The Effect of Written Posted Instructions on Collection of Clean-Catch Urine Specimens in the Emergency Department

Background

Urinalysis testing is frequently ordered in the emergency department (ED), but contamination of urine specimens limits the interpretation of results. The mid-stream, clean-catch (MSCC) procedure for urine specimen collection is recommended to decrease contamination rates, but without instructions this procedure has poor compliance.

Diagnostic Stewardship Protocol to Reduce Urine Contamination: A Quality Improvement Project

Specimen contamination generates unreliable results, leading to potential misdiagnosis and improper treatments. The purpose of this multidisciplinary continuous quality improvement project was to implement an evidence-based diagnostic stewardship program to reduce urine specimen contamination rates. We conducted educational in-service sessions introducing a 3-step preanalytical protocol within the emergency department. Pre- and postintervention chart review was used to evaluate the impact on urine contamination. Urine culture contamination rates were significantly reduced between the pre- and postintervention phases (χ² = 3.78, P = .05). An evidence-based preanalytical protocol supplemented with an educational intervention reduced the contamination of urine specimens.     

Contamination in Adult Midstream Clean-Catch Urine Cultures in the Emergency Department: A Randomized Controlled Trial

IntroductionA midstream clean-catch urine sample is recommended to obtain a urine culture in symptomatic adults with suspected urinary tract infection. The aim of this randomized controlled trial was to determine whether a novel funnel urine-collection system combined with a silver-colloidal cleaning wipe would decrease mixed flora contamination in midstream clean-catch urine cultures from ambulatory adults in the emergency department.MethodsIn a 2x2 factorial trial, adult participants were randomized to 4 groups: (A) sterile screw-top urine collection container/cup paired with a castile-soap wipe (control group); (B) sterile screw-top urine collection container/cup paired with a colloidal silver-impregnated wipe; (C) sterile urine-collection funnel paired with a castile-soap wipe; (D) sterile urine-collection funnel paired with a colloidal silver-impregnated wipe.ResultsThe trial was stopped after interim analysis, as the contamination rate in the control group (30%) was markedly lower than the historical ED contamination rate (40%) at the study site. From 1,112 urinalysis results, 223 urine culture results were analyzed (190 female patients and 33 male patients). Urine contamination rates were as follows: Group A, n = 67 (29.9% contaminated); Group B, n = 69 (34.8% contaminated); Group C, n = 51 (23.5% contaminated); Group D, n = 36 (22.2% contaminated). The differences in contamination rates were not statistically different among any of the groups.DiscussionThe use of a funnel urine-collection system and silver-impregnated wipe did not reduce urine-culture contamination in adult midstream clean-catch urine cultures in the emergency department.     

Use of a Urine Dipstick and Brief Clinical Questionnaire to Predict an Abnormal Serum Creatinine in the Emergency Department

Objectives:  Prior data demonstrated that a urine dipstick used alone was a sensitive predictor of abnormal creatinine, but not sufficiently enough to forego screening of serum creatinine prior to administration of contrast for diagnostic studies. The authors hypothesized that a brief historical questionnaire coupled with a urine dipstick would have high sensitivity for renal dysfunction, potentially eliminating the need for a serum creatinine prior to contrast administration.
Methods:  This was a prospective study of a convenience sample of patients at two academic tertiary-care emergency departments (EDs) during 2006–2007. Subjects included patients who had both a serum creatinine result reported by the laboratory and a urine dipstick result reported in the medical record. Data included triage vital signs, basic demographic data, 14 medical history items, dipstick urinalysis, and serum creatinine results. The main outcome measure was an abnormal serum creatinine, defined as greater than 1.5 mg/dL.
Results:  Complete data sets were collected on 1,354 patient visits. Of these, there were 161 (12%) with a serum creatinine of >1.5 mg/dL. Logistic regression analysis identified the following independent predictors associated with elevated creatinine: age greater than 60 years, known renal insufficiency, diabetes, hypertension, diuretic use, vomiting, and proteinuria. Nearly all patients with abnormal creatinine (98%) had at least one of these seven predictors. A decision tool combining these predictors would have identified 158 of 161 patients with an abnormal creatinine (sensitivity, 98.1%; 95% confidence interval [CI] = 95.8% to 99.9%) and a specificity of 21.2% (95% CI = 18.8% to 23.2%).
Conclusions:  The absence of six historical factors and absence of proteinuria can be safely used to identify patients who are unlikely to have an abnormal creatinine.     

