Kristina Hammon, Jenna Noland, Amanda Wells, and Jennifer York

1
Best Practice for Urine Collection in Pediatric
Patients

• Kristina Hammon, Jenna Noland, Amanda Wells, and
  Jennifer York

2
Identification of the Problem

• The method of urine collection in pediatric
  patients is important because contamination can
  make the accurate diagnosis of urinary tract
  infection difficult. Improper collection can
  cause misdiagnosis leading to ineffective
  treatment.

3
Identification of Problem

• Population
• Pediatric patients presenting to facility
• Intervention
• Non-invasive urine collection method
• Comparison
• Catheterized urine specimen
• Outcomes
• Low contamination rates, improved parent and
  nurse satisfaction, and accurate diagnosis of UTI
  

4
Evidence-Based Practice Study Question

• Is a urine specimen from a urethral catheter
  compared to a sterile bag equally effective for
  accurate diagnosis of a UTI in a symptomatic
  child less than 5 years?

5
Pros and Cons
6
Pros and Cons
7
Review of Literature

• Urine culture is best practice for diagnosing UTI
• The gold-standard for pediatric urine specimen
  collection is suprapubic needle aspiration.
• The majority of the research concludes urethral
  catheterization has a lower rate of contamination
  than specimens collected by sterile bag method.

8
Review of Literature

• McGillivary, D., Mok, E., Mulrooney, E., Kramer,
  M.S. (2005). A head-to-head comparison
  Clean-void bag versus catheter urinalysis in
  the diagnosis of urinary tract infection in young
  children.
• Journal of Pediatrics
• 303 non-toilet trained children under the age of
  3 in a childrens emergency department
• Compared bag and catheter samples from each child
• Specificity for bag samples 62
• Specificity of catheter samples 97
• Recommends catheterization for every non-toilet
  trained child with symptoms or history of UTI

9
Review of Literature

• Al-Orifi, F., McGillivray, D., Tange, S., Kramer,
  M. S. (2000). Urine culture from bag specimens in
  young children Are the risks too high?Urine
  culture from bag specimens in young children Are
  the risks too high?
• Journal of Pediatrics
• 7,584 children less than age 24 months
• Samples obtained in an emergency center and a
  pediatric test center
• Contamination rate of bag specimen 62.8
• Contamination rate of catheterized specimen9.1
• Recommended catheterized sample be obtained on
  all febrile infants less than 3 months of age and
  older children who are not toilet trained that
  have other factors associated with UTI

10
Review of Literature

• Loane, V. (2005, November). Obtaining urine for
  culture from non-potty trained children.
  Obtaining urine for culture from
  non-potty-trained children.
• Pediatric Nursing
• 44 non-potty trained community based children
• Compared bag, pad, and clean-catch methods of
  urine specimen collection
• States the clean-catch method of collection is
  accurate in diagnosing UTI
• Recommends suprapubic aspiration and urethral
  catheterization as the most reliable specimen
  collection method in infants and children who are
  very ill

11
Expert Recommendations

• Long, E., Vince, J. (2007). Clinical Review
  evidence behind the WHO guidelines hospital care
  for children what are appropriate methods of
  urine collection in UTI?
• World Health Organization
• Clinical review comparing various methods of
  urine collection including catheter and bag
  methods
• States gold-standard is suprapubic needle
  aspiration
• Specificity of catheter obtained specimens 100
• Sensitivity of catheter obtained specimens 95
• False-positive rate of greater than 50 with bag
  collection method
• Recommends suprapubic aspiration and catheterized
  specimens for the accurate diagnosis of UTI in
  infants and children who are unable to void on
  command and do require immediate antibiotic
  treatment

12
Expert Recommendations

• National Guideline Clearinghouse (NGC). (2009,
  Feb). Guideline synthesis diagnosis and
  management of pediatric urinary tract infection
  (UTI).
• Evidence-based care guideline for medical
  management of urinary tract infection in children
  12 years of age or less
• States suprapubic aspiration and urethral
  catheterization are the most sensitive methods of
  urine collection
• The bag collection method has a false-positive
  rate of 85-99
• Recommends suprapubic needle aspiration or
  catheterization for the most accurate sample in
  children where UTI is suspected and the need for
  antibiotic treatment is immediate

13
Expert Recommendations

• American Academy of Pediatrics. (2007, April)
  Urinary Tract Infection.
• Provides criteria and symptoms of UTI in children
• Recommends urethral catheterization for infants
  and children less than 2 years of age who are
  febrile and need immediate antibiotic treatment
• Recommends the bag method of collection be used
  with infants and children who are afebrile and
  asymptomatic, but a catheterized specimen be
  obtained immediately if urinalysis is positive
  for leukocytes or nitrite

