Opportunity
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
- 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:
- For 'Complex' patients, treatment based on microbiology lab test - no need for POCT
- For 'Non-Complex' patients, treatment based on POCT positive test result - no need for microbiology lab test
- 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