Evaluation of a Novel Midstream Urine Collection Technique for Infants in the Emergency Department
Evaluation of a Novel Midstream Urine Collection Technique for Infants in the Emergency Department
Urinalysis and urine culture are commonly employed laboratory tests in the Emergency
 Department (ED), particularly for the purposes of investigating febrile infants in whom
 bacterial etiologies must be ruled out. The standard of care for obtaining sterile urine
 specimens in this age group remains transurethral bladder catheterization, an invasive
 procedure that is painful and has the potential for causing specimen contamination and
 iatrogenic urinary tract infection (UTI). A recent study by Herreros Fernández et al (2013)
 described a novel bladder stimulation technique for newborns that facilitates midstream urine
 collection. The success rate for this procedure was 86.3%. It remains unknown however as to
 whether this technique is reproducible amongst infants who present to the ED with a
 potentially greater severity of illness. The primary objective of this study is to determine
 the success rate of this technique in children ≤ 90 days old in the ED.
Two persons (at least one trained nurse [RN] or physician [MD] and/or one health care aid
 [HCA]) will be required to perform the procedure, one of whom will also measure the time
 between critical steps of the protocol using a stopwatch. The technique involves a
 combination of fluid administration and non-invasive bladder stimulation manoeuvres that
 include gently finger tapping the abdomen with or without lower back massage.

 The first step involves bottle or breastfeeding each infant with an amount of milk that is
 appropriate for its weight and age. Breastfed babies that have no history of poor feeding
 will be fed ad libitum. Those that feed poorly will be encouraged to supplement the feed with
 either expressed breast milk or formula at the discretion of the parent/guardian. Formula fed
 infants will receive a 10 ml feed on the first day of life, increasing by 10 ml per day of
 age to a maximum of 70 ml per feed. For infants greater than 7 days old, 25 ml/kg will be
 administered per feed. Babies that demonstrate mild clinical dehydration and/or fail attempts
 at oral feeding may, at the discretion of the most responsible physician (MRP), have a
 peripheral intravenous (IV) catheter placed and receive a fluid bolus of 0.9% normal saline
 up to a maximum of 10-20 ml/kg given over 20-25 minutes. Infants will not be excluded if they
 do not feed well.

 Approximately 20 minutes after the feeding or IV fluid bolus, the infant's genitals will be
 cleaned in a sterile technique using 0.05% chlorhexidine. Non-pharmacological analgesia, as
 achieved with a soother and/or 24% sucrose will be offered to prevent or lessen crying.

 The second major step of the technique involves holding the infant under the axillae with
 their legs dangling safely above the crib mattress. An RN or MD then begins bladder
 stimulation by gently finger tapping on the lower abdomen in the midline just above the pubic
 symphysis at a frequency of 100 taps per minute. If this step is unsuccessful after 30
 seconds, the RN/MD will then stimulate the lower back in the lumbar paravertebral zone by
 lightly massaging the area in a circular motion using both thumbs. This too will be performed
 for a maximum of 30 seconds. The two stimulation manoeuvres will be repeated in succession
 (up to a maximum of 5 minutes, or 5 cycles) until micturition occurs and a midstream urine
 sample can be caught in a sterile container.

 Infants who spontaneously urinate after cleaning, but prior to bladder stimulation, will have
 their clean catch urine sent to the lab. These cases will be considered successful
 "non-invasive" attempts.

 Infants who fail to produce urine will have further feeding/fluid administration and bladder
 catheterization at the discretion of the MRP.
Inclusion Criteria:

 -  Age ≤ 90 days

 -  Ped-CTAS (Canadian Pediatric Triage and Acuity Scale) Level = 2-5

 -  Urine specimen required for culture and/or urinalysis at the discretion of the most
 responsible physician (MRP) or as part of a nurse-initiated medical care directive

 Exclusion Criteria:

 -  Age > 90 days

 -  Ped-CTAS Level = 1 (i.e. critically ill patient)

 -  Moderate to severe dehydration

 -  Significant feeding issues (e.g. suspected pyloric stenosis)

 -  Burn/infection/injury over site of bladder stimulation

 -  Previous enrollment