In this study, we assessed the degree of guideline non-accordant urine dipstick test use and associated factors in NHs, and explored current processes and perceptions regarding urine dipstick test use among nursing staff. We found that the urine dipstick test is still used in two-thirds of UTI suspicions, and that almost half of these urine dipstick tests are not according current guidelines.3 15 In addition, we gained in-depth insight in the work processes, knowledge and perceptions regarding urine dipstick use, and in opportunities to improve guideline-accordant urine dipstick use.
Remarkably, we found that the urine dipstick test was used in a considerable number of suspected UTI cases in which a indwelling urinary catheter was present, while it has been known for decades that biofilm formation along the catheter surface causes bacteriuria, making the urine dipstick test a futile diagnostic tool in these patients17. For residents without an indwelling urinary catheter, we found that mental status change (other than delirium) and renal and urinary tract abnormalities are associated with more guideline non-accordant dipstick test use. It is striking that In line with previous literature, comorbidities such as renal or urinary tract abnormalities make it difficult to recognize UTI-related S&S.18–20 As for mental status change, this is known as an important trigger for UTI suspicion in the older population, irrespective of the presence of UTI-specific S&S. 2122 If a urine dipstick test is subsequently performed en found to be positive, a UTI may be incorrectly diagnosed and the many other possible causes for mental status change may be overlooked (and not addressed). It appears that the paradigm of atypical disease presentation is still present. Finally, having cloudy urine, urine color change, and/or urine odor change are associated with more guideline-accordant use of the urine dipstick test. This result is not in line with previous research observing that nursing staff members associate these symptoms with a UTI, 23 urging them to dipstick use (guideline non-accordant).
Based on the qualitative study findings, improving guideline-accordant urine dipstick test use requires improved work processes, and knowledge and skills among nursing staff members. Clear work processes may contribute to more guideline-accordant urine dipstick test use, for instance with regard to agreements about who takes the initiative to use the test, who is allowed to perform the test, and the accessibility of the test. Knowledge gaps appeared to exist with regard to which S&S are indicative of UTI, the role of the urine dipstick test in UTI diagnosis (i.e., not to confirm, but to rule out), and possible alternatives for performing a urine dipstick test in case of non-UTI related S&S (e.g., ‘watchfull waiting’). Finally, improved skills are needed with regard to the interpretation of urine dipstick test results, mapping UTI-related S&S in NH residents, and dealing with urinalysis requests of residents or their relatives.
From the interviews and focus groups, we can learn conditions for bringing about change towards more guideline-accordant urine dipstick test use. First, given that urine dipstick test use is very much embedded in daily routine practice, sufficient time should be allowed for the change process. Second, clear and repeated communication seems to be crucial: what should be changed? What is the reason hereford? And what is expected from nursing staff? Finally, to facilitate support for change, involvement of nursing teams is considered important in the change process given their central role in UTI diagnosis.2425,26
In addition to the abovementioned conditions, the identified perceptions of nursing staff regarding the urine dipstick test are important to bear in mind and address throughout the change process. Based on our qualitative findings, the urine dipstick test is a tool that brings a sense of ‘control’, and is perceived as ‘easy-accessible’, ‘easy-to-use’ and ‘non-invasive’. In the change process, instead of communicating that ‘something is being taken away’ from the nursing staff, if may therefore be better to focus on ‘something that is changing’ for nursing staff, and thereby to emphasize the important role that nursing staff plays in the recognition of UTI-related S&S. Finally, as nursing staff members appreciate the ‘tangible’ nature of the urine dipstick test, it may be beneficial to look for other ‘tangible’ tools as replacements, such as fluid intake registration lists or a previously developed observation checklist for UTI-related S&S in NH residents with impaired awareness or ability to communicate S&S.27
Strengths & Limitations
A strength of this study is the use of mixed-methods, with qualitative data in-depth complementing the quantitative results. Another strength is the combination of interviews, with nursing staff expressing their personal views, with focus groups, in which there was interaction between the participants.
A limitation of this study is that two focus groups were held, more focus groups might have provided additional information. A second limitation of this study is that in the ANNA study cases were included at the level of a UTI-diagnosis as stated by the physician, and not at the level of a performed urine dipstick test (e.g., a dipstick test may have been performed by nursing staff, but the physician did not register the patient as he/she did not suspect a UTI). This may have led to an underestimation of the percentage guideline-non accordant urine dipstick tests.