Urine Testing Improvement


The first step in MSU testing is a point-of-care test carried out in the Emergency Department (ED). The results of the point-of-care test guide whether further microbiology cultures are needed. Often patients presenting to ED with UTIs are discharged on empiric antibiotic treatment based on point-of-care test results and may be contacted if a change in antibiotics is required based on microbiology cultures.

From previous work carried out to improve MSU testing we ound that:

  • the indices in the MSU point-of-care testing may be too sensitive or unclear, resulting in inappropriate escalation for a full microbiology cuture
  • false results have occurred due to unclear indices, timing of MSU collection, or contamination of urine sample during collection process by patients resulting in inappropriate treatment
  • there is unnecessary urine testing at both point-of-care and microbiology laboratory

Mid-stream urine (MSU) test is the most frequently requested microbiology test at Waitemata DHB

Results of MSU tests guide the choice of appropriate antibiotic treatment for patients presenting with urinary tract infections (UTIs)

  • Improve and optimise the end-to-end process for patients presenting to ED with Urinary Tract Infections (UTIs)
  • Create a lean process by eliminating the unnecessary MSU testing
  • Improve the quality of mid-stream urine samples to reduce the need for re-testing

The project team mapped the "As is" process for patints presenting to ED with UTIs and identified 5 main work packages. For each work package we identified a working group that could further analyse the package and recommend improvements.

We defined two streams for patients (complex or non-complex) and mapped a new pathway with appropriate testing for each stream. The new pathway is based on:

  • choosing wisely
  • literature reviews
  • collaborative team review 

We reviewed the previous 12 months' worth of data for MSU testing across both North Shore and Waitakere EDs to determine (conservatively) 'Complex' and 'Non-Complex' patients. We then calculated estimated financial benefits form our new UTI process based on:

  1. For 'Complex' patients, treatment based on microbiology lab test - no need for POCT
  2. For 'Non-Complex' patients, treatment based on POCT positive test result - no need for microbiology lab test
  3. Improving the quality of MSU samples - reduce the need for repeat testing

The estimated annual financial benefits are at $246K. Additional soft savings will be achieved from the reduction in clinician time spent on reading unnecessary test results.

  • Confirm and release new version of UTI bundle (including the new pathway)
  • Finalise MSU sample posters layout and translation
  • Roll out the new process
  • Post implementation review and feedback
  • Patient experience survey
  • Urine Testing Process Improvement Project Charter
  • "As is" UTI in ED Process Map with identified work packages
  • New UTI in ED Pathway

Executive Sponsor

  • Matt Rogers, Clinical Director Laboratories

Working Group

  • Dina Emmanuel, i3 Innovation + Improvement Project Manager
  • Imran Giado, ED Clinical Lead

Project Team

  • Sinead O'Malley
  • Stephanie Williams
  • Cecilia Rademeyer, ED Clinician
  • Satra Browne
  • Elizabeth McChlery, Laboraty Quality Advisor
  • Delwyn Armstrong, i3 Head of Analytics
  • Heena Kidiwala
  • Hasan Bhally, Clinical Director, Infectious Diseases
  • Jane Francis
  • Marja Peters, Charge Nurse Manager, Waitakere ED
  • Nick Gow
  • Sue Lamb, Charge Nurse Manager, North Shore ED


Dina Emmanuel

Innovation + Improvement Project Manager

Delwyn Armstrong

Head of Analytics