Getting urines quicker

Have a dishwashing station in triage, because every time I put my hands in the warm soapy water- it's 'go time'.

We struggle with this in my ED as well. Depending on the chief complaint, the age of the patient, and the status of the patient, there are times with non-emergent cases where the provider can do a reasonable job of ruling out without the urine if all of the blood and imaging are back, and we don't necessarily worry about it. Otherwise, as long as things aren't entirely nuts in the unit (funny, right?) and a fluid bolus is ordered, I'll hook them up and give a few minutes to see if they are inspired to provide the sample.

If it's a frequent flyer situation (where we can strongly suppose what the complaint and result are likely to be based on history), or if it's an elderly patient that might have a prostate or shy bladder issue, we will give the (sometimes firm) alternative of a straight cath to capture if the provider really needs the urine to rule out. When I first started I was a little taken aback at the directness of the cath option, but patients that truly cannot get the urine out and want to know what's wrong (or not wrong, as it were) are more amenable to it than I would have imagined.

I'm gonna have to put meanmaryjean's idea in the suggestion box though, because I am digging the promise that has at increasing bladder productivity!

Hi,

Where I used to work we had protocol orders so we could order urine tests on most patients. Once we finished their triage, we would hand appropriate patients a urine cup with instructions and then we had a bucket they could drop it in. We would either send it off to the lab while they were waiting or do POC testing if it just needed a simple dip stick or pregnancy test.

Annie

We collect urine on any patient who might get a UA or urine hcg (belly pain, females of reproductive age, et cetera), we send off a portion to the lab so that they can run orders as soon as the provider enters them and keep some in the ED for any POC orders.

I think a big piece is being proactive for patients who cannot produce a urine sample on their own. If a patient cannot or will not produce a urine then a straight cath is not necessarily unreasonable.

Depending on the complaint and stability of the pt, I make sure to get the urine before they're even settled in the bed. A lot of times for females I just say that i can't give pain medications without knowing for sure if they're pregnant and low and behold they have a urine for me inside two minutes. If the pt states they can't do it, it depends on why they're there. I typically will give them until the blood work starts coming back and then it's straight cath time.

For unstable patient's I typically just grab a foley (temperature sensing, of course!) and end up having urine inside twenty minutes. My ER gets *tons* of septic patient's because we are surrounded by 10+ SNFs and we're the closest ER. The patient's generally prefer the temperature sensing foley to q1hr rectal temperature (which is the alternative).

Ask them if they would rather pee, or be catheterized. Then show them a Yankour, but tell them it is a Foley.

I just interviewed for a per-diem position at an ER that does not allow any protocol orders, not even an IV or urine dip stick! I was like yea, no thanks!!

Annie

Our ER has a one hour guide to obtain a urine. If a female pt has diarrhea or vag bleed, we are only getting a straight cath urine anyway. If the pt is elderly and has dementia or we just think it will take a while, we have standing orders to go ahead with the straight cath.

For the younger, walky-talky pt, we kindly threaten and remind them we can't give meds or get any imaging until we have the urine. That usually does the trick. More often than not, that pt will be in the lobby for a while and will eventually have to go so it isn't a big deal.

As a patient, I always expect to give a urine sample when I enter the er. The same as I realize I may be asked for one when I go the doctor depending on my symptoms and what they need to rule out. I do not understand why if you are called to triage and you walk and talk they don't just get the urine sample then. In many cases, they are going to have to rule out other causes of someone being lightheaded or possible urinary issues. So why not after they have triaged you, made sure they have your insurance information so they can start the billing process, etc are you not given a cup to use and the sample sent on. You are going to be seen anyway and that stops part of the problem right there. You won't be strapped down with wires and machines then have a nurse or tech come in and say now I have to insert a cath or threaten anyone. Just a simple statement at the very beginning of you can't be seen without a urine sample would stop a lot of the issues, if the doctor does not order one get rid of it. Of course there are cases where a cath I is necessary but is it really in the best interest of the patient to insert any invasive object into their body that is uncalled for and could be prevented at the very beginning? There is no reason why a patient has to be exposed any more than absolutely necessary. If I as patient feel threatened, I will shut down. I do believe the next time I or a family member has to be taken to the er and I have my wits about me that will be one of the first things I will ask "Do you need a urine sample, please let me give it now so there is no need to have a cath inserted later." That would save everyone a lot of time and frustration.

I bring it up immediately as I meet the patient. It goes something like this:

"Hi, my name is HermioneG and I'm going to be your nurse today. What brought you into our ER today? (pt explains) Ok so I took a look at your chart and I see that we have done (A, B, C) already and are waiting for results for (X, Y, Z). Something important that you can do to help get results for the docs and answers for you faster, is to pee in this cup here." (hands patient urine cup and biohazard bag). "Now, I know you might not feel the urge to go, but lets at least try. The lab only needs a little bit." Then I will usually do a quick assessment and then we try for urine. Even if I don't have an active order yet, I still ask them to try since I've gotten to the point where I can start to anticipate when it will be ordered.

Usually when I explain to the patient/parent/family that the quicker we get urine the quicker we can get results and expedite their stay they're able to provide urine quite quickly. I've personally found that when I get a hugeeeee delay with the urine often times the patient just didn't understand that I wanted it sooner rather than later and will wait for a completely full bladder to give the urine sample.

I also find that unless I have a truly urgent or emergent situation going on its easier to help the patient get into a gown, get them in socks, help them get settled, and help them with getting set up to go pee early on (for non ambulatory pt) so that way I don't get the "NURSE I NEED A BEDPAN RIGHT NOW" routine when I'm swamped juggling a million things. Its not foolproof, but it at least helps a bit.