Ethical Considerations in Urine Drug Testing

ABSTRACT

Recent passage of a House Bill in the state of Washington led to a commentary on whether mandates for urine drug testing of pain patients represented a breach of the Fourth and Fourteenth Amendment rights of patients. Issues over true consent to such tests and potential view of warrantless searches were discussed. The authors address these concerns in a broader context of risk management and stratification efforts, along with discussion about the need for a tailored approach in this arena and consideration of cost burden for such tests. Finally, the argument is made that social justice issues need to be considered (along with issues of autonomy, beneficence, and nonmaleficence).     

Urine Dipstick as a Screening Test for Serum Creatinine Elevation in Emergency Department Patients with Severe Hypertension

OBJECTIVE: Patients presenting to the emergency department (ED) with severe hypertension require assessment for acute end-organ damage. Serum creatinine (SCr) measurement is routinely recommended to detect renal dysfunction. The authors assessed the utility of the urine dipstick test in screening for acute SCr elevation in this population. METHODS: The authors performed a prospective study of adult ED patients with diastolic blood pressures > or = 115 mm Hg that persisted for > or = 30 minutes or necessitated emergent treatment. Excluded were menstruating and pregnant women and patients with urinary infection, trauma, or dialysis dependence. Patients reporting a history of renal disease were excluded if the SCr was abnormal and no baseline value was available. Each subject had an SCr and urine dipstick test. The authors examined the performance of the dipstick in identifying an elevated SCr, defined as SCr > 1.2 mg/dL or > 25% above baseline. RESULTS: Of 143 patients, 42 had SCr > 1.2 mg/dL. Eighteen reported prior renal disease but had an SCr that was normal or < or = 25% above baseline. The remaining 24 subjects comprised the elevated SCr group. The presence of either proteinuria or hematuria on dipstick identified these patients with 100% sensitivity and 29.7% specificity. Specificity rose to 42.4% without loss of sensitivity when an abnormal dipstick was defined as hematuria or > or = 1+ proteinuria. CONCLUSIONS: The urine dipstick may be an effective screening test for SCr elevation in patients with severe hypertension. A restrictive definition of an abnormal dipstick would identify all patients with elevated SCr and substantially reduce the number of SCr assays necessary.     

尿淀粉酶及其与肌酐比值的测定与应用评价

目的测定尿淀粉酶/肌酐比值,并将它与单纯的尿淀粉酶进行比较和评价.方法同时测定正常人尿淀粉酶及尿肌酐,建立尿淀粉酶及其与肌酐比值的参考值范围;将该两项指标同时用于43例拟诊胰腺炎病人的诊断之中,进行比较和评价.结果尿淀粉酶的参考值范围为0～595 U/L(x-±2s),尿淀粉酶/肌酐的参考范围为3.2～57.2 U/rmo1(x-±2 s);尿淀粉酶的灵敏度为55.6%,而尿淀粉酶/肌酐的灵敏度为72.2%,特异性分别为57.1%和85.7%,尿淀粉酶/肌酐有效地降低了假阳性率和假阴性率.结论尿淀粉酶/肌酐可消除诸多因素的影响,优于单一的尿淀粉酶.     

尿淀粉酶/尿肌酐比值在急性胰腺炎诊断中的意义

目的:探讨尿淀粉酶/尿肌酐比值在急性胰腺炎诊断中的意义。方法:对52例急性胰腺炎患者、50例非胰腺炎急腹症患者和50例健康对照人员进行血淀粉酶(Samy)、尿淀粉酶(Uamy)、尿肌酐(Ucr)测定。结果:急性胰腺炎尿液Uamy/Ucr敏感性为92.31%,特异性为92.00%,均高于临床常用的诊断指标Samy和Uamy。结论:尿淀粉酶/尿肌酐比值是较好的早期诊断急性胰腺炎的指标。     

Emergency Provider Attitudes and Barriers to Universal HIV Testing in the Emergency Department

