Accidental and Unintentional Findings From the Midstream Clean-Catch Urine Contamination Study: Insights From Applying the Behavior Engineering Model

Abstract

Over 2.6 million ED visits across the United States result in a primary diagnosis of urinary tract infection.1Centers for Disease Control and Prevention National Center for Health StatisticsNational hospital ambulatory medical care survey: 2016 emergency department summary tables. emergency department visits 2017.https://www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdfDate accessed: May 12, 2019Google Scholar While much attention has been paid to reducing blood culture contamination rates in the emergency department,2Emergency Nurses Association Clinical Practice Guideline CommitteeClinical practice guideline: Prevention of blood culture contamination.J Emerg Nurs. 2018; 44 (285.e281-285.e224.)https://doi.org/10.1016/j.jen.2018.03.019Google Scholar, 3Bell M. Bogar C. Plante J. Rasmussen K. Winters S. Effectiveness of a novel specimen collection system in reducing blood culture contamination rates.J Emerg Nurs. 2018; 44: 570-575https://doi.org/10.1016/j.jen.2018.03.007Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 4Denno J. Gannon M. Practical steps to lower blood culture contamination rates in the emergency department.J Emerg Nurs. 2013; 39: 459-464https://doi.org/10.1016/j.jen.2012.03.006Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 5Harding A.D. Bollinger S. Reducing blood culture contamination rates in the emergency department.J Emerg Nurs. 2013; 39: e1-e6https://doi.org/10.1016/j.jen.2012.10.009Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 6Marini M.A. Truog A.W. Reducing false-positive peripheral blood cultures in a pediatric emergency department.J Emerg Nurs. 2013; 39: 440-446https://doi.org/10.1016/j.jen.2011.12.017Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 7Moeller D. Eliminating blood culture false positives: Harnessing the power of nursing shared governance.J Emerg Nurs. 2017; 43: 126-132https://doi.org/10.1016/j.jen.2016.07.001Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 8Ramos M. Reducing blood culture contaminations.J Emerg Nurs. 2017; 43: 7https://doi.org/10.1016/j.jen.2016.08.002Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 9Sautter R.L. Multidisciplinary team to achieve low blood culture contamination rates in health care facilities.J Emerg Nurs. 2015; 41: 182-183https://doi.org/10.1016/j.jen.2015.02.009Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar a substantial gap remains in projects aimed at reducing contamination in clean-catch urine specimens obtained in the ED setting. Obtaining an adequate urine culture is clinically important to the care of several vulnerable patient groups, including patients with diabetes or compromised immune responses, those with high risk for subsequent urosepsis, previous antibiotic resistant infections, multiple antibiotic allergies and/or repeated infections, and older adults.10Schuh S.K. Seidenberg R. Arampatzis S. et al.Diagnosis of urinary tract infections by urine flow cytometry: Adjusted cut-off values in different clinical presentations.Disease Markers. 2019; 2019 (5853486-5853486)https://doi.org/10.1155/2019/5853486Google Scholar, 11Toniolo A. Cassani G. Puggioni A. et al.The diabetes pandemic and associated infections: suggestions for clinical microbiology.Rev Med Microbiol. 2019; 30: 1-17https://doi.org/10.1097/MRM.0000000000000155Crossref PubMed Scopus (65) Google Scholar, 12Kalra O.P. Raizada A. Approach to a patient with urosepsis.J Glob Infect Dis. 2009; 1: 57-63https://doi.org/10.4103/0974-777X.52984Crossref PubMed Google Scholar The purpose of this editorial is to 1) recognize a potential accidental and unintentional finding from a study that appears in this issue of the Journal of Emergency Nursing (JEN), titled “Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial,” and 2) briefly apply the Behavior Engineering Model as a tool for questions and insights on human work performance root causes of this accidental and unintentional finding.13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar, 14Chevalier R. Improving workplace performance.Performance Improvement. 