NIHR Signal Placing wet gauze on babies’ tummies speeds up urine collection

Published on 17 October 2017

Almost a third of infants managed to urinate within five minutes after a painless, cheap technique that stimulates the skin, compared with 12% of infants observed only, as is standard practice.

The ‘Quick-Wee’ method involved rubbing the babies’ abdomens gently with gauze soaked in cold saline before collecting urine. This trial was carried out with 354 babies aged one to 11 months in one Australian paediatrics emergency room.

NICE guidelines recommend non-invasive ‘clean catch’ collection if possible but this can be difficult, especially in young children. They estimate that 20 minutes of staff time can be needed to obtain a sample. Hospital paediatrics settings and primary care may want to try this promising, cheap and safe technique.

There was no difference in rates of contamination and it may reduce the number of babies who need to go on to the less desirable collection by pad samples or invasive techniques.

Placing wet gauze on babies’ tummies speeds up urine collection

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Why was this study needed?

Around 3% of girls and 1% of boys will have had an infection affecting their kidneys or ureter by the age of seven. Most urinary tract infections resolve without harm, but complications such as renal scarring may result. Therefore, testing urine for bacteria is recommended when children have unexplained fevers.

NICE recommends ‘clean catch’ urine collection in most cases. However, practical difficulties can be a barrier to using this method. Waiting for a baby to pass urine is time-consuming. In addition, catching urine in a sterile container requires sustained focus until urination occurs.

Gently rubbing a baby’s lower abdomen circularly with cold wet gauze had been observed to stimulate faster urination in a pilot study, but prior to this study, it was unknown how successful this might be. A randomised controlled trial was conducted to test the effectiveness and acceptability of this ‘Quick-Wee’ technique. The trial took place during regular clinical care in a tertiary Australian hospital, led by the intervention developers.

What did this study do?

In this trial, 354 infants aged one to 11 months were randomly allocated to receive either standard practice enhanced by the ‘Quick-Wee’ technique, or standard practice alone. The standard practice involved cleaning the genital area and collecting urine in a pot, consistent with NHS guidance.

As part of seamless clinical care, the same staff recruited and allocated patients; delivered the intervention and collected samples (along with parents). Hospitals tested samples for contamination. Practitioners and parents were asked a satisfaction question.

Drop-out from the trial was low. However, practitioners, parents and data analysts knew whether the babies received the intervention. This may have led to bias in results for satisfaction ratings and the success of urine collection.

What did it find?

  • Infants receiving the ‘Quick Wee’ technique were almost three times more likely to urinate within five minutes (31%), compared with those receiving standard practice only (12%) (absolute difference 19%, 95% confidence interval [CI] 11% to 28%).
  • When the intervention was used, staff or parents were almost three times more likely to collect a successful sample (30%) than with standard practice only (9%) (absolute difference 21%, 95% CI 13% to 29%). Around five babies would need to receive the intervention to successfully catch one extra urine sample within five minutes (95% CI 3 to 8 babies).
  • There was no difference in contamination between the groups. 
  • Parents and practitioners expressed slightly more with the ‘Quick-Wee’ technique than standard practice alone, equivalent to one point more satisfaction on a scale of very satisfied to very unsatisfied.
  • The results did not differ for age or sex of the infant.

What does current guidance say on this issue?

The 2007 NICE guideline recommends that urine samples are collected non-invasively through ‘clean catch’ methods if possible. If a urine sample cannot be obtained, then use of urine collection pads is recommended. If neither technique is successful, then invasive testing should be performed through use of catheter samples or suprapubic aspiration. NICE has said recently that new evidence is unlikely to alter these recommendations. The guideline is due for a partial update in 2017.

What are the implications?

In 2007, NICE estimated one ‘clean catch’ urine sample to cost £8.20 by using 20 minutes of staff time. Other interventions used to speed up clean catch have been more intrusive and tested only with young babies or in non-randomised evaluations.

Though there may have been some bias in this trial through lack of blinding, hospitals and primary care might try this cheap, safe method for collecting urine from babies. The trial used face to face staff training, but it may be possible to create a short video for staff and parents.

Invasive collection methods may remain appropriate if a useable sample is required urgently.

Citation and Funding

Kaufman J, Fitzpatrick P, Tosif S, et al. Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial. BMJ. 2017;357:j1341.

There was no UK funding for this study.

Bibliography

NHS Choices. Urinary tract infections in children. London: Department of Health; 2016.

NICE. Urinary tract infection in under 16s: diagnosis and management. CG54. London: National Institute for Health and Care Excellence; 2007.  

NICE. Urinary tract infection in under 16s: Costing report: Implementing NICE guidance. CG54. London: National Institute for Health and Care Excellence; 2007.

O’Brien K, Edwards A, Hood K, Butler C. Prevalence of urinary tract infection in acutely unwell children in general practice. Br J Gen Pract. 2013;63(607):e156-64.

Why was this study needed?

Around 3% of girls and 1% of boys will have had an infection affecting their kidneys or ureter by the age of seven. Most urinary tract infections resolve without harm, but complications such as renal scarring may result. Therefore, testing urine for bacteria is recommended when children have unexplained fevers.

NICE recommends ‘clean catch’ urine collection in most cases. However, practical difficulties can be a barrier to using this method. Waiting for a baby to pass urine is time-consuming. In addition, catching urine in a sterile container requires sustained focus until urination occurs.

Gently rubbing a baby’s lower abdomen circularly with cold wet gauze had been observed to stimulate faster urination in a pilot study, but prior to this study, it was unknown how successful this might be. A randomised controlled trial was conducted to test the effectiveness and acceptability of this ‘Quick-Wee’ technique. The trial took place during regular clinical care in a tertiary Australian hospital, led by the intervention developers.

What did this study do?

In this trial, 354 infants aged one to 11 months were randomly allocated to receive either standard practice enhanced by the ‘Quick-Wee’ technique, or standard practice alone. The standard practice involved cleaning the genital area and collecting urine in a pot, consistent with NHS guidance.

As part of seamless clinical care, the same staff recruited and allocated patients; delivered the intervention and collected samples (along with parents). Hospitals tested samples for contamination. Practitioners and parents were asked a satisfaction question.

Drop-out from the trial was low. However, practitioners, parents and data analysts knew whether the babies received the intervention. This may have led to bias in results for satisfaction ratings and the success of urine collection.

What did it find?

  • Infants receiving the ‘Quick Wee’ technique were almost three times more likely to urinate within five minutes (31%), compared with those receiving standard practice only (12%) (absolute difference 19%, 95% confidence interval [CI] 11% to 28%).
  • When the intervention was used, staff or parents were almost three times more likely to collect a successful sample (30%) than with standard practice only (9%) (absolute difference 21%, 95% CI 13% to 29%). Around five babies would need to receive the intervention to successfully catch one extra urine sample within five minutes (95% CI 3 to 8 babies).
  • There was no difference in contamination between the groups. 
  • Parents and practitioners expressed slightly more with the ‘Quick-Wee’ technique than standard practice alone, equivalent to one point more satisfaction on a scale of very satisfied to very unsatisfied.
  • The results did not differ for age or sex of the infant.

What does current guidance say on this issue?

The 2007 NICE guideline recommends that urine samples are collected non-invasively through ‘clean catch’ methods if possible. If a urine sample cannot be obtained, then use of urine collection pads is recommended. If neither technique is successful, then invasive testing should be performed through use of catheter samples or suprapubic aspiration. NICE has said recently that new evidence is unlikely to alter these recommendations. The guideline is due for a partial update in 2017.

What are the implications?

In 2007, NICE estimated one ‘clean catch’ urine sample to cost £8.20 by using 20 minutes of staff time. Other interventions used to speed up clean catch have been more intrusive and tested only with young babies or in non-randomised evaluations.

