Urine dipstick test use in Dutch nursing homes: a mixed-methods study to inform strategies for improved guideline-accordance

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Paap, Jeanine J.J.S. Rutten, Anouk M. van Loon, Cees M.P.M. Hertogh, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4467344/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Current guidelines stated that urinalysis should no longer be used to confirm a urinary tract infection (UTI) diagnosis in nursing home (NH) residents, urine dipstick tests are still frequently used by nursing staff in response to a broad array of – often non-UTI related – S&S. This study gain insight into factors associated with guideline non-accordant urine dipstick test use in NHs, and explore the current processes and perceptions regarding urine dipstick test use among nursing staff. Methods : Mixed-methods study in Dutch NHs. Participants: NH residents with a suspected UTI and nursing staff members. Measurements: In an existing dataset of 294 cases of suspected UTI, we compared patient characteristics between guideline-accordant and non-accordant urine dipstick test use. We additionally explored processes and perceptions regarding urine dipstick test use, using data from previously conducted interviews with 9 nursing staff members complemented with 2 newly conducted focus groups with 14 nursing staff members. Results : A urine dipstick test was performed in 13.7% of 51 residents with an indwelling urinary catheter. A urine dipstick test was performed in 61.3% of 243 suspected cases without an indwelling catheter, 45% of which was not guideline-accordant. Renal or urinary tract abnormalities [OR 0.29, 95% CI 0.09─0.96] and mental status change other than delirium (OR 0.34, 95% CI 0.15─0.77) were associated with more guideline non-accordant dipstick use. Having cloudy urine, urine color change and/or urine odor change (OR 2.47, 95% CI 1.06─5.73) was associated with more guideline-accordant urine dipstick test use. The qualitative findings provided in-depth insight into current work processes regarding the urine dipstick test, knowledge and perceptions, and points for improvement. Conclusions : Guideline non-accordant urine dipstick test use is common in NHs. Improved knowledge and skills of nursing staff is needed, as well as clear work processes. As the urine dipstick test is very much embedded in everyday practice, the change process requires sufficient time, clear and repeated communication, and involvement of nursing staff. Throughout the change process, the perceptions of nursing staff identified in this study are important to consider and address. Nursing home urinary tract infection urine dipstick urinalysis guideline-accordance Background Urinary tract infections (UTIs) represent the most commonly diagnosed type of infection among nursing home (NH) residents. 1 , 2 In many cases, however, this diagnosis is incorrect, leading to unnecessary antibiotic prescribing. One third of the antibiotic prescriptions for suspected UTIs has been reported to be inappropriate in the NH setting. 3 Inappropriate antibiotic prescribing should be avoided as it unnecessarily poses residents at risk of adverse events and is an important contributor to antibiotic resistance development. 4 , 5 A substantial part of inappropriate antibiotic prescribing for UTIs includes prescribing in response to positive urine dipstick test results. 2 A urine dipstick test indicates the presence of bacteria (i.e., bacteriuria), and an inflammatory response (i.e., leukocyturia). Until recently, a positive urine dipstick test was considered a confirmation of a UTI in NH residents. However, a substantial part of older adults was found to have bacteriuria without the presence of (relevant) signs and symptoms (S&S): asymptomatic bacteriuria (ASB). Therefore, current guidelines state that urinalysis should no longer be used to confirm a UTI diagnosis. Instead, this diagnosis should be merely based on the presence of UTI-related S&S, such as dysuria and urgency. 6 – 10 If such S&S are present, a urine dipstick test may be used to rule out a UTI diagnosis (i.e., an infection is unlikely if no nitrite and leukocytes are present). This implies that urine dipstick tests in NHs should only by performed when a physician considers a UTI based on the presence of UTI-related S&S in a resident. In current NH practice, however, urine dipstick tests are still frequently used by nursing staff in response to a broad array of – often non-UTI related – S&S, and a common reason to consult a physician. 11 To improve guideline-accordant urine dipstick test use, it is important to first understand current processes and perceptions regarding urine dipstick test use. In the current study, we therefore first quantified guideline non-accordant urine dipstick tests use, using an existing dataset of NH residents with suspected UTI, and assessed factors associated with guideline non-accordance. In addition, using qualitative methods, we in-depth explored current processes and perceptions regarding urine dipstick test use among nursing staff. Methods Study design and population In this mixed-methods study, we used a quantitative dataset of NH residents with suspected UTI, from a previous study (ANNA study), 12 to assess the degree of guideline non-accordant cases of urine dipstick test use and associated factors. To explore current processes and perceptions regarding urine dipstick test use among nursing staff in NHs, data from semi-structured interviews with nine nursing staff members, previously conducted as part of the aforementioned ANNA study, were used and complemented with newly conducted focus groups with 14 nursing staff members. Sampling and data collection The ANNA study, from which the quantitative dataset was reused in the current study, was a cluster randomized controlled trial (cRCT) conducted in the period March 2019 – March 2020. 12 In this study, the appropriateness of treatment decisions for 295 cases of 'suspected UTI' (i.e, based on discretion of the physician) - was evaluated among residents of 16 Dutch NHs. In the intervention group (10 NHs), an electronic health record (EHR) integrated decision tool for the treatment of residents with suspected UTI, and supportive interventions, were implemented. In the control group (6 NHs), usual care was provided. For the current study, data of 294 cases of suspected UTIs (both control and intervention group data) with available data on urine dipstick test use were analyzed, including: patient characteristics, comorbidities, risk factors for UTI (i.e., recurrent UTI, renal or urinary tract abnormalities, diabetes mellitus, or compromised immunity (e.g., due to radiation therapy or use of immunosuppressive medication)), UTI related S&S, nonspecific S&S and other factors (i.e., consultation during evenings/weekends and whether the physician spoke to the resident in person). We also reused transcripts of semi-structured interviews with 9 nursing staff members, conducted as part of a process evaluation of the ANNA study in the period February – April 2020. 13 Details on the methods regarding the conduction of these interviews can be found elsewhere. 14 For the current study, transcript fragments coded with the labels ‘working method regarding urinalysis’ and ‘influence of the ANNA study on the working method regarding urinalysis’ were extracted by LvB, and subthemes were identified. The subthemes derived from the ANNA study interviews informed the development of the semi-structured topic (Additional file 1.) for the focus groups conducted in the current study. The focus group meetings started with an in-depth exploration of the work processes and perceptions regarding urine dipstick test use. Next, current evidence and guidelines on urine dipstick test use in NH residents was presented and reflected upon with the participants. Finally, possible opportunities for improvement of urine dipstick test use were explored with the participants. Focus group participants were recruited though regional and national online communication channels of organisations active in the care for older people. Participants were eligible for participation if they were working in a NH as nurse practitioner (NP), registered nurse (RN), certified nurse assