The Bag Is Not Always Bad: Intrahospital Spread of 2-Step Urinary Tract Infection Screening

OBJECTIVES: Urine cultures are frequently collected in hospitalized children for urinary tract infection (UTI) screening, despite often being unnecessary, invasive, and resource intensive. We aimed to decrease the proportion of unnecessary urine cultures in admitted children aged 90 days to 24 months from 65% to 45% over 1 year. METHODOLOGY: The Model for Improvement guided problem understanding and change ideas. The main intervention included a 2-step UTI screening pathway previously implemented at our institution's emergency department with emphasis on completing point-of-care urinalysis (UA) on noninvasive urine bag sample. If positive for pyuria, bladder catheterization was performed for urine culture. Additional interventions included electronic medical record order set, education, interdisciplinary collaboration, and alignment with the institution's Choosing Wisely program. The primary outcome was the proportion of urine cultures completed without preceding positive UA screen. The balancing measure was the number of missed UTIs. Analysis used Statistical Process Control charts. RESULTS: Baseline data (April 2020-March 2021) demonstrated that 65% of urine cultures were collected without a preceding positive UA. Postintervention data (April 2021-January 2025) demonstrated a decreased proportion of urine cultures collected without preceding positive UA screen from 65% to 22%. Special cause variation was detected 1 year following implementation of the pathway with sustained change during the study period. There was no increase in missed UTIs. CONCLUSIONS: Process standardization using 2-step UTI screening pathway reduced unnecessary invasive urine culture collection in hospitalized children. The novel spread of this initiative to inpatient pediatric units aligns with best practices promoting high-value care.