I have authorised a little flurry of urine cultures recently with ESBL producing organisms. A good proportion of these had no clinical details, and a significant proportion were from Rest Home residents.
It is the lack of clinical information which frustrates me the most..
These urine samples could have been taken for any one of the following reasons:
- a) The nurse at the Rest Home had decided to routinely dipstick the urine of all the residents.
- b) The urine was taken and sent to the lab because there was a “whiff” of urine from the patient.
- c) The patient is known to be MDRO colonised, so another urine was taken to ‘check’ if it is still there.
- d) The patient gets a 6 monthly urine sample sent to the lab because they are known to have a history of recurrent UTIs.
- e) The patient is new to the practice or Rest Home so an initial screening urine was taken off.
- f) The patient had symptoms or signs suggestive of an acute urine infection.
It is dangerous to assume that the majority of urines arriving at your lab (without clinical details) are specifically for reason F.
My bet is that this is not the case…
When we release antibiotic susceptibilities from the laboratory on a urine culture, we are essentially giving the green light for antibiotic use. An ‘endorsement’ of sorts, a licence to treat, regardless of the clinical indication. In essence we are reporting susceptibilities “blind”…
However reason F is the only reason listed above where I would actually want to routinely release susceptibilities. It could easily be argued that for the laboratory to release susceptibilities on an MDRO without there being any clinical details, simply represents poor antibiotic stewardship.
My laboratory has recently made the provision of clinical details mandatory for Infectious serology tests. If no clinical details, then the serum is simply stored until they are provided. Uptake by clinicians has been very good, and there have been virtually no complaints. What is there to complain about? The quality gains that we have made from this have been very significant.
I am now wondering whether a similar model should be applied to urine samples. Obviously specimen integrity (and ease of recollection) should be taken into account, but there are a couple of possible models as follows:
- No clinical details, urine stored for maximum 24 hrs until provided. Otherwise recollect.
- No clinical details, urine processed, but susceptibilities only released on provision of clinical details.
As microbiologists, I don’t think we should be scared of having these kinds of conversations. In fact, I believe we owe it to our patients…
Michael
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True enough Michael! This is exactly what happened in the practice. We always been given blind lab request!
This is exactly the way the microbiology lab should go. In my hospital (Switzerland) tests can be ordered in duplicate within one or two days (because a doctor did not know that the same test was already ordered in the ED) without being cancelled or even questioned by the micro lab). Similarily, just requesting a Tb culture in almost everyone who gets a bronchoscopy without any clear reason is not helpful. Clinicians may even benefit from discussions with the micro team (I am a clinician).
Thanks for your comment Michael. Electronic requesting and gatekeeping will obviously increasingly facilitate this in the future, but there is no reason to wait for it in the meantime.
As well as minimising possibility of duplicate orders, electronic order requests will also facilitate the capture of ‘compulsory’ clinical details – i.e through mandatory text fields, or drop down selections lists.
Thanks for your comment Deborah, can’t wait!
Also if epithelial cells > 50 (or other) specimen is discarded on basis of poor collection technique …
Interestingly, the nursing staff on health care for elderly wards at Northland DHB are not ‘allowed’ to order urinalysis without checking with physician first.
Think this might be my next project Arlo!