AbstractBackground

To identify nurses’ knowledge, perception and practice around urinalysis and asymptomatic bacteriuria (ASB) and to determine drivers of inappropriate urinalysis practice in an Australian hospital setting.

Methods

Undertaken in eight geriatric wards over four hospitals, a questionnaire inviting voluntary, anonymous participation tested nursing staff knowledge on urinalysis, recognition of urinary tract infection (UTI) and perception of the utility of urinalysis as a routine test on all ward admissions. A retrospective one-month audit was performed on admissions to a 32-bed geriatric ward.

Results

132 of 220 (60%) distributed surveys were completed. Performing urinalysis on all new admissions was identified as routine practice by 89%, and with indwelling catheter change by 35% of respondents. Over-three-quarters believed that routine urinalysis on admission was useful practice and up to one-third believed urinalysis abnormalities warranted antibiotic prescribing. Dark urine (57.6%), foamy urine (55.3%) and vaginal itch (34.5%) were identified as features suggestive of a UTI. In the ward audit, routine urinalysis on admission accounted for most urinalysis testing (59%, 24/41). Of occasions with clinical prompt, delirium accounted for 60% of urinalysis and urinary symptoms 33% however urine culture was undertaken on 53% of occasions.

Conclusion

There was an overall lack of nursing knowledge regarding ASB, with a high perception that urinalysis abnormalities would be suspicious of a UTI irrespective of clinical findings and that routine urinalysis on ward admission was useful practice. In hospital settings, nursing stewardship can deliver strategies to increase knowledge, motivation and opportunity to improve appropriateness of UTI treatment and recognition of ASB.

IntroductionIt is well recognised that inappropriate practice around urine testing can contribute to overdiagnosis of urinary tract infection (UTI) and overtreatment of asymptomatic bacteriuria (ASB). As well, inappropriate use of antibiotics that can contribute to antimicrobial resistance [[1]Stuart Rhonda L. Kotsanas Despina Webb Brooke Vandergraaf Susan Gillespie Elizabeth E. Hogg Geoffrey G. et al.Prevalence of antimicrobial-resistant organisms in residential aged care facilities.,[2]Eleni Flokas Myrto Alevizakos Michail Shehadeh Fadi Andreatos Nikolaos Mylonakis Eleftherios Extended-spectrum β-lactamase-producing Enterobacteriaceae colonisation in long-term care facilities: a systematic review and meta-analysis.].In hospital settings, there are widely endorsed guidelines largely focussing on urine culture stewardship [[3]Centers for Disease Control and Prevention
Healthcare-associated infections: urine culture stewardship.,[4]Australian commission on safety and quality in health care. Antimicrobial stewardship in Australian healthcare.] where multifaceted recommendations are made to ensure that urine cultures are performed only when appropriate indications are present in order to determine if treatment with antibiotics is indicated and formalised processes in place to ensure appropriate clinical specimen collection and testing, to ensure the accuracy and quality of diagnostic testing, and timely reporting with comments that assist in interpretation. Guidelines discourage the collection of urine cultures as screening for ASB in most patient groups [3Centers for Disease Control and Prevention
Healthcare-associated infections: urine culture stewardship., 4Australian commission on safety and quality in health care. Antimicrobial stewardship in Australian healthcare., 5Therapeutic guidelines: antibiotics. Urinary tract infections., 6RACGP aged care clinical guide (Silver Book) 5th edition. Part A. Infection and Sepsis.]; recognising that urine is not intrinsically sterile and the prevalence of ASB in the healthy population ranges from 1% to 15% [[7]Trautner Barabara Grigoryan Larissa Approach to a positive urine culture in a patient without urinary symptoms.].

At our health service, we identified that nurse-initiated urinalysis on admission was common practice on many wards and a long-standing practice; with nursing staff pivotal to identifying suspected UTI and alerting medical staff to symptoms that influenced prescribing decisions. The objective of this study was to identify knowledge, perception and practice around urinalysis and ASB and to determine drivers of inappropriate urinalysis practice in an Australian hospital setting by undertaking a survey of nursing staff and a ward audit.

MethodsStudy setting: This was a multi-site study was conducted in a Victorian health service with subacute wards over five hospital sites and consisted of a nurse questionnaire at four hospitals (eight wards) and a ward-based audit at one hospital. Continuity of care in our sub-acute setting is provided by nursing and medical staff with on-site pharmacy services during working hours.

