Two-Step Process for ED UTI Screening in Febrile Young Children: Reducing Catheterization Rates

Abstract

BACKGROUND AND OBJECTIVES: Urinary tract infection (UTI) screening in febrile young children can be painful and time consuming. We implemented a screening protocol for UTI in a high-volume pediatric emergency department (ED) to reduce urethral catheterization, limiting catheterization to children with positive screens from urine bag specimens. METHODS: This quality-improvement initiative was implemented using 3 Plan-Do-Study-Act cycles, beginning with a small test of the proposed change in 1 ED area. To ensure appropriate patients received timely screening, care teams discussed patient risk factors and created patient-specific, appropriate procedures. The intervention was extended to the entire ED after providing education. Finally, visual cues were added into the electronic health record, and nursing scripts were developed to enlist family participation. A time-series design was used to study the impact of the 6-month intervention by using a p-chart to determine special cause variation. The primary outcome measure for the study was defined as the catheterization rate in febrile children ages 6 to 24 months. RESULTS: The ED reduced catheterization rates among febrile young children from 63% to <30% over a 6-month period with sustained results. More than 350 patients were spared catheterization without prolonging ED length of stay. Additionally, there was no change in the revisit rate or missed UTIs among those followed within the hospital’s network. CONCLUSIONS: A 2-step less-invasive process for screening febrile young children for UTI can be instituted in a high-volume ED without increasing length of stay or missing cases of UTI.

Development and Validation of a Calculator for Estimating the Probability of Urinary Tract Infection in Young Febrile Children

“…A pproximately 7% of children younger than 2 years who present to an emergency department with fever have a urinary tract infection (UTI). 1,2 However, testing for UTI in young children, whether by catheterization or via the 2-step process (testing bag specimens first and limiting catheterization to children with positive results), 3,4 is challenging. Accordingly, clinicians obtain samples only when they judge the probability of UTI to be sufficiently high.…”

A novel screening method for pediatric urinary tract infection using ordinary diapers

“…On the other hand, leukocyte contamination can result in a false-positive result. Although urine bag can be used in certain settings for a first step screen 20 , bagged urine tends to be contaminated with leukocytes from around the perineum as well as from first-pass urine. Diaper urine is less likely to be contaminated by perineal leukocytes because urine is immediately absorbed after urination by the diaper's superabsorbent polymers.…”

Reducing Invasive Care for Low-risk Febrile Infants Through Implementation of a Clinical Pathway

“…Previous studies have also revealed benefit in the use of clinical pathways for the reduction of unnecessary testing or interventions in pediatrics, including reducing broad-spectrum antibiotic use for pneumonia, computed tomography scans for appendicitis and head injury, catheterization to test for UTIs, and decreased use of antibiotics for lowrisk febrile infants. 22,25,[32][33][34] The implementation of the clinical pathway reduced ED LOS for patients who were discharged from the ED. Factors that may have contributed to this include earlier initiation of workup by residents due to comfort with pathways and order sets, reduced time spent on LPs and antibiotic administration, and earlier disposition due to the standardization of risk-stratification and admission criteria.…”