Though there may have been some bias in this trial through lack of blinding, hospitals and primary care might try this cheap, safe method for collecting urine from babies. The trial used face to face staff training, but it may be possible to create a short video for staff and parents.

Invasive collection methods may remain appropriate if a useable sample is required urgently.

Citation and Funding

Kaufman J, Fitzpatrick P, Tosif S, et al. Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial. BMJ. 2017;357:j1341.

There was no UK funding for this study.

Bibliography

NHS Choices. Urinary tract infections in children. London: Department of Health; 2016.

NICE. Urinary tract infection in under 16s: diagnosis and management. CG54. London: National Institute for Health and Care Excellence; 2007.  

NICE. Urinary tract infection in under 16s: Costing report: Implementing NICE guidance. CG54. London: National Institute for Health and Care Excellence; 2007.

O’Brien K, Edwards A, Hood K, Butler C. Prevalence of urinary tract infection in acutely unwell children in general practice. Br J Gen Pract. 2013;63(607):e156-64.

Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial

Published on 9 April 2017

Kaufman, J.,Fitzpatrick, P.,Tosif, S.,Hopper, S. M.,Donath, S. M.,Bryant, P. A.,Babl, F. E.

Bmj Volume 357 , 2017

Objective To determine if a simple stimulation method increases the rate of infant voiding for clean catch urine within five minutes.Design Randomised controlled trial.Setting Emergency department of a tertiary paediatric hospital, Australia.Participants 354 infants (aged 1-12 months) requiring urine sample collection as determined by the treating clinician. 10 infants were subsequently excluded.Interventions Infants were randomised to either gentle suprapubic cutaneous stimulation (n=174) using gauze soaked in cold fluid (the Quick-Wee method) or standard clean catch urine with no additional stimulation (n=170), for five minutes.Main outcome measures The primary outcome was voiding of urine within five minutes. Secondary outcomes were successful collection of a urine sample, contamination rate, and parental and clinician satisfaction with the method.Results The Quick-Wee method resulted in a significantly higher rate of voiding within five minutes compared with standard clean catch urine (31% v 12%, P<0.001), difference in proportions 19% favouring Quick-Wee (95% confidence interval for difference 11% to 28%). Quick-Wee had a higher rate of successful urine sample collection (30% v 9%, P<0.001) and greater parental and clinician satisfaction (median 2 v 3 on a 5 point Likert scale, P<0.001). The difference in contamination between Quick-Wee and standard clean catch urine was not significant (27% v 45%, P=0.29). The number needed to treat was 4.7 (95% confidence interval 3.4 to 7.7) to successfully collect one additional urine sample within five minutes using Quick-Wee compared with standard clean catch urine.Conclusions Quick-Wee is a simple cutaneous stimulation method that significantly increases the five minute voiding and success rate of clean catch urine collection.Trial registration Australian New Zealand Clinical Trials Registry ACTRN12615000754549.

Urinary tract infections are bacterial infections of the kidneys, the bladder, the tubes that link them (ureters), and/or the tube that carries urine out of the body.

Clean-catch urine collection seeks to avoid contamination of the sample by bacteria from the skin or rectum. The genital area is first cleaned, and a sterile container is used to collect urine. Other non-invasive methods use pads or towels.

Invasive urine collection methods use catheters or needles. They can be painful and carry risks. The benefit is that the samples collected have a lower contamination rate than clean-catch samples.

Expert commentary

Obtaining urine samples from children who are at the pre-continent stage is extremely difficult; even more so as a paediatric nurse, when you are required to obtain samples from a number of patients.

As acquiring a urine sample is not part of everyday habitual tasks for parents, often clinicians need to get involved, sometimes for prolonged amounts of time. The ‘Quick-Wee’ method, in theory, is a time efficient method for obtaining a clean catch specimen, however, the overall need for clinical involvement would remain the same; nevertheless, with good parental education and systematic integration in nursing practice, it can prove functional and time efficient.

Miriam Rahman, Paediatric General Practice Nurse, City and Hackney GP Confederation