How a Multidisciplinary Team Improved Patient Outcomes Using Best Practices
Urol Nurs. 2013;33(5):249-256.
Abstract and Introduction
Abstract
The Institute of Medicine challenged the health care system to ensure safe care for all patients. This article reviews one hospital's attempt to minimize contamination of urine specimens by using a multidisciplinary team to implement evidencebased best practices. The clinical nurse specialist (CNS) collaborated with microbiology and laboratory personnel to review literature, collect and analyze data, provide staff education, and facilitate change in urine collection kits and urine processing that significantly improved the quality of urine specimens in a 350-bed hospital in the Midwest.Objectives:
1. Discuss the potentially negative impact of poorly collected urine specimen on patient care.
2. Explain the proper urine collection method for males.
3. Explain the proper urine collection method for females.
4. Describe benefits of implementing a multidisciplinary approach to urine collection.
Introduction
Specimen management in microbiology includes selection, collection, transport, storage, analysis, and reporting. When errors occur at any point in this process, the result may adversely affect the patient (i.e., misdiagnosis, extended length of hospital stay, or inappropriate therapy). Clinicians base treatment decisions on urine culture results, and patients are affected either positively or negatively by the accuracy of those results. A chain of people with varying levels of education, diverse backgrounds, and different foci on patient care impact this process.In 2007, the director of micro biology at a 350-bed community hospital observed that the incidence of culture results that grew only coagulase-negative staphylococcus greater than 100,000 colony forming units (CFU)/ml in urine specimens was increasing. This is an unusual finding because coagulase-negative staphylococcus (CoNS) is an uncommon cause of urinary tract infection (UTI) (McCarter, Burd, Hall, & Zervos, 2009). Additionally, CoNS is a common contaminate of microbiology specimens, including urine specimens (Versalovic et al., 2011). The urine specimens were, for the most part, collected by staff nurses via straight catheterization in the emergency department (ED) and inpatient care areas. This raised a question of possible contamination of the specimens or another quality assurance issue, such as prolonged transport (defined as greater than 2 hours) or storage at incorrect temperatures (urines should be stored at a refrigerator temperature of 4 degrees centigrade) (McCarter et al., 2009).
The microbiology director alerted the medical director of pathology, the infection prevention department, and the patient multidisciplinary meeting was convened and included nursing leaders, infection prevention staff, laboratory leaders/supervisors, information technology specialists, and patient safety and process improvement (PI) leaders and staff. A committee was formed to investigate the issue, make recommendations if problems were found, and facilitate implementation of solutions.
The purpose of this article is to 1) review how one hospital addressed the investigation of a potentially flawed pre-analytic urine collection/transport process by forming a multidisciplinary performance improvement team; 2) share "best practices" found during the literature review regarding obtaining, transporting, and processing urine specimens; and 3) discuss implementation of these best practices in our institution as recommended in the literature.
Significance
Patients may be negatively impacted when results from faulty urine specimens are re ported. Inappropriate use of anti biotic therapy can occur when prescribed based on the result of a contaminated specimen. The mean cost to treat a catheter-associated urinary tract infection (CAUTI) is $759 (Anderson et al., 2007). In the intensive care unit (ICU), the mean cost of a CAUTI is $1,955 (Chen, Wang, Liu, & Chou, 2009). In addition to being costly, antibiotic overuse is a factor in development of Clostrid ium difficile(C. difficile) and/or multidrug-resistant organisms. Fluoroquinolone use has a strong association with the development of C.difficile (Cohen et al., 2010). A prospective study of 1,703 patients by Loo et al. (2005) found C.difficile to be associated with fluoroquinolone use in 82% of cases. A retrospective chart review by Khawcharoenporn, Vasoo, Ward, and Singh (2010) found the fluoroquinolone resistance rate for health care-associated UTIs to be 38% vs. 10% in the community. They also identified other evolving drug resistances: trimethoprim-sulfamethoxazole (TMPSMZ) (26% vs. 17%), amoxicillin (53% vs. 45%), and amoxicillinclavulanate (16% vs. 6%).Performance Improvement Processes