Background: The Centers for Disease Control and Prevention (CDC) recently published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of adults in all health care settings, including the emergency department (ED). Study Objective: The objective of this study was to examine the willingness of ED providers to offer HIV testing, as well as their perceived barriers to implementation of these guidelines. Methods: Before the establishment of a routine HIV testing program in the ED, a 21-item survey was used to assess ED providers' knowledge, attitudes, and perceived challenges to HIV testing. Six months after program initiation, the identical survey was re-administered to determine whether HIV testing program experience altered providers' perceptions. Results: There were 108 of 146 (74%) providers who completed both the pre- and post-implementation surveys. Although the majority of emergency providers at 6 months were supportive of an ED-based HIV testing program (59/108 [55%]), only 38% (41/108) were willing to offer the HIV test most or all of the time. At 6 months, the most frequently cited barriers to offering a test were: inadequate time (67/108 [62%]), inadequate resources (65/108 [60%]), and concerns regarding provision of follow-up care (64/108 [59%]). Conclusions: After the implementation of a large-scale HIV testing program in an ED, the majority of emergency providers were supportive of routine HIV testing. Nevertheless, 6 months after program initiation, providers were still reluctant to offer the test due to persistent barriers. Further studies are needed to identify feasible implementation strategies that minimize barriers to routine HIV testing in the ED.     

A Quantification of the Impact of Awaiting Results of a Urinalysis upon Emergency Department Length of Stay

BackgroundDespite the popular conception that ordering a urinalysis causes a significant increase in emergency department (ED) length of stay (LOS), there is little research on its actual impact.ObjectivesThis study investigated the quantitative impact of obtaining the results of a urinalysis, compared with the quantitative impact of obtaining the results of any laboratory testing of blood (“blood testing”), upon ED LOS in the National Hospital Ambulatory Medical Care Survey–Emergency Department (NHAMCS-ED) dataset.MethodsThe NHAMCS-ED dataset was queried from 2006–2015, comparing LOS in visits where urinalysis was ordered, blood testing was ordered, both were ordered, or neither.ResultsThere were 1,232,279,000 ED visits with LOS data found in the study period. Urinalysis was performed in 24.2% of visits, blood testing in 36.7%, both in 18.2%, and none in 57.4%. Median LOS was 153 min. No blood or urine testing had a median LOS of 109, urinalysis only 161 min, blood testing only 221 min, and both, 250 min.ConclusionUrinalysis does increase LOS, but blood testing increases it more, with additive effects when both are ordered.     

尿甘油三酯测定替代尿乳糜定性试验

目的 探讨尿甘油三酯测定与尿乳糜定性试验的关系,以取而代之。方法 对33例乳糜性尿液同时作尿乳糜定性试验和尿甘油三酯测定。结果 试验组33例乳糜尿乳糜定性试验阳性,甘油三酯含量为3．2—40．4mmo1／L,两者的关系为正相关关系。对照组31份非乳糜性尿液甘油三酯测定不显色。结论 尿甘油三酯测定,可以正确反映轧糜尿中脂肪含量,且简便、快速、灵敏、准确,可以替代尿乳糜定性试验。     

Amphetamine Abuse in Emergency Department Patients Undergoing Psychiatric Evaluation

Background

Amphetamine abuse accounts for numerous Emergency Department (ED) visits and is often associated with psychiatric disease, with many patients requiring involuntary psychiatric hold placement. It is a common practice in EDs to obtain a urine drug screen (UDS) as part of the “medical clearance” process for psychiatric patients. However, the prevalence of amphetamine-positive UDS in ED patients with psychiatric disease is unknown, as is the relationship of the UDS test to the final patient disposition.

Objectives

The objectives of this study were to determine the prevalence of amphetamine-positive UDS in ED patients undergoing psychiatric evaluation, and whether amphetamine-positive UDS is associated with involuntary psychiatric hold placement.

Methods

This was a retrospective study of adult patients seen in a single urban university ED who had a psychiatric evaluation and a UDS over a 1-year period. Eligible patients had results of the UDS, placement of involuntary holds, past psychiatric history, chief complaint, insurance status, and demographic information recorded. Regression analysis was performed, adjusting for the listed covariates, to evaluate the independent association of amphetamine-positive UDS and involuntary psychiatric hold placement.