2014; 53: 6-19https://doi.org/10.1002/pfi.21410Google Scholar In this issue of JEN, Lough and colleagues13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar conducted a randomized controlled trial to test if a novel funnel urine collection device and silver-colloid cleaning wipe decreased urine culture mixed flora contamination. Clinical scholars often use the PICO mnemonic, for Population, Intervention, Comparison, and Outcome, to review and translate research to practice.16Carman M.J. Wolf L.A. Henderson D. et al.Developing your clinical question: The key to successful research.J Emerg Nurs. 2013; 39: 299-301https://doi.org/10.1016/j.jen.2013.01.011Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar A PICO for the Lough and colleagues’ study is provided here to summarize the intended research question of focus.13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar The population was ambulatory adults who required a midstream clean-catch urine specimen in the emergency department. The interventions were 1) the novel funnel urine collection system and 2) a silver colloidal cleaning wipe. The comparison interventions were 1) the sterile screw-top urine collection and 2) castile-soap cleaning wipe. The study included four groups to pair the two collection systems with the two genital cleaning products. The outcome was mixed flora contamination. The study took place in one emergency department with a pre-study contamination rate of 40%, refractory to quality improvement projects to reduce this high contamination rate. The amount of missing data regarding participants’ race and ethnicity means generalizing the results to other ED sites may be challenging. The study was stopped before all the planned data collection was complete, also known as early termination. One key reason the study was stopped early was because the control group’s specimen contamination rate of 30% was much lower than the site’s pre-study 40% contamination rate. For those who completed the study, groups using the novel device demonstrated no difference in contamination, compared to using the traditional specimen cup. Likewise, there was no difference in contamination between the groups using the castile soap and silver colloid cleaning wipes. The results from the Lough and colleagues13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar study have several important implications for practice, quality improvement, and ongoing research addressing meaningful solutions to midstream clean-catch urine specimen contamination rates. The importance of transparently publishing negative findings is crucial.15Wolf L.A. Giving the complete picture: Why publishing negative results is important.J Emerg Nurs. 2017; 43: 289-290https://doi.org/10.1016/j.jen.2017.03.020Abstract Full Text Full Text PDF Scopus (2) Google Scholar Publishing these statistically nonsignificant findings allows others to avoid using a product that may require more refinement and development, or a product that simply may not work well in the ED setting. Further, the control group's lower contamination rates, compared to the site’s pre-study contamination rate, may be an accidental and unintentional discovery. It is common knowledge that a broad range of life-changing scientific discoveries, including penicillin, the microwave, X-rays, velcro, and Viagra were accidental and unintentional discoveries. Analyzing the possible reasons for the 10% reduction from the pre-study, background contamination rate of 40% at the site to the control group's 30% rate is warranted.13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar Clearly, the control group of the study did not represent the usual care at the study site.13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar Applying the updated Behavior Engineering model, a tool for systematic thinking about human performance in the workplace, provides insights into several potential root causes for the change in urine contamination rates.15Wolf L.A. Giving the complete picture: Why publishing negative results is important.J Emerg Nurs. 2017; 43: 289-290https://doi.org/10.1016/j.jen.2017.03.020Abstract Full Text Full Text PDF Scopus (2) Google Scholar The updated Behavior Engineering Model relays three environmental and three individual factors that affect human performance.15Wolf L.A. Giving the complete picture: Why publishing negative results is important.J Emerg Nurs. 2017; 43: 289-290https://doi.org/10.1016/j.jen.2017.03.020Abstract Full Text Full Text PDF Scopus (2) Google Scholar Environmental factors are 1) information, 2) resources, and 3) incentives. Individual level factors are 1) knowledge/skill, 2) capacity, and 3) motives. The Table summarizes initial analytic questions for the possible causes of the contamination rate reduction. This questioning may provide a useful example to focus future practice, quality improvement, and research interventions. It is important to note that the midstream clean-catch urine contamination rates reflect human performance at multiple levels of an organization, each of which are intricately linked: the patient, nurse, nursing unit, and hospital system (including the analyzing laboratory). Lough and colleagues13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar anticipated that the novel device and wipes could reduce the contamination rate below 20%, which was not achieved. In applying this research to emergency nursing practice, what is a reasonable goal for contamination rates? What are the priority intervention questions, of the analyzed possibilities (Table), for ongoing testing and implementation? In a classic reference, Bekeris and colleagues17Bekeris L.G. Jones B.A. Walsh M.K. Wagar E.A. Urine culture contamination: a College of American Pathologists Q-Probes study of 127 laboratories.Arch Pathol Lab Med. 2008; 132: 913-917https://doi.org/10.1043/1543-2165(2008)132[913:UCCACO]2.0.CO;2PubMed Google Scholar did identify that emergency departments had been able to achieve contamination rates of zero, which is an ideal goal. The poorest performing sites (10th percentile) demonstrated contamination rates of over 40%, for which a zero contamination rate goal might not be realistic. When categorized by 5% increments, the most frequent contamination rate was 5% to 9%, which may represent the most realistic goal for sites with contamination rates currently above this benchmark. In reviewing the practices of over 127 laboratories, the study revealed that the quality of instruction, and particularly written instructions for patients, as well as refrigerating specimens between collection and analysis were associated with lower contamination rates.17Bekeris L.G. Jones B.A. Walsh M.K. Wagar E.A. Urine culture contamination: a College of American Pathologists Q-Probes study of 127 laboratories.Arch Pathol Lab Med. 2008; 132: 913-917https://doi.org/10.1043/1543-2165(2008)132[913:UCCACO]2.0.CO;2PubMed Google Scholar These results provide an important, evidence-based cue for practice, that prioritizing clear and simple written instructions for patients when collecting midstream clean-catch urine samples is indicated in the emergency department setting.TableUpdated Behavior Engineering Model application for possible causes of 10% reduction in urine sample contaminationInformationResourcesIncentivesEnvironmentWas there a change in the emergency nurses’ knowledge about contamination in the samples collected in their patient assignments?Did the procedure to check fidelity to the research protocol increase the feedback and patient performance in using proper technique?Did the educational handouts with simple anatomical drawings alone increase adherence to proper technique?Did the involvement in an externally funded research study provide an incentive for clinical laboratory staff to analyze samples more quickly than usual? For nursing staff to reinforce proper technique with patients? For decreased transport time between patient collection and clinical laboratory?Did the knowledge that the research coordinator would check the fidelity to the research protocol provide an incentive to the patient to adhere to proper procedure?Knowledge/SkillsCapacityMotivesIndividualDid the study personnel have additional knowledge and skills regarding proper technique compared to usual staff?Did the study personnel pragmatically increase staffing and workforce capacity to educate patients on proper technique?Were patients more motivated to use proper technique by participating in a research study, compared to participating in their usual clinical care?Note: Refers to Lough and colleagues.13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar Open table in a new tab Note: Refers to Lough and colleagues.13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar Lough and colleagues13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar provided all of their study groups with clear, one-page educational handouts with simple anatomical drawings on the correct procedure to collect the urine sample. A sample of the handouts is printed at the conclusion of the study in this issue of JEN. Additional examples, from other studies, can be found online (http://luto.co.uk).18LutoMaking health information clear. Case Studies.https://luto.co.uk/wp-content/uploads/2016/10/Peezy_case_study_FINAL.pdfDate accessed: June 6, 2019Google Scholar While there is still uncertainty if this educational handout was the causal factor in reducing the urine specimen contamination rates in the study, the handouts may provide a useful resource to augment current best-practices.13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar, 17Bekeris L.G. Jones B.A. Walsh M.K. Wagar E.A. Urine culture contamination: a College of American Pathologists Q-Probes study of 127 laboratories.Arch