A multidisciplinary microbiology performance improvement team was formed to address the suspected faulty urine collection process. Representatives from eight departments were members of this team; these included nursing, performance improvement, medicine, pathology, laboratory, specimen control, microbiology, and information technology (IT). Each member brought a unique perspective and best practice recommendations from review of the literature regarding urine specimen collection and processing. Discussion content focused on current practice, evidence-based practices (EBPs), and improvement opportunities. To complete the project, current practices were evaluated, the literature was reviewed, and practice changes were made. Each of those processes will be addressed in further detail in this article.Evaluation of Current Practice
Urine Specimen Collection. The clean-catch midstream void collection process was found to have differing instructions in outpatient (ED) and inpatient settings. Patients were not routinely instructed about the importance of collecting a true clean-catch urine specimen correctly and how it may influence results.Observation of urine collection processes via straight catheterization revealed that the initial (first void) 10 ml of urine was being collected because the catheter was pre-attached by the manufacturer to the specimen collection container, which only had a total volume of 10 ml. This method allowed bacteria from the urethra to be processed. Urine specimens from chronic indwelling catheters were frequently collected from catheter tubing without changing the catheter prior to collection, even when the catheter had been in place for longer than two weeks. This allowed for collection of biofilm build up along the catheter tubing wall instead of a true specimen of urine from the bladder.
Specimen Labeling. A patient identification label was affixed to the specimen container and dated. The hospital used a paper requisition format with no requirement for all elements to be completed and no consequence to the collector for incomplete forms. In March 2008, staff compliance with completing the requisition form correctly was 30%. Staff indicated that barriers to completing the form correctly were lack of time and lack of clear instructions on what elements were required.
Transportation. Data were collected during three separate one-month time periods. Data collected for the month of August 2009 revealed that urine specimens remained at room temperature for between 4 to 120 minutes prior to being sent to the laboratory. This was often well over the 20-minute doubling time it takes for some common bacteria to replicate at room temperature (see ).
Table 1. Urine Specimen Transport Time
| Date | Average Time from Collection to Arrive in Laboratory (at room temperature) | Average Time from in Laboratory to Being Processed (UA) | Average Time from Collection to Being Processed |
|---|---|---|---|
| January | Range: 10 to 81 minutes | Range: 13 to 28 minutes | Range: 26 to 109 minutes |
| June | Range: 8 to 62 minutes | Range: 11 to 37 minutes | Range: 19 to 79 minutes |
| August | Range: 4 to 120 minutes | Range: 13 to 29 minutes | Range: 23 to 133 minutes |
PICOT Question
A PICOT question was formulated to guide the literature review search. PICOT is an abbreviation for the Population affected, Intervention being studied, Comparison group, Outcome evaluated, Time frame (Polit & Beck, 2012). The question was: "What is the best practice for urine specimen collection process in acute care hospitals to decrease incidence of contaminated urine culture results?"Following development of the PICOT question, the clinical nurse specialist (CNS) and director of microbiology reviewed the research literature and practice guidelines related to urine specimen collection. The Institute of Medicine (IOM) (2000) recommended implementation of best practices at the bedside and use of a multidisciplinary team to help ensure patient safety.
Literature Review
The purpose of the literature review was to research best practices for obtaining and processing urine specimens. The literature review is organized under three headings: pathology, asymptomatic versus symptomatic infections, and specimen collection processes.Pathology. Wilson (2008) describes the female and male urethra and presence of normal flora found. A normal female urethra is 3.8 cm in length. It is colonized with 2 to 11 different organisms, with the total population between 105 and 106 viable microbes. Examples of urethral bacteria include lactobacilli (protective), coagulase-negative Staphylococcus, diptheroids, anaerobes, and mycoplasma. Age and sexual maturity result in changes in bacteria present; older age groups have greater numbers and greater variety of organisms present, including gram-negative rods. Treatment with antibiotics can result in colonization with gram-negative rods, such as Escherichia coli, Klebsiella species, and Proteus mirabilis.
