What’s the catch? Urine sample collection from young pre-continent children: a qualitative study in primary care.

Knowledge

Theoretical knowledge about collection methods was varied among clinicians, but knowledge of likely contamination rates, particularly for urine bags, was commonly reported:

'And you can use urine bags, but, my understanding anyway, is that they’re much more prone to contamination. So we try to steer away from those if possible.' (3, urban GP)

A minority of clinicians held differing views regarding likely contamination for bag samples:

​'I find that I get very clean samples. And so yeah, I generally don't get any squames or very rarely in my samples, so I'm very happy with the accuracy of it.' (4, urban GP)

Training

For many clinicians, their knowledge and preference for collection methods were strongly influenced by their previous training, both in hospital and in GP settings:

​'Because of my training at the children's hospital when I was a young GP.' (1, urban GP)

'I think my GP supervisor when I was training, he did it. And that's where I learnt it.' (14, urban GP)

Experience

Several clinicians learnt how to perform catheterisation or SPA during hospital paediatric training terms. However, infrequent ongoing practice in the GP setting resulted in them no longer feeling confident to perform these procedures:

​ 'I haven’t done a suprapubic aspiration for a while now, so I could certainly try, I know the theory behind it, but I have a feeling that I may not be successful. So I think lack of practice, probably would slightly caution me.' (17, urban GP)

Rurality

Geography and practice location frequently determined how likely GPs were to perform invasive collection methods. In urban and regional areas, many clinics were located close to a hospital:

​'... being close to a paediatric emergency department I think I would be sending them in, rather than completing that procedure.' (2, urban GP registrar)

In rural and remote areas, GPs often performed invasive collection procedures, as the clinicians working at the local hospital or in isolated locations:

​'I think in general our rural colleagues do a lot more procedures than we do. Often they are on call for the base hospital.' (17, urban GP)

'I was in remote Queensland … So I did everything out there.' (12, urban GP)

Age, size, and mobility

Patient factors were a commonly mentioned barrier in relation to clean catch collection, particularly for older and more mobile children:

'And certainly if the child is distressed and uncooperative and won't sit still, that's really tricky.' (11, urban GP registrar)

Hydration

All clinicians considered hydration status to be important, with poor hydration being a barrier, and optimising hydration being an enabling strategy for collection success:

'If they're really dehydrated, you're not going to get much urine out.' (8, regional GP registrar)

How unwell the child is

The clinical state of the child strongly influenced whether clinicians felt the child should be referred to hospital for invasive sample collection and further assessment:

​'If … something about their clinical examination makes me concerned, I don't think sending the family home would be appropriate in that setting, and I would send them off to the hospital.' (17, urban GP)

Advice

The explanation and advice given to parents and carers were seen to strongly influence collection success, as in most cases parents enacted the actual collection process. Several clinicians felt it was important that parents understood why collecting a sample was important, as well as the logistics of the actual collection process:

'... the better they understand that generally the more persistent they are, and successful getting the sample.' (3, urban GP)

Printed handouts were identified as a valuable tool to educate and engage parents, enable collection success, and save time:

'A lot of people take information in differently, and a lot of people are overwhelmed by words, and just words on a page, I think visual instructions are always helpful.' (13, regional GP registrar)

Motivation

Many clinicians described the importance of parents being motivated to collect a sample, which was further enabled by parental health literacy. This was particularly the case for successful clean catch collection, which could be time-consuming or difficult:

'So clearly some parents are really good at following instructions, you know, "Yes, we've gotta get this done," and others, I don't know, get caught up in other things.' (11, urban GP)

Availability

However, for families with multiple children, or other resource limitations, clinicians recognised that collection could be challenging:

​'... if they've got multiple other kids just the logistics of not being able to be two places at once.' (7, regional GP registrar)

Time

Time availability in primary care was identified as a major barrier to sample collection, and influenced the choice of collection method:

'Probably using the bag, simply because, time is often ... a bit pressed for time yeah. It's often very busy.' (10, regional PN)

Several GPs discussed that if collection was going to take a long time, then in practice this would then need to happen at home:

'… often it's a time-consuming thing trying to get a sample from an infant and it's time the doctors don't have.' (24, rural PN)

Clinic resources

The availability of a suitable space also limited capacity for clean catch collection, and for invasive procedures:

'You can't just sit them in the waiting room without their nappy on. I mean, you could but we generally choose not to because I think it would put other people off.' (11, urban GP)

Separate treatment rooms or an unoccupied consulting room were an enabler, but this was available in a minority of clinics:

​'GP clinics are run to make sure that rooms are occupied. So, room availability can be an issue.' (13, regional GP registrar)

Some clinics had PNs who were able to help with sample collection:

'In my practice its good because I have skilled nurses who can follow that up, so I can still be seeing other patients while we wait for that sample.' (2, urban GP registrar)

However, often the nursing staff were also busy, or not available at the time required:

​'… we're not very well staffed with nurses, and the nurse is super busy doing other things.' (18, urban GP)

Convenience of method

Collecting urine samples from young children was generally regarded as a challenging process:

'… as soon as you hear “fever” there’s always that little part of you that says “I bloody hope I can find a source here, because if I can’t find a source, it’s going to be a pain in the ass trying to get that urine sample.”' (3, urban GP)

The perceived convenience of urine bags, for both the clinician and family, was a strong consideration for the clinicians who favoured their use:

'I actually do like that bag collecting method. I think that's something that's a little easy. You can pop that on a child and perhaps set and forget for a bit, rather than standing there with a cup, hoping and waiting.' (13, urban GP registrar)

In contrast clean catch was often seen to be inconvenient, often related to the attention required from parents:

'In my experience, parents often say, “Oh, we can't do it,” or “It's too hard.”' (1, urban GP)

Likely speed and success

Whether collection occurred in the clinic or at home, the likely speed and success of the collection method was a strong consideration for many clinicians. There was a consistent sense that clean catch collection was often time-consuming and, therefore, would often be something parents needed to do at home:

'I think it's an excellent method, but it's obviously very time consuming.' (4, urban GP)

While some clinicians felt that successful clean catch collection was very unlikely, others felt that most clean catch attempts were successful:

​'... a clean catch is nearly impossible ... fluky if you can do it.' (6, regional GP)

'I've found most parents have come back with something.' (7, regional GP registrar)

Some GPs reported difficulties with urine bag collection as well:

'It is just difficult to get those urine bags to work, difficult to apply, difficult to get a clean sample. So I'm not sure what the percentage would be, but lots of the time the parent comes back and says it's just leaked and they haven't been able to get anything.' (5, regional GP)

Clinicians were interested in ways of improving the speed and success of collection:

'Definitely. If there were sort of practical, simple things that would make it easier to collect. Yes, I would be very keen to try that.' (19, remote GP)

Voiding stimulation methods, such as the Quick-Wee technique,²³ were felt to improve the speed and success of clean catch collection:

'… one way to try and get the urine sample without having to wait for too long is to get the nappy off and then get a cool cloth and then rub in a circular motion just above the pubic bone where the bladder is, and sometimes it will induce a reflex where it starts urination, and you collect a sample from there.' (3, urban GP)

Clinicians perceived these methods, when they knew about them, as simple to incorporate into practice, and acceptable to parents:

'I learnt that in my hospital time, where I was doing it. And I think also from the nursing staff. Can't remember, but anyways, it's been quite successful.' (21, urban GP registrar)

This timeliness of collection also influenced whether the child would need to attend hospital:

'If we weren't getting a quick sample, I may consider referring them into the emergency department.' (2, urban GP registrar)

Invasiveness

Using a catheter or needle to extract urine directly from the bladder was seen as highly invasive:

'… there's the impression that it's, well, it's not a pleasant thing to do, it's really invasive, it's a bit of a nasty thing to do.' (5, regional GP)

It was also thought that parents would not consider invasive methods acceptable outside the hospital setting, unless in rural or remote locations:

​'I think the idea of a percutaneous intervention for an infant or baby is quite intimidating for a parent. They may not understand the relevance or appreciate the significance of it in a general practice setting, but in the hospital setting where there is generally a higher acuity of pathology, I think parents are more accepting of the need to undergo such a procedure.' (17, urban GP)

Collection in clinic or at home

For the preferred non-invasive collection methods, clinicians varied in whether collection usually occurred in the clinic or at home:

'I do try to get them to do that while they're in the clinic, which, again, most parents are pretty happy to do.' (19, remote GP)

'… well in our particular practice, um, we'll encourage them to catch the urine at home.' (12, urban GP)

Collection at home also raised possible logistic challenges and concerns that parents may not return with the requested sample:

'If you see them for example at 12:30 on a Saturday and the clinic centre closes at 2, how are you gonna deal with that if they manage to collect the specimen at 5 or 6, who's actually gonna do the dipstick and how would you deal with that.' (1, urban GP)

Many clinicians reported initially trying to collect a sample in the clinic, but sending the child home for continued collection attempts if required:

'We'll just get the jar ready and if they start to pee, we'll catch the specimen or then I'll give the jar to the parent and get them to wait and watch while I type up notes or do other things. And then if everything's done and we still don't get a specimen, then I might send them home to do it.' (11, urban GP)

Contamination

Contamination was a recurring theme during interviews. Most clinicians were aware that urine bags had high contamination, but this did not always deter them from using them:

'Well, probably what we would do is put one of the urine bags on, which I know is usually contaminated because of various things, but that's what we would do.' (9, regional PN)

However, clinicians who preferred the clean catch method mostly did so because of its lower rate of contamination:

'I would also explain to them the reason why the clean catch is important is the dilemma of if you get a contaminated specimen you're not sure what you're treating.' (1, urban GP)

Some GPs felt that efforts should be made to discourage the use of urine bags, particularly for culture:

​'Why are they still making bags for bag urine? If it's not accepted practice … remove the bag altogether because it just gives people the wrong idea.' (17, urban GP)

Definitive sample

Collecting a sample that was ultimately likely to be definitive was often considered important. Many clinicians who preferred the clean catch method recognised that urine bags might be helpful for dipstick screening, but felt that urine bag culture would be unreliable owing to contamination and false-positives:

'I groan because I think it’s only useful when it’s negative.' (25, rural GP)

Where sample collection was difficult, some GPs might treat empirically for suspected UTI without a confirmatory sample:

'… it’s not uncommon for GPs to treat empirically.' (13, regional GP registrar)

Clinical progress

Often with time, further clinical information emerged influencing the ongoing need for a sample. Sometimes an alternate clinical focus developed, and some children simply got better with time:

'If the child improves or things like that, and they haven't been able to get it, then I won't see them again. But then obviously the child has improved, and that’s OK.' (4, urban GP)

Broadly, the barriers and enablers identified by clinicians in this study suggest four approaches to urine sample collection in primary care (Table 2). An evidence-based approach utilises clean catch for its lower contamination rate. A convenience approach favours urine bags given the time and space limitations of primary care. A pragmatic approach uses clean catch, but also uses urine bags in some circumstances. In rural and remote settings clean catch is used, but catheterisation or SPA are also performed when required for more unwell infants who cannot easily access hospital services.