After implementation of a quality improvement initiative to more effectively screen febrile children for urinary tract infections (UTIs) in the emergency department, catheterization rates dropped from 63% to 30% over a 6-month period, a study found.
The sustained drop prevented more than 350 young children from catheterization without increasing revisit rates or missing UTIs in the 39% of children who were followed in the care network. This was in a study that compared catheterization rates in 1,520 children aged 6-24 months in the year before the intervention and 828 children in the 6 months during the intervention.
“Although urine catheterization remains the gold standard in diagnosing UTIs, it is an invasive procedure that may be avoided in most patients who are being screened,” wrote Dr. Jane M. Lavelle of Children’s Hospital of Philadelphia (CHOP) and her associates. UTI screening by this method can be “painful, time consuming, and costly,” they added (Pediatrics. 2016 June 2. doi: 10.1542/peds.2015-3023).
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An alternative method to automatic catheterization is a two-step process already included as an option in American Academy of Pediatrics guidelines: Instead of collecting urine through catheterization just once for screening and culture, an emergency department first noninvasively collects urine with a urine bag for screening in those indicated with evidence-based risk factors, and then catheterizes only those who screen positive (Pediatrics. 2011;128[3]:595-610).
“Due to the predictive models’ higher sensitivity than specificity for screening, most urine samples will have a negative screen for pyuria or bacteriuria by urine dipstick or microscopy,” the authors wrote.
At baseline, CHOP’s ED was screening 63% of febrile children under age 24 months using catheterization, but screens were most commonly negative and only 4.3% had positive cultures. The authors therefore initiated a switch to the two-step method as a pilot run in one ED area before educating all ED personnel and expanding to the full department in the second month, using three cycles of Plan-Do-Study-Act protocol.
Children aged 6-24 months comprised approximately 20% of the ED’s more than 90,000 annual patients, and about 22% of these children presented with fever as the primary concern. Children with a history of genitourinary problems or immune deficiency were excluded.
The pilot ran in an “urgent care section of ED where there are typically more children with less complex medical histories and where ‘fever’ is a common complaint,” the investigators said. The staff completed a learning module with assessment and then received in-person and visual reminders of the procedure. Nurse feedback was then used to develop a nursing-specific educational module before expanding the intervention to all ED areas.
While 69% of 828 febrile young children still underwent screening during the 6-month intervention period, only 16% still underwent urethral catheterization as the initial screening step, typically because of strong clinical indications for a UTI. Another 14% underwent catheterization only after a positive urine screen from an initial noninvasive urine collection or because of an inability to get an adequate urine specimen with the bag. The reduction in catheterization dropped to 55% within 2 weeks of the intervention’s start and spread to other hospital departments. The drop to a 30% catheterization rate remained throughout 18 additional months of monitoring.
“Through online education modules, staff meetings, printed and EHR reminders, family involvement, team review of weekly data, individual and group feedback, and nurse scripting, the ED was able to achieve our aim of reducing catheterization rates among febrile young children ages 6-24 months by half over a 6-month period with sustained results,” Dr. Lavelle and her associates reported.
The research did not use external funding, and the researchers reported they had no financial disclosures.