The normal male urethra is 20 cm in length; the first 6 cm is colonized with bacteria, which may account for fewer urinary tract infections in males. Types of bacteria vary with age and sexual activity just as in females. Sexual activity results in a greater number and diversity of bacteria ( Gardnerella vaginalis, gram-negative rods, anaerobes, Group B streptococcus, and yeast).
Asymptomatic vs. Symptomatic Infections. Diagnostic criteria for a UTI from both the clinical and epidemiologic perspective can be likened to a moving target. It is not within the scope of this article to provide an exhaustive list of all the criteria and definitions for UTIs. Mul ti ple guidelines are available, all of which vary slightly in their definitions because they were published at different times by different au thors and organizations (such as the Infection Diseases Society of America [IDSA], Centers for Disease Control and Prevention [CDC] National Healthcare Safety Network [NHSN], Ferr [2010], and the Association for Professionals in Infection Control and Epi demiology [APIC]/Society for Healthcare Epidemioloysis of America [SHEA]). The CDC NHSN hosts a Web site ( www.cdc.gov/nhsn/) that provides guidelines on health care-associated infections, including urinary tract infection. These guidelines are periodically updated as new information becomes available. The literature reviewed will be described under additional categories of asymptomatic and symptomatic urinary tract infections.
Asymptomatic Urinary Tract Infection: According to the IDSA (Nicolle et al., 2005) guidelines, asymptomatic bacteriuria is defined as follows:
- In women: two consecutive clean-catch mid-void specimens with same bacteria at greater than or equal 10 5.
- In men: one clean-catch mid-void specimen with single bacteria at greater than or equal to 10 5.
- A single straight catheter specimen with one bacterial species at greater than or equal 10 2.
Symptomatic urinary tract infection: Symptomatic urinary tract infection (SUTI) is defined by clinical symptoms and a positive urine culture that demonstrates colony counts of greater than or equal to 10 3 colony-forming units per milliliter (CFU/ml) (Ferri, 2010). Presenting symptoms can vary from person to person, as can the location or cause of the infection, including cystitis, pyelonephritis, or CAUTI (see ).
Table 2. Location and Presenting Symptoms of Symptomatic Urinary Tract Infection
| Acute uncomplicated cystitis (symptomatic bladder infection in a normal genitourinary tract) | Urinary frequency, urgency Dysuria Urge incontinence Suprapubic pain Gross or microscopic hematuria |
| Acute pyelonephritis | Flank or abdominal pain Chills Malaise Vomiting Diarrhea |
| Catheter-associated urinary tract infection (CAUTI) | New onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause Flank pain Costovertebral angle tenderness Acute hematuria Pelvic discomfort Dysuria, urgent or frequent urination, and/or suprabuic pain and tenderness if urinary catheter has been removed |
- Criteria 1 – Patient had an indwelling urinary catheter in place at the time of specimen collection or removed within the 48 hours prior to specimen collection and at least one of the following signs or symptoms with no other recognized cause: fever greater than 38 degrees Celsius, suprapubic tenderness, or costovertebral angle pain or tenderness and a positive urine culture of greater than or equal to 10 5 CFU/mL with no more than 2 species of microorganisms.
- Criteria 2 – Same as Criteria 1, with the addition of a positive urinalysis demonstrated by at least one of the following findings: positive dipstick for leukocyte esterase and/or nitrite, pyuria, urine specimen with greater than or equal to 10 white blood cells (WBCs)/mm 3 or greater than or equal to 3 WBC/high power field of unspun urine, microorganisms seen on gram stain of unspun urine.
Clean-catch mid-stream: The purpose of collecting mid-stream specimens is to avoid collection of bacteria from the urethra, vaginal, and perineal areas that are colonized with gastrointestinal flora. Wilson (2005) identified numerous microbes lining the urethra that are shed during urination. Viable bacteria per ml found in this initial stream range from 0 to 10 5 CFU in patients without a urinary tract infection (Wilson, 2005). See Figures 1 and 2 for specific instructions on collection steps.
Figure 1.
Male Instructions on How to Obtain a Clean Catch Urine Specimen
Source: Adapted from South Central Association for Clinical Microbiology (n.d.). Used with permission from Nebraska Methodist Hospital, Omaha, NE.