Design: A paper questionnaire was distributed to nursing staff at clinical team meetings on eight geriatric (subacute) wards in February 2019. It invited voluntary anonymous participation, with a verbal reminder by the clinical team leader (usually nurse unit manager) at a similar meeting two weeks later.

Participants: Nurse unit managers of each ward were invited to provide baseline information on number of different staff rostered to undertake shifts on the week of questionnaire distribution to establish participants invited. All staff working shifts over the period of questionnaire distribution were eligible to participate.

Data tool and collection: The questionnaire was developed following a literature review to identify common themes for inappropriate practice around urine testing and built on a previous survey by Midthun and colleagues [[8]Midthun Susan Paur Ruth Bruce Wayne Peter Midthun Urinary tract infections in the elderly: a survey of physicians and nurses.]. It was piloted for acceptability at one site. The questionnaire consisted of a demographic section (hospital ward and site they worked at, designation, permanent staff or agency member) and five multiple choice questions where more than one option could be chosen and also invited free text responses for each. The questions tested these dimensions; 1) assessment of knowledge of patient clinical signs and symptoms and settings where they would perform urinalysis 2) confidence in interpretation of urinalysis results 3) symptoms, signs or settings that they believed warranted antibiotic prescribing 4) their perception of the utility of urinalysis as a routine test on all patients on admission.

Design: A retrospective one-month audit was performed on all patients admitted to a 32-bed ward of a subacute facility in August 2018. New admissions were identified by daily list updated by ward clerk. Each patient record was manually reviewed to identify all urinalysis episodes and pathology results for urine culture testing and results.

Participants: All patients admitted to the ward over this period were included. Since the unit of analysis in our study was a single urinalysis episode, repeated urinalysis on a patient were counted as separate events.

Data collection: Data was collected on urinalysis performed, documented indications and outcomes including if urine culture performed and antibiotics prescribed. Testing and prescribing appropriateness were assessed against Therapeutic Guidelines: Antibiotics [[2]Eleni Flokas Myrto Alevizakos Michail Shehadeh Fadi Andreatos Nikolaos Mylonakis Eleftherios Extended-spectrum β-lactamase-producing Enterobacteriaceae colonisation in long-term care facilities: a systematic review and meta-analysis.] and local guidelines.

This study was approved by Eastern Health Human Research Ethics Committee (reference 69/2018).

Results

In total, 132 of 220 distributed surveys were completed, representing a 60% response rate. Responses were received from all eight wards over four hospital sites, with response rates from individual wards ranging from 26% to 100%, median 63%. 59% of responses were from registered nurses, 20% enrolled nurses, 8% nurse unit manager, with 13% unknown.

Performing urinalysis on new admissions to the ward was identified as routine practice by 117 (89%) of respondents, and with indwelling catheter change by 45 (35%) respondents. Nursing staff surveyed were familiar with urinary symptoms that could suggest urinary tract infection such as dysuria (100%), the majority familiar with urgency (75%) and frequency (74%) however just over half were also likely to identify changes in appearance such as dark urine (57.6%) and foamy urine (55.3%) and vaginal itch (34.5%) as also suggestive of a UTI (Table 1). 48.5% would initiate urinalysis testing at request of patient or family.

Table 1Urinalysis triggers for nursing staff on eight hospital wards.

104/132 (78.8%) responded that they were confident in interpreting leukocytes, nitrites and glucose in urinalysis results. 126/132 (95.5%) responded that they felt abnormalities in leukocytes and/or nitrites on urinalysis testing warranted further urine culture testing. Table 2 shows that over half nurses surveyed identified dysuria as an indication warranting antibiotics; however up to one-third also identified that abnormalities identified in urinalysis as also requiring antibiotics. 78% (Table 3) responded that urinalysis as routine practice on all newly admitted patients was useful practice and some recognised that it might influence medical antibiotic prescribing.

Table 2Nursing perception of clinical triggers and settings that warrant antibiotic prescription in eight hospital wards.

Table 3Nursing perception of clinical utility of performing urinalysis routinely on new hospital ward admissions in eight hospital wards.

