Reduce contamination rates, improve diagnosis and reduce infection

In my line of business, it’s hard to underestimate the importance of urine in the diagnosis and treatment of a myriad of urological problems. Historically, specimen contamination is a major issue that can delay diagnosis and treatment.

Last month NHS Improvement issued a report citing urinary tract infection as a source of 50% of gram-negative blood infections; these can lead to sepsis.

The average national contamination rate runs to around 22.5% and recently I have heard that, depending on where you are in the UK, it can be anything between 0.3% and over 70%. This must surely be down to the variety of collection methods?

Midstream is the preferred choice of sample. We give the patient a pot, tell them to start to pee, place the pot under the middle part of their urine stream, fill it and finish into the toilet. Not straightforward, not easy and often messy.

What this also means is an embarrassed, slightly damp patient and a container of urine with a damp label, which the patient has tried to dry and is difficult to write on! It’s unhygienic for all involved.

We don't always get a midstream and what we do get is often contaminated. Patients will usually just pee whatever they can into the pot, including the first flow. It happens much of the time and a key reason why the contamination rate is so high.

A few years ago I came across an innovative alternative MSU collection device – the Peezy Midstream - designed by an NHS GP Dr Vincent Forte.

It struck me as being an ingenious way of getting a MSU without getting urine all over the place and without patients having to worry whether they are at the beginning of the stream, the middle or the end.

I decided to run a Quality Improvement Audit at the Royal London Hospital (Barts) to see if we could improve how urine samples being checked for infection were collected and whether the analysis results were better.  We looked for three things:

• would we get a proper MSU for analysis?
• would it be easier to collect the sample, especially for women?
• would it be cleaner - and drier?

Up until this point, our contamination rate had reached 17.5% - below average but still in my opinion too high. The microbiology report would come back saying “scanty growth” or “mixed growth” and so on, whereas you want it to say either no growth or that there is growth of a particular organism, which is often E. coli (also responsible for aforementioned blood infections).

We looked to see if using this device we could reduce contamination, get a better representation of was happening within the bladder and whether an infection was present.

We have taken and analysed 66 urine samples and found contamination significantly reduced to 1.5% - that’s a massive difference to the historic 17.5% and means that the NHS’s Getting It Right First Time ethos can be met.

Certainly, it would appear that Peezy delivers a better quality of urine sample which leads to better diagnosis and in turn, the right prescribed treatment for the problem.

Feedback from our patients was mainly positive.  Some found it fiddly, but most said it was easy to use and were appreciative with the cleanliness aspect – dry hands and dry containers all round. Their experiences are borne out by a recent usability study by the National Institute for Health Research, where 70% of users would prefer to use it in future.

I sometimes wonder what the future holds for urine sample collection in general.  There is a clear protocol for the blood specimen collection and many tissue samples but more needs to be done around urine and one would like to think a Gold Standard could be introduced.

Using a device like Peezy Midstream would make a positive difference. Not only would I and my colleagues be able to provide right-first-time diagnosis and treatment but patients would receive the quality of service that they should expect from the NHS. And not come back for second and third tests, which costs us too.

Adoption of new processes in the NHS is challenging and, of course, there is an up-front investment in return for later savings. However, I believe though that in cases such as this, the argument of the cost of the device against better and more accurate diagnosis and treatment is worth it and, in due time, would be cost-effective.

At a recent conference, one of the speakers said it takes on average around 17 years for an innovation to progress from conception to adoption.

In this case, I hope we will move faster.   A better process enabling right-first-time diagnosis and treatment plus costly financial savings can only be to the benefit of all.

Prof. Frank Chinegwundoh MBE Consultant urological surgeon [email protected].          will be presenting at the Forte Medical Forum on 26th September 2017 as part of Urology Awareness Month.

Tickets are free and can be booked via Eventbrite - https://www.eventbrite.com/e/urine-trouble-why-a-diagnostic-standard-is-overdue-tickets-36605546174