Figure 2.
Female Instructions on How to Obtain a Clean Catch Urine Specimen
Source: Adapted from South Central Association for Clinical Microbiology (n.d.). Used with permission from Nebraska Methodist Hospital, Omaha, NE.
Chronic Indwelling Catheter: Formation of biofilm is addressed by several authors (Hooton et al., 2010; Smith et al., 2008; Trautner & Darouiche, 2004). Biofilm build up occurs along the inner and outer walls of urinary catheters from urethral organisms. Chronic catheter placement results in 100% colonization of the urine by bacteria due to biofilm development.
Bacterial colonization of a urethral catheter can begin within a few days of catheter insertion. Encrustation from proteins, electrolytes, and other organic molecules build along the catheter walls. Antibiotics do not frequently clear resistant bacteria in biofilms from catheter surfaces (Trautner & Darouiche, 2004). According to Hooten et al. (2010), if a chronic indwelling catheter has been in place for more than two weeks, the catheter should be changed prior to obtaining a urine specimen for culture if a UTI is suspected.This practice has been associated with improved resolution of UTI, as well as accurate urine culture results.
Specimen Labeling. The College of American Pathologists (CAP) (2013), Centers for Medicare and Medicaid Services (CMS) (2003), and Miller (1999) specify that the following elements must accompany a urine specimen to the laboratory: patient's first and last name, hospital identification number, specific culture source site, and date and time of collection.
Specimen Transport: Escherichia coli can have a doubling time as short as 20 minutes when urine is kept at room temperature (Lewin, Krebs, Goldstein, & Kilpatrick, 2011). Within two hours, one E. coli per mL will replicate to the quantity of 105 E.coli per mL. Urine specimens should be kept cold to prevent growth, and thus, prevent falsepositive results due to low levels of bacterial contamination when present, and should be sent to the laboratory as soon as possible (CAP, 2008; McCarter et al., 2009; Miller, 1999).
Summary of the Literature Review. After the literature re view was completed, the following conclusions were used as the basis for practice changes: urine specimens should be collected via mid- or late-stream; all specimens should be labeled with the patient's first and last name, hospital identification number, specific culture site, date and time of collection. Urine specimens should be kept cold to prevent bacterial replication, and thus, prevent false-positive results due to contamination, and should be sent to the laboratory as soon as possible (Bekeris, Jones, Walsh, & Wagar, 2008; CMS, 2003). Findings were shared with the multidisciplinary microbiology PI subcommittee, and action plans were developed to implement best practices to minimize re porting of inaccurate urine results.
Practice Changes Based On Best Evidence
Clean-catch Mid-stream. Standardized steps to obtain midstream voided urine specimen in outpatient and inpatient areas were developed collaboratively by the CNS and the director of clinical microbiology. Rationale on the importance of collecting the specimen correctly was provided to patients on the new collection instructions: "Important: It is important to follow the instructions below exactly, to properly clean the bacteria from the skin and urinary opening. A dirty specimen may result in the need for a second test, or worse yet, may be the cause of a wrong diagnosis, unnecessary medicine, or the wrong medicine being given to you." Changes to the hospital's nursing service policy were implemented to reflect evidence-based recommendations. Nursing staff were educated through e-mails and fliers posted on each inpatient unit and in the ED. E-mails and updated instructions were sent to outpatient clinics.Straight-catheterization Collection. Quick-cath kits were removed from the central supply department and nursing units, and replaced with straight catheterization kits to collect mid- to late-stream urine specimens rather than early stream specimens. The hospital's nursing service policy for urine collection via straight catheterization was revised. Practice changes were reviewed at the Nursing Practice Council.
Chronic Indwelling Urinary Catheter. The director of microbiology and the hospital patient safety department facilitated discussions with physicians. Physicians expressed concern regarding making a blanket statement to change all chronic indwelling catheters prior to collecting a urine culture without the clinician having the final say. The potential inability of nurses to reinsert an indwelling catheter was a concern. Physicians unanimously agreed to having chronic catheters changed prior to collecting a urine specimen only with a physician order first. Practice change of contacting the physician to change a chronic in dwelling catheter prior to urine collection was shared with nursing through the Nursing Practice Council, e-mails, and fliers posted on each inpatient unit and in the ED. Additional communication to nursing staff included collaboration with the information technology (IT) department. A reminder was placed on the electronic physician urine collection order and the urine requisition form.