Pathol Lab Med. 2008; 132: 913-917https://doi.org/10.1043/1543-2165(2008)132[913:UCCACO]2.0.CO;2PubMed Google Scholar Simple patient handouts may be especially important since teaching is often the first nursing care responsibility to become de-prioritized when time or workload is compressed.19Castner J. Suffoletto H. Emergency department crowding and time at the bedside: A wearable technology feasibility study.J Emerg Nurs. 2018; 44: 624-631.e622https://doi.org/10.1016/j.jen.2018.03.005Abstract Full Text Full Text PDF Scopus (7) Google Scholar While simple, clear, and potentially extremely useful for practice, ongoing improvements to the handouts should be considered.13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar These handouts do not specifically address cleaning the urinary meatus site. Further, the procedure to hold the inner labia to reduce contamination for women is unclear. Likewise, the procedure to retract and clean the foreskin for uncircumcised males might be missed. Using pictorial educational material is useful and important, but addressing cultural taboos and privacy considerations for potentially offensive material and/or same- and opposite-gender communication between nurses and patients may be controversial, and require further considerations.20Abdulghani H.M. Haque S. Irshad M. Al-Zahrani N. Al-Bedaie E. Al-Fahad L. Al-Eid M. Al-Mohaimeed A. Students’ perception and experience of intimate area examination and sexual history taking during undergraduate clinical skills training: A study from two Saudi medical colleges.Medicine. 2016; 95 (https://doi.org/10.1097/MD.0000000000004400): 30Google Scholar Nurses, as the end clinical users, must be empowered and engaged in device-purchasing decisions in the emergency department. Nurse involvement in inventing, testing, and purchasing devices is essential to define efficient and cost-effective care processes.21Castner J. Sullivan S.S. Titus A.H. Klingman K.J. Strengthening the role of nurses in medical device development.J Prof Nurs. 2016; 32: 300-305https://doi.org/10.1016/j.profnurs.2016.01.002Crossref PubMed Scopus (17) Google Scholar, 22Shah S.G. Robinson I. AlShawi S. Developing medical device technologies from users' perspectives: A theoretical framework for involving users in the development process.Int J Technol Assess Health Care. 2009; 25: 514-521https://doi.org/10.1017/S0266462309990328Google Scholar The Lough and colleagues’ study provided a powerful example of the need for nursing research to test devices in the ED setting.13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar Even though the novel device contributed to successfully reducing contamination in women in obstetric and general practice outpatient clinics,23Jackson S.R. Dryden M. Gillett P. Kearney P. Weatherall R. A novel midstream urine-collection device reduces contamination rates in urine cultures amongst women.BJU Int. 2005; 96 (https://doi.org/10.1111/j.1464-410X.2005.05631.x): 360-364Google Scholar more ED patient participants reported the device was difficult to use, compared to the usual screw-top collection device.13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar The funnel device was particularly difficult to use where the patient was not able to produce a forceful stream of urine. The difficulty in using the different genital cleaning wipes, due to the compactness of the wipe packaging, difficulty opening the package, and moisture of the wipe are also relevant to evaluate for patient specimen collection in other ED settings. These ED-specific, user-centered considerations are important to measure in future study. Overall, the Lough and colleagues’ study provided useful negative results to impact contamination rates for a novel urine funnel system collection device.13Lough M.E. Shradar E. Hseih C. Hedlin H. Contamination in adult midstream clean-catch urine cultures in the emergency department: A randomized controlled trial.J Emerg Nurs. 2019; 45 (https://doi.org/10.1016/j.jen.2019.06.001): 488-501Abstract Full Text Full Text PDF Scopus (16) Google Scholar Analysis of the unexpected findings in the study reveals important implications for emergency nursing practice, quality improvement, education, and research. The educational handouts for patients on correct collection procedure may provide a particularly useful intervention to reduce specimen contamination. Further initiatives are warranted to engage nurses in all aspects of device development, testing, and site purchasing decisions as professional end users of these products. Jessica Castner, Member, Western New York ENA Chapter, is Editor-in-Chief of Journal of Emergency Nursing.