Urine Trouble: A Program Evaluation of Urinalysis Ordering and Assessment at an Assisted Living Facility and Geriatric Clinic

Background: Geriatric clinics and assisted living facilities (ALFs) collaborate in the provision of care to; patients who reside in ALFs. Both share the goal of optimizing healthcare outcomes and improving quality of life. Communication barriers between these organizations, however, can impede upon this shared goal and complicate care. These communication barriers are magnified when it comes to protocols and processes that differ between organizations with resultant poor outcomes. Local Problem: A geriatric clinic was in the process of updating their urinalysis (UA) protocols with hopes of improving diagnostic stewardship and decreasing the number of UAs ordered for non-specific symptoms. They sought to understand why local ALFs would send in unsolicited UAs without an order from a geriatrician and to determine if education or changes to the ALFs protocols would be helpful in improving diagnostic stewardship in the community. Methods: A program evaluation guided by the PDSA theory was used to determine current practice, barriers to change, and other potential factors resulting in unsolicited UAs being sent to the geriatric clinic. Stakeholder identification, interviews, and comparison to best-practice literature were performed with results from the program evaluation shared with stakeholders for feedback. Interventions: A program evaluation found key stakeholders at the geriatric clinic and ALF and interviewed these stakeholders to assess areas of interest that may result in miscommunication regarding UAs and signs and symptoms specific to urinary tract infections (UTI). Identification of stakeholders in adjacent services (e.g., laboratories) were also engaged to assess current practice and protocols surrounding UAs. Multiple interviews were conducted throughout the study period across the various organizations and with different roles and disciplines within these organizations. A case study was also performed. Memoranda on topics and key points regarding current practice were kept in a running document to identify potential systemic issues, barriers to change, and themes later. Results: The geriatric clinic identified two ALFs as sending in unsolicited UAs without provider knowledge or orders. One ALF RN manager responded to requests for an interview. In total, eleven stakeholders were identified and interviewed with five providing direct care (three registered nurses (RN), one Medical Doctor (MD), and one Advanced Practice Clinician (APC) and six providing indirect care (2 laboratories, 3 leadership RNs, and 1 sales manager). Interviews were conducted with a focus on potential areas of systemic issues, barriers to change, and assessment of current practices and protocols. Although no systemic issues were identified, it was determined that a former RN manager of memory care could unilaterally order UAs using lab requisition sheets at the ALF. In addition, barriers to change and issues regarding communication between organizations were also found. These barriers resulted in misperceptions of care and poor inter-organizational relationships. Conclusion: Although an individual actor resulted in unsolicited UAs being sent to a geriatric clinic without proper orders and means for follow-up, this program evaluation discovered larger communication issues that led to a poor inter-organizational relationship.