Specimen Labeling. Patient identification labels are affixed to the specimen container and dated. Collaboration with IT facilitated the development of an electronic requisition form and automation of the form's appearance on the nurse's computer when a urine collection order is entered. This electronic requisition form has required elements to mandate compliance with the laboratory's recommendations. Once completed, it prints at the nurse's front desk for the nurse to pick up and send to the laboratory with the specimen. A clinician order triggers an electronic requisition documentation form for the nurse to complete.
To promote compliance, a rejection policy was developed. Any required elements not completed prompt laboratory personnel to reject the specimen and notify nursing that another specimen must be collected. This policy was disseminated widely to nursing staff before implementation. Magnets with "reminders" of the new policy were placed at stations where specimens were sent to the laboratory. E-mails were sent to nursing staff, and fliers explaining the new electronic requisition form were posted on each inpatient unit and in the ED. Content was also shared at the Nursing Practice Council.
Specimen Transport. Urine specimens must be sent to the laboratory within 15 minutes of collection to prevent prolonged time at room temperature. Collaboration with the Pathology and Laboratory Specimen departments helped develop a rejection policy to assist nursing compliance. If the specimen is not received in the laboratory within 15 minutes of documented specimen collection time, laboratory personnel reject the specimen. The same guidelines apply as when the specimen labeling elements are not complete. Fliers were posted on each in-patient unit and emergency department; magnets with this reminder were placed at stations where specimens are sent to the laboratory. In addition, this time requirement was added to the electronic requisition form as another reminder for nursing staff.
Cost Benefits and Outcomes
Data on incidence of urine cultures positive for coagulasenegative Staphylococcus (CoNS) were collected by the pathology department to determine effectiveness of practice changes. Laboratory findings of CoNS in urine decreased by 250 in one year, indicating a reduction of contaminated urine specimens following changes in urine specimen collection practices. The laboratory urine evaluation (urinalysis, culture and sensitivity) costs $141.00 per specimen. This reduction in evaluation of probable contaminated specimens saved $35,250 in laboratory fees in one year. Additionally, at a cost savings of up to $3,000 per patient (depending on medication used), another potential $750,000 per year was saved in antibiotic use.Staff compliance with correct specimen labeling and completion of the requisition form was evaluated by the laboratory personnel. Prior to implementation of changes (March 2008), compliance was only 30%. After the rejection policy was completely in place, compliance increased to 100% (see ).
Table 3. Specimen Labeling Data
| Data Collection Dates | Inpatient Floor Compliance | Outpatient Compliance | Overall Compliance | Inpatient Number of Specimens Rejected |
|---|---|---|---|---|
| Before Practice Change | 55% | 36% | 46% | – |
| After Practice Change. | 100% | 96% | 98% | 1 |
Table 4. Urine Transport Data
| Data Collection Dates | Floor to Laboratory Less Than 15 Minutes (Inpatient Areas Only) | Urine Analysis to Micro Set-Up Less Than 3 Hours (7:00 a.m. to 10:00 p.m., Inpatient Areas Only) |
|---|---|---|
| Before Practice Change | 87% | 84% |
| After Practice Change | 97% | 90% |
Nursing Implications
This performance improvement project supported a multidisciplinary collaboration approach to improve patient outcomes. Staff compliance with practice changes was facilitated with several interventions. Evidence-based practice provided the rationale to support practice change. IT support to hardwire practices provided automation and visual reminders for health care providers. Additionally, consequences for not following recommended practice improved compliance. Providing optimal health care to patients takes a team effort. The purpose of collecting a urine specimen for culture is to detect pathological organisms in a patient suspected of having an infection. The consequence of reporting inaccurate results is costly to the patient and the health care system. Accurate and standardized collection, transportation, and handling of urine specimens are essential to provide the best outcome for all patients.References
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