Results

A total of 1207 patients were included for analysis. Amphetamine-positive UDS were found in 14.8% of patients. Multivariate analysis showed no association of a psychiatric hold due to presence of amphetamines on UDS (adjusted odds ratio [OR] 0.76, 95% confidence interval [CI] 0.55–1.05, p = 0.1). The only significant factor in placement of an involuntary hold was a past psychiatric history (adjusted OR 1.8, 95% CI 1.2–2.7, p = 0.005).

Conclusions

The prevalence of amphetamine-positive UDS was high in the study population; however, there was no independent association of amphetamine-positive UDS with involuntary psychiatric hospitalization.     

尿沉渣倒置显微镜分析系统专用尿沉淀板的选择

目的 对倒置显微镜法检查尿沉渣使用的细胞培养板和酶标板进行比较，以寻找适合作为专用尿沉淀板的容器。方法 采用倒置显微镜法对美国生产的细胞培养板和厦门生产的酶标板进行尿液细胞计数的对比观察。结果 二者在尿沉渣计数结果上无显著性差异(P＞0．05)。结论 孔底直径一致、底面平整且透光性好的细胞培养板和酶标板都可以作为尿沉渣倒置显微镜分析系统的专用尿沉淀板。     

Blood Culture Accuracy: Discards From Central Venous Catheters in Pediatric Oncology Patients in the Emergency Department

Introduction

Lack of specific guidelines regarding collection of blood for culture from central venous catheters (CVCs) has led to inconsistencies in policies among hospitals. Currently, no specific professional or regulatory recommendations exist in relation to using, reinfusing, or discarding blood drawn from CVCs before drawing blood for a culture. Repeated wasting of blood may harm immunocompromised pediatric oncology patients. The purpose of this comparative study was to determine whether differences exist between blood cultures obtained from the first 5 mL of blood drawn from a CVC line when compared with the second 5 mL drawn.

Methods

During 2009-2011, 62 pediatric oncology patients with CVCs and orders for blood cultures to determine potential sepsis were enrolled during ED visits. Trained study nurses aseptically drew blood and injected the normally discarded first 5 mL and the second specimen (usual care) into separate culture bottles. Specimens were processed in the microbiology laboratory per hospital policy.

Results

Positive cultures were evaluated to assess agreement between specimen results and to determine that the identified pathogen was not a contaminant. Out of 186 blood culture pairs, 4.8% demonstrated positive results. In all positive-positive matches, the normal discard specimen contained the same organism as the usual care specimen. In 4 matches, the normally discarded specimen demonstrated notably earlier time to positivity (4 to 31 hours) compared with the usual care specimen, which resulted in earlier initiation of definitive antibiotics.

Discussion

These findings support the accuracy of the specimen that is normally discarded and suggest the need to reconsider its use for blood culture testing.     

Partial Hydatidiform Mole With False-Negative Urine Human Chorionic Gonadatropin Test in the Emergency Department

Background

Hydatidiform mole (molar pregnancy) is a benign tumor of placental trophoblastic cells, which release human chorionic gonadotropin (hCG). Several case reports have described complete hydatidiform moles with false-negative urine qualitative hCG tests. These negative pregnancy tests have been attributed to the hook effect. We report an unusual presentation of a partial mole and review an alternative explanation for the negative hCG test. As partial moles are usually not associated with a large proliferation of trophoblastic cells, levels of hCG are commonly < 100,000 mIU/mL. The most common presentation of a hydatidiform mole is vaginal bleeding. Hydatidiform mole is associated with a risk of malignant transformation and disseminated disease.

Objective

In a pregnant patient, vaginal bleeding and abdominal pain are common presentations. Molar pregnancy is an uncommon cause of abdominal pain and vaginal bleeding that should be considered.

Case Report

A 47-year-old female presented to the emergency department with abdominal pain and vaginal bleeding. Urine qualitative hCG was negative and serum quantitative hCG was 1,094,950 mIU/mL. Pelvic ultrasonography showed a uterine cavity containing a soft-tissue mass with multiple cystic lesions and the hydatidiform mole was extracted with suction curettage. Tissue pathology confirmed partial hydatidiform mole.

Conclusions

In addition to the hook effect, we present another possible explanation for the false-negative test; namely the inability of some assays to detect hCG-degradation products, which may be higher in clinical samples from patients with hydatidiform mole. This case underscores the importance of knowing the limitations of the commonly used hCG assays.     