This one-month audit of a 32-bed subacute ward identified 30 admitted patients and 41 urinalysis episodes undertaken (Fig. 1). All episodes of urinalysis performed without clinical prompt was in the setting of on routine on admission to the ward; on this ward, long-standing accepted practice is for nurse-initiated urinalysis to be undertaken on all new admissions. This represented over half of occasions that urinalysis was performed over this period where 7% of UA testing also resulted in further samples collected for urine culture. Acute symptoms related to cognitive change was the trigger for 60% of urinalysis tests performed with a clinical prompt, urinary symptoms and signs the trigger for 33%. Urine culture was undertaken on 53.3% (8/15) of occasions. Antibiotics were prescribed in 50% of patients who had MSU performed, 42.9% of patients who had no MSU performed. Overall appropriateness of urinalysis testing according to indication was 34.1%; for urine culture testing appropriateness where testing was undertaken was lower than when no testing was undertaken (Table 4).

Figure 1Urinalysis episodes in 30 hospitalised patients on a geriatric ward over one-month, by urine culture testing and antibiotic prescribing outcomes.

Table 4Appropriateness of urine testing in 30 hospitalised patients on a geriatric ward over one-month.

DiscussionOur study demonstrated gaps in nursing knowledge regarding patient clinical signs and symptoms and settings where they would perform urinalysis on suspicion of UTI; with under-interpretation of clinical significance of symptoms such as urgency and frequency and over-interpretation of changes in appearance in urine (e.g. dark or foamy) or vaginal itch. These findings are similar to published work in hospital [[9]Drekonja Dimitri M. Grigoryan Larissa Lichtenberger Paula Graber Christorpher Patel Payal Van John et al.Teamwork and safety climate affect antimicrobial stewardship for asymptomatic bacteriuria.], community [[8]Midthun Susan Paur Ruth Bruce Wayne Peter Midthun Urinary tract infections in the elderly: a survey of physicians and nurses.] and aged care settings [[10]NHS BathNorth East Somerset Clinical Commissioning Group
To Dip or Not to Dip: a patient centred approach to improve the management of UTIs in the Care Home environment.]; where quality improvement activities were specifically developed to improve use of urine testing incorporated educational content targeted at correcting mental cues that drive unnecessary testing of ASB (pyuria, cloudy urine, dark urine).

Nurse respondents were confident in interpretation of leukocytes and nitrite results on urinalysis and over-three-quarters believed that of urinalysis as a routine test on all patients on admission was useful practice; furthermore nearly all responded that urinalysis abnormalities would warrant urine culture testing. Up to one-third believed urinalysis abnormalities warranted antibiotic prescribing.

Our results demonstrated an overall lack of knowledge regarding ASB amongst surveyed staff, where there was a perception that abnormalities on urinalysis would be suspicious of a UTI; irrespective of clinical findings. Previous surveys which examined knowledge and practice gaps in hospital medical and nursing staff [11Lee M.J. Kim M. Kim N.H. Kim C.J. Song K.H. Choe P.G. et al.Why is asymptomatic bacteriuria overtreated?: a tertiary care institutional survey of resident physicians., 12Cheung Anne Karmali Gulzar Noble Sandra Song Howard Antimicrobial stewardship initiative in treatment of urinary tract infections at a rehabilitation and complex continuing care hospital., 13Yin Penny Kiss Alex Leis Jerome A. Urinalysis orders among patients admitted to the general medicine service.] have identified similar findings. A study in hospitalised patients demonstrated that positive urinalysis results from asymptomatic patients significantly increased their probability of receiving additional low-value care, including urine culture and antibiotics for asymptomatic pyuria or bacteriuria [[13]Yin Penny Kiss Alex Leis Jerome A. Urinalysis orders among patients admitted to the general medicine service.]. A systematic review incorporating 30 studies with over 4000 cases examining the management of patients with positive urine cultures [[14]Eleni Flokas Myrto Andreatos Nikolaos Alevizakos Michail Kalbasi Alireza Onur Pelin Mylonakis Eleftherios Inappropriate management of asymptomatic patients with positive urine cultures: a systematic review and meta-analysis.] identified that almost half of the ASB cases were managed inappropriately; with one of the contributors being overinterpretation of urinalysis that places undue emphasis on the presence of pyuria, nitrite positivity, and higher bacterial counts appears to drive inappropriate antimicrobial prescription for ASB.

Respondents included a mix of permanent and temporary staff including registered nurses, enrolled nurses, and nurse unit managers. As this study is limited to four hospitals within a health service, it is difficult to say if the cohort is representative of all Australian ward nurses. However, given the mix of the nurse groups, we expect that the results are applicable to other geriatric wards. As level of nursing work experience was not surveyed, we were unable to assess differences in this variable for knowledge domains and perception of utility of urinalysis as a routine test on admission.

