Do you treat pediatric UTIs inconsistently?
Children with urinary tract infections (UTIs) are treated surprisingly differently across hospitals, according to a new study.1 Researchers looked at 20,892 children between the ages of 1 month and 12 years old hospitalized for UTIs at 25 children's hospitals between 1999 and 2004. They found significant variability for length of stay and tests performed.
"The high degree of variability in care was surprising," says Patrick H. Conway, MD, one of the study's authors and an assistant professor of pediatrics at University of Cincinnati College of Medicine. "The largest area of variability in EDs is the decision whether to admit children from the ED to the hospital. Some EDs admit almost all children under a certain age such as 6 months, whereas other EDs are comfortable sending children home on oral antibiotics."
Cynthia Anderson, RN, BSN, clinical educator for the ED at Children's Hospitals and Clinics of Minnesota in Minneapolis, says, "The ED nurse plays a critical role in making sure the child receives proper diagnosis and the right treatment in a timely manner."
Having a focused assessment and a urine specimen are "excellent ways to expedite the care" of a child with a suspected UTI, according to Cam Brandt, RN, MS, CEN, CPEN, CPN, education coordinator of emergency services at Cook Children's Medical Center in Fort Worth, TX.
A child with a UTI might present with a chief complaint of "problems urinating," "burning when urinates," or even back or abdominal pain, says Brandt. "Knowing that these are symptoms of several genitourinary complaints, your focused assessment would include questions regarding voiding patterns and pain, and in the nonverbal child, questions responding to presence of fever, fussiness, and foul-smelling diapers," says Brandt. "A history of previous UTI is also a significant finding."
Anderson says to ask these questions if you suspect a child has a UTI:
- Does it burn or is it hot when the child urinates?
- Do they have to go frequently or never feel like they are done?
- Do they feel like they have to go all the time, but it is only small amounts?
- Does it smell funny when they urinate?
- Has the child has ever had a UTI in the past?
Anderson says ED nurses have a protocol order to obtain and send a urine sample to lab for analysis and culture, if the symptoms suggest a UTI and the patient is able to provide a clean catch specimen.
"When the triage team recognizes that this may be a UTI diagnosis, they work to obtain a urine sample so the results are returned quickly. This expedites treatment," she says.
Brandt advises obtaining the first available urine sample, as a child with a UTI might hold their urine until they are incontinent or at the very least, will not be able to wait while a doctor's order is obtained. "Antipyretics for fever are generally given in the child over 2 months of age. The exception is the child 2 months and under," she says. "Fever in the young infant is an emergent finding. UTI is a common cause for fever, and care should be expedited."
Brandt gives two examples to show how the ED nursing assessment differs:
• A 3-week-old presenting with fever and "drawing up knees when urinating" would be considered an emergency.
"The triage nurse would obtain birth history and other information including length of complaint, maximum temperature, and parent's perception," says Brandt. The focused assessment includes a primary survey; vital signs, especially rectal temperature; and a Face/Legs/Activity/Cry/Consolability (FLACC) pain scale. The diaper is checked for the presence of unusual odors, discharge, and/or blood. "Nurses need to prioritize this child to be seen quickly, and anticipate lab work and catheter urinalysis," says Brandt.
• For a 6-year-old with a complaint of pain and burning, the triage nurse would include questions on previous history of UTI, current medications, presence of discharge in the underwear, and questions involving genitourinary trauma, such as the possibility of a straddle injury.
"A urine cup, cleaning wipes, and instructions on obtaining a urine sample should be given to the parent at this time," says Brandt. "Cloudy, dark, or malodorous urine is suspective of UTI."
Reference
- Conway P, Keren R. Factors associated with variability in outcomes for children hospitalized with urinary tract infection. J Pediatr 2009; 154:789-796.
Sources
For more information about treatment of urinary tract infections, contact:
- Cynthia Anderson, RN, BSN, Clinical Educator, Emergency Department, Children's Hospitals and Clinics of Minnesota, Minneapolis. Phone: (612) 813-7535. E-mail: [email protected].
- Cam Brandt, RN, MS, CEN, CPN, Educator, Emergency Services, Cook Children's Health Care System, Fort Worth, TX. Phone: (682) 885-1402. Fax: (682) 885-7499. E-mail: [email protected].
- Patrick H. Conway, MD, Assistant Professor of Pediatrics, University of Cincinnati College of Medicine. Phone: (513) 803-0425. Fax: (513) 803-0270. E-mail: [email protected].
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