Impact of Urinalysis on Medical Decision-making and Length of Stay

Abstract

IntroductionThe emergency department (ED) is under pressure to meet length of stay (LOS) metrics for care in the ED. An aspect that we propose affects LOS is the order for urine sample collection and subsequent urinalysis (UA) as both are time consuming steps. This project’s primary goals are to determine if ordering a UA increases LOS and how often UA contributes to clinical decision-making and/or disposition decisions in the ED. Secondary objectives were to identify factors that contribute to the ordering of a UA and to decipher if LOS was more impacted in patients who were discharged vs. admitted to the hospital.MethodsRetrospective chart review was conducted of patients who presented to our ED in April 2016 during 12 consecutive days. Data were abstracted onto a data collection sheet with the abstractor blinded to study hypotheses. Variables included whether a UA was ordered, times of UA order and result, who ordered the UA (mid-level provider [MLP] vs. physician), whether the UA was cancelled, whether the UA result influenced clinical decision-making (based on the medical decision-making section of the physician chart) or disposition decision, LOS, age, and gender. Descriptive statistics and multivariable regression analysis were used to analyze relationships between the variables collected and their influence on LOS.ResultsThe overall median LOS was 157 minutes, with an interquartile range (IQR) of 81 to 246 minutes. For discharged patients, it was 142 minutes, with an IQR of 46 to 236 minutes. For admitted patients, it was 177 minutes, with an IQR of 118 to 260 minutes. Amongst admitted patients, multivariable regression analysis demonstrated that the following factor was associated with increased LOS: being seen first by the provider-in-triage (PIT) then physician in main ED (p < 0.0001). Amongst discharged patients, multivariable regression analysis demonstrated that the following factors were associated with increased LOS: being seen first by the PIT then physician in main ED (p = 0.0296), being seen by MLP only (p < 0.0001), having a UA ordered (p = 0.0005), being seen on weekend (p = 0.0166), and being an older patient (p = 0.0475). The UA was cancelled in 9% of our patients, and in 60% of cases, these UAs were ordered by the PIT. Patient disposition decision was made prior to UA resulting in 60 cases (25%). The UA was used in clinical decision-making in 118 cases (66%). The following predictor factors were associated via univariate analysis with using a UA for decision-making: being female (p = 0.0050, 95% CI: 0.0068–0.378), being an older patient (p < 0.0001, 95% CI: -0.010 to -0.004), being first seen by the PIT and then a physician (p = 0.0486, 95% CI: 0.0048–0.1555), and discharged patients (p < 0.0001, 95% CI: -0.6749 to -0.4487).ConclusionOur results suggest that having a UA ordered increased ED LOS, especially in patients who are ultimately discharged. In our ED, routine UAs are ordered more often by MLPs than physicians. A routine UA may not impact clinical decision-making up to 33% of the ti...

Quality Improvement Interventions and Implementation Strategies for Urine Culture Stewardship in the Acute Care Setting: Advances and Challenges

“…While diagnostic stewardship interventions generally result in a reduction in the number of urine cultures ordered, their impact on appropriate antimicrobial use or clinician's response to an abnormal urinalysis is not clear [74]. Abnormal urinalysis parameters in patients without urinary symptoms are a powerful stimulus to start antibiotic treatment, thwarting diagnostic and antibiotic stewardship interventions [75,76]. The level of pyuria on urinalysis correlates with increasing use of urine cultures and inappropriate antimicrobial prescribing [74].…”

“…The level of pyuria on urinalysis correlates with increasing use of urine cultures and inappropriate antimicrobial prescribing [74]. Routine urinalysis screening is a surprisingly common practice, used in about 25% of emergency department visits, but does not directly impact decisions of care and delays the final disposition in most patients [75,77]. Similar misuse of urinalysis is associated with reflex urine cultures.…”

Why Are We Frequently Ordering Urinalyses in Patients without Symptoms of Urinary Tract Infections in the Emergency Department?

“…Nurses possibly felt as though they ordered more routine urine tests than physicians due to following the local operational protocols that were mainly developed by physicians [ 17 ]. In addition, the results of a recently performed study showed that urinalyses were more likely to be ordered by mid-level providers (e.g., nurse practitioners or physician assistants) than physicians [ 2 ]. Further, we hypothesized that fewer physicians than nurses agreed that routine urine tests should be reduced because this would obstruct the fast work process and prolong a patient’s length of stay in a crowded ED [ 19 ].…”

“…Urine tests, such as urinalyses and urine cultures, are frequently ordered in the emergency department (ED) [ 1 , 2 ]. A urinalysis is ordered for a variety of indications, for instance, the diagnosis or cause of urinary tract infections (UTIs), kidney failure, or hyperglycemic crisis [ 3 ].…”

Deconstructing the urinalysis: A novel approach to diagnostic and antimicrobial stewardship

“…Routine urinalysis screening is a surprisingly common practice, used in˜25% of emergency department visits, but does not directly impact decisions of care and delays the final disposition in most patients. 44,45 Even though routine urinalysis testing (ie, screening) is presumed to help detect urinary tract malignancy, renal disease, and diabetes, these diseases are rare in young asymptomatic persons, making false-positive and incidental findings more likely. An annual urinalysis is not warranted for screening healthy asymptomatic individuals without major risk factors for bladder cancer (eg, persons with heavy exposure to cigarette smoke and other bladder carcinogens).…”