The ward audit showed that the practice of nurse-initiated routine urinalysis on patient admission resulted in unintended outcomes including unnecessary urine culture testing. This practice is recognised to contribute to antibiotic prescribing for ASB [[11]Lee M.J. Kim M. Kim N.H. Kim C.J. Song K.H. Choe P.G. et al.Why is asymptomatic bacteriuria overtreated?: a tertiary care institutional survey of resident physicians.] and should be discouraged. Interestingly, further urine culture testing for clinical triggers such as delirium and urinary symptoms was only undertaken on only half the occasions when warranted suggesting education is also required to encourage urine culture testing to guide diagnosis and further antibiotic decision-making. Promotion of clinical assessment pathways similar to the “UTI in aged-care facility residents” in Therapeutic Guidelines: Antibiotics [[5]Therapeutic guidelines: antibiotics. Urinary tract infections.] and ACSQHC fact sheet on ASB [[15]Australian commission on safety and quality in health care. Fact sheet- asymptomatic bacteriuria.] which can be applicable to older people in all healthcare settings will support education and practice change in addressing these outcomes.The results of our study identified opportunities to Increase nursing engagement on these hospital wards by increasing knowledge diagnosis and management of UTI (including antimicrobial prescribing) and empowering decision-making around when not to perform urinalysis or urine cultures. Some may lack an understanding of antimicrobial stewardship (AMS) activities and antimicrobial resistance reduction strategies or may not view AMS as part of their scope of practice. Nursing staff may also not be aware that they can influence prescribing behaviour; in the comments captured in survey responses on whether routine urinalysis is useful practice, some concerns were raised around potential impact on antibiotic prescribing but nursing respondents felt that the responsibility was up to medical staff to make that decision. It has been suggested that effective resources tailored to practical nursing and midwifery tasks in AMS activities include checklists, clinical pathways and other point-of-care guidance can include a prompt for nurses and midwives to consider the potential for reviewing processes, microbiology results, intravenous-to-oral switching or initiating patient education [[4]Australian commission on safety and quality in health care. Antimicrobial stewardship in Australian healthcare.]. A similar approach successfully employed in UK care home staff in the “To Dip or Not to Dip Project” [[10]NHS BathNorth East Somerset Clinical Commissioning Group
To Dip or Not to Dip: a patient centred approach to improve the management of UTIs in the Care Home environment.] aimed at improving awareness on preventing and diagnosing UTIs in care home staff; components involved delivering an evidence-based algorithm to diagnose UTI, delivered within an educational bundle. We acknowledge the importance of patients and their families in initiatives to reduce the practice of overtesting and overprescribing; our study identified that nearly 50% of nursing respondents would initiate urinalysis testing at the request of patient or family. Jones et al. identified similar findings [[16]Jones Leah Ffion Cooper Emily Joseph Amelia Allison Roslaie Gold Natalie Donald Ian et al.Development of an information leaflet and diagnostic flow chart to improve the management of urinary tract infections in older adults: a qualitative study using the Theoretical Domains Framework.] in a qualitative study of focus groups involving care home staff, residents, relatives, GP staff; where apart from a diagnostic flow chart to support staff, a patient-facing leaflet for patients aged >65 years with consistent messaging was also developed to ensure consistent messaging across the care pathway.

There are limitations of our study; there may have been some misclassification of episodes of urinalysis because of the retrospective part of the study. However, to minimize possible biases incurred from a retrospective review, one doctor (NG) and one ID specialist (LL) participated in the classification. Secondly, our ward audit findings may not be generalisable due to small numbers, single ward to other hospital settings and to other situations such as long-term care facilities. Thirdly, we surveyed only nurses on knowledge and practice regarding urinalysis and not doctors however, we are aware that on the wards that we surveyed, urinalysis on admission and on the basis of clinical concern is commonly nurse-initiated.

Unnecessary urinalysis testing can contribute to overdiagnosis of UTI in patients, potentially leading to increased antimicrobial resistance. Understanding the drivers for urinalysis testing is important when developing antimicrobial stewardship initiatives to improve UTI recognition, testing and management. In hospital settings, nursing stewardship can deliver strategies to optimise appropriateness of UTI treatment and recognition of ASB; delivery requires activities to promote an increase in nursing knowledge, motivation and opportunity in these areas.