14
Recommended Protocol

• Children that require urethral catheterization
  urine specimen include those who are
• Symptomatic for UTI
• History of UTI, renal disease, or renal
  abnormalities
• If immediate treatment is needed
• If bagged specimen is positive for leukocytes
  and/or nitrites

15
Recommended Protocol

• Bagged or clean catch urine specimen is
  appropriate in children who are
• Asymptomatic for UTI
• Low risk for developing UTI

16
Recommended Protocol
17
Recommended Nursing Interventions

• Teach nurses and parents about the importance of
  obtaining an uncontaminated urine specimen.
• Teach proper cleaning technique to nurses and
  parents to avoid contaminated urine specimens.
• Implementing a skills lab for nurses and parents.
  
• Implement a patient follow-up protocol.

18
Evaluation Method

• The evaluation method for the recommended
  protocol is
• Chart Reviews
• Satisfaction surveys of patients and staff
• Direct observation of procedure by quality
  control personnel
• Statistical analysis of contamination rates

19
Suggestions for Further Study

• New Question
• Comparing and contrasting different variables
  among different age groups.
• Variables include age, gender, circumcised or
  uncircumcised, ability to urinate on command,
  cleaning technique used, who obtained the sample
• Other problems needing further study
• Follow up with patient outcomes
• Education on proper procedures
• How to prepare for clean catch, proper cleaning
  techniques for bagged specimen, etc.
• Patient follow-up to check on progress of
  treatment or to see if new symptoms of UTI have
  developed.

20
Conclusion

• What is the best practice for urine collection in
  a pediatric patient?

21
Literature Review

• Al-Orifi, F., McGillivray, D., Tange, S., Kramer,
  M. S. (2000). Urine culture from bag specimens
  in young children Are the risks too high?.
  Journal of Pediatrics, 137 (2), 221-226.
  Retrieved February 21, 2009, from the Ovid
  database.
• Gilljam, B., Svensson, M. (2008). In-Out
  catheterization of young children with suspected
  urinary tract infection a retrospective journal
  study. Pediatric Nursing 34 (3), 241-245.
  Retrieved on March 21, 2009, from the Ovid
  Database.
• Lau, A., Wong, S., Yip, K., Fong, K., Li, S. P.,
  Que, T. (2006). A comparative study on bacterial
  cultures of urine samples obtained by clean void
  technique versus urethral catheterization. Acta
  Paediatrica, 96, 432-436. Retrieved February 21,
  2009, from Ovid database.
• Loane, V. (2005, November). Obtaining urine for
  culture from non-potty trained children.
  Paediatric Nursing, 17 (9), 39-42. Retrieved
  March 21, 2009, from Academic Search Elite
  database.

22
Literature Review

• Long, E., Vince, J. (2007). Clinical Review
  evidence behind the WHO guidelines hospital
  care for children what are appropriate methods
  of urine collection in UTI?. Journal of Tropical
  Pediatrics. Retrieved February 21, 2009, from
  Ovid database.
• McGillivary, D., Mok, E., Mulrooney, E., Kramer,
  M.S. (2005). A head-to-head comparison
  Clean-void bag versus catheter urinalysis in
  the diagnosis of urinary tract infection in
  young children. Journal of Pediatrics 147,
  451- 456. Retrieved February 21, 2009, from Ovid
  database.
• Schroeder, A.R.,Newman, T., Wasserman, R.C.,
  Finch, S.A., Pantell, R.H. (2005). Choice of
  urine collection methods for the diagnosis of
  urinary tract infections in young, febrile
  infants. Arch Pediatr Adolesc Med 159, 915-922.
  Retrieved February 21, 2009, from Ovid Database.
• Vaillancourt, S., McGillivray, D., Zhang, X.,
  Kramer, M. (2007). To clean or not to clean
  effect on contamination rates in midstream urine
  collections in toilet-trained children. Journal
  of the American Academy of Pediatrics 119 (6),
  1288-1293. Retrieved on February 23, 2009, from
  the Ovid Database.

23
Additional References

• National Guideline Clearinghouse (NGC). (2009,
  Feb). Guideline synthesis diagnosis and
  management of pediatric urinary tract infection
  (UTI). Retrieved March 27, 2009, from
  http//www.guideline.gov
• Urinary Tract Infection. (2007, April). Retrieved
  March 29, 2009, from American Academy of
  Pediatricshttp//www.aap.org/publiced/BR_UTI.htm