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Urine Testing: If It’s Not Captured Via Catheter, It’s Not Accurate

After eight years of hospitalist medicine and seeing inaccurate urinalysis results day after day, year after year, I’ve come to the conclusion that the straight cath vs clean catch debate is not a debate.  If the urine didn’t come from a straight cath, I have zero faith in the accuracy of the results.

I know, I know.  It takes time and effort for a nurse to perform the straight cath.  It’s not comfortable for the patient to have a catheter inserted into their urethra.  Plus, with bad nursing technique, one could introduce bacteria into the bladder when performing a straight cath urinalysis.

All that aside, if I’m a physician trying to make medical decisions based on accurate data, then having bad urine results that don’t represent the true picture is worse than not having any data at all.  For example, here’s a classic case of what I have to deal with day in and day out when trying to make medical decisions on my patients.  Below is a snap shot of three UA results obtained from Happy’s ER over two visits.  I’m sure it’s the same no matter where you get your care in this country.  The first two urinalysis results came from a clean catch sample of a horribly weak 89 year old female who presented with family complaints of “fever and weakness”, both days.

There are several issues going on here.

  1. The patient  got sent home from the ER on Day #1 with a diagnosis of UTI based on a horribly inaccurate clean catch UA.  The final culture returned a verified contaminated sample (greater than three organisms present, which means the sample was too dirty to be interpreted with any accuracy. )
  2. I was asked to admit the patient on D#2 for “weakness and fever” after the patient  presented to the ER for the second time in less than 24 hours.
  3. I asked that the third urinalysis be performed in the ER as a straight cath sample after eight years of knowledge that clean catch urinalysis is about as accurate as diagnosing a pulmonary embolism on a chest xray.

Ultimately, I showed that this patient did not have a UTI.  In fact, they had a DVT, that I diagnosed in the ER after removing the knee high wool socks the woman was wearing. Just one of the physical exam findings one can find when you properly prepare the patient for exam by taking off their socks (or shoes, or jeans for that matter).

I have had many moans and groans over the years from nurses questioning why I need a straight cath urinalysis on my 45 year old schizophrenic we are asked to see in the psych floor with “abnormal UA”, or the confused 84 year hanging out in the dementia unit with agitation.

From now until eternity, if I ever have a nurse question why they can’t just do a clean catch vs a straight cath, I’m going to refer them here, to my nonrandomized, highly scientific N=1 case presentation.  Or tell them to show me they have received extra training on how to obtain a clean catch UA.  Because the training they currently have isn’t cutting it.

*This blog post was originally published at The Happy Hospitalist*

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