Decreasing Invasive Urinary Tract Infection Screening in a Paediatric Emergency Department: A Quality Improvement Initiative

Purpose/Objectives: Fever is a common presentation to the Emergency Department (ED) and a urinary tract infection (UTI) often needs to be excluded in young children. Sterile techniques, like catheterization, are invasive, can be traumatizing, and are time-consuming to complete. A two-step approach has been shown to reduce the catheterization rate in febrile, young children without unintended consequences. Our aim was to implement a two-step approach for UTI screening in febrile children 6-24 months to decrease unnecessary urine catheterizations by 50% without impacting ED length of stay (LOS), return visits (RVs).

Design/Methods: We first engaged key stakeholders and created a multidisciplinary project team. Using the model for improvement, we adapted a 2-step pathway for UTI testing in children 6-24 months as our change idea. The pathway involved nursing identification of children who met inclusion criteria for UTI screening, followed by application of a urine bag and urinalysis (UA) if deemed indicated by the physician. If the UA was positive, a second urine sample was collected via catheterization, and a repeat UA and urine culture was performed. Through multiple PDSA cycles, our pathway was implemented in the ED along with concurrent staff education and electronic order modifications. Using statistical process control charts, the outcome measure was the percent of ED urine catheterizations. Process measures included the total number of urine cultures sent to microbiology and percent positivity. The balancing measures included ED LOS and the number of RVs.

Results: Since project initiation in July 2019, the ED catheterization rate decreased from 70% to 46% (FIGURE 1) saving approximately 30 children from invasive catheterization per month. The number of urine cultures sent to microbiology decreased by 30%, with an increased positivity rate by 4%. There was a slight 10-minute increase in ED LOS (FIGURE 2) and RVs, but with further process changes, ED LOS has now returned to baseline.

Conclusion/Discussion: Using improvement methodology, we successfully decreased the number of unnecessary catheterizations and urine cultures sent to microbiology from our ED. We mitigated the initial impact on ED LOS through workflow modifications including optimizing equipment in patient rooms with urine bag kits, poster reminders, re-education for providers, and re-launching a simplified pathway. ED RVs did significantly increase with the COVID-19 pandemic, but was likely due to many factors unrelated to this project, including limited access to community in-person follow-up and increased screening of febrile children for Multi-inflammatory Syndrome in Children (MIS-C). Given the overall project success and cultural change experienced in the ED, this initiative has now spread to the hospital’s paediatric wards, and is adopted as part of the hospital’s Choosing Wisely campaign. This stewardship initiative can easily be spread to other paediatric and community hospitals caring for children.