bladder massage through our initiative (beginning February 15, 2018* and ending February 14, 2019**)

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