Evaluation of a Bedside Whole-blood Rapid Troponin T Assay in the Emergency Department

Objective : To evaluate the performance of a new bedside whole-blood rapid assay for cardiac troponin T (cTnT) in patients presenting to the ED with symptoms consistent with acute coronary ischemia. Methods : A prospective, observational trial was performed in 8 participating medical centers. Serial blood samples were obtained on presentation to the ED and 3 and 6 hours later. The cTnT whole-blood rapid assays were performed immediately at the site. Treating physicians and patients were blinded to the results of the rapid assays. Serum samples were analyzed at the core laboratory for serum cTnT, creatine kinase (CK)-MB, and myoglobin. The sensitivity of the rapid assay for detecting acute myocardial infarction (AMI) was compared with the sensitivities of serum cTnT, CK-MB, and myoglobin assays. Results : Of 721 patients, 102 were diagnosed as having AMI. The median elapsed time from symptom onset to ED arrival was 3 hours. The sensitivities of the rapid assay for detecting AMI were 19.6%, 59.0%, and 69.7% at 0, 3, and 6 hours, respectively. The sensitivities of the serum cTnT assay (p-values for comparison with the rapid assay for cTnT) were 25.0% (p = 0.18), 69.6% (p = 0.04), and 79.8% (p = 0.02) at 0, 3, and 6 hours, respectively. The CK-MB and myoglobin sensitivities were 21.9%, 64.5%, and 81.0%; and 43.8%, 77.4%, and 71.4%, respectively. There were 7 patients with AMI who had negative rapid assay readings and positive serum cTnT levels; 4 of these patients were enrolled at the same site. Twenty patients not diagnosed as having AMI had at least one positive rapid assay. Fourteen of these 20 patients had a diagnosis of clinically relevant cardiac disease. Conclusions : The sensitivity of this whole-blood rapid cTnT assay for detecting AMI is comparable to that of current serum assays and offers the advantage of providing rapid bedside results. Discrepancies between serum and whole-blood assays for cTnT noted in this study may indicate the need for further education for the test reader prior to patient use.     

随机尿、晨尿与24 h尿生化指标的相关性分析

目的:研究分别用肌酐和渗透压校正随机尿、晨尿中的常规生化指标与24 h尿中对应指标含量的相关性。方法:收集患者同一天内的24 h尿、晨尿和随机尿,分别测定三种不同类型尿液中的蛋白、电解质(钾、钠、氯)、和尿酸UA的含量,其中晨尿和随机尿的结果分别以肌酐比值和渗透压比值表示,用SPSS11.5软件进行数据处理和秩相关分析。结果:随机尿、晨尿尿蛋白/尿肌酐比值和尿蛋白/尿渗透压比值与24 h尿蛋白定量结果相关性良好(P<0.05),相关系数约为0.8;随机尿、晨尿尿电解质/尿肌酐比值和尿电解质/尿渗透压比值与24 h尿电解质的相关性较差;随机尿、晨尿尿酸校正后没有相关性。结论:晨尿和随机尿尿蛋白/尿肌酐比值代替24 h尿蛋白的测定有标本收集方便易行的优势;用肌酐校正随机尿、晨尿尿电解质的临床评价有待进一步的研究;尿酸的测定仍须采用24 h尿标本。而晨尿、随机尿用渗透压做校正效果与肌酐校正一致。     

UF-100全自动尿沉渣分析仪测定不同时段尿沉渣

目的　探讨同一患者不同时段尿沉渣分析变化及其临床意义。方法　用流式ＵＦ １００ 全自动尿沉渣分析仪测定８７ 例在本院住院的经尿干化学法测定尿红细胞、尿白细胞及尿蛋白阳性病人和２５ 例对照组健康人尿液三个时段,即晨尿、随意尿和餐后尿作尿沉渣定量分析。结果　尿红细胞、尿白细胞浓度依大小分别为晨尿＞ 餐后尿＞ 随意尿;尿白细胞各时段间比较均有显著差异（ Ｐ＜ ０ ．０１） 。尿红细胞：晨尿与随意尿、餐后尿与随意尿间均有显著差异（ Ｐ＜ ０ ．０１） 。晨尿和餐后尿尚未发现有显著区别（ Ｐ＞ ０ ．０５） 。结论　同一患者不同时段尿沉渣结果有差异,测定时应采用同一时段尿进行比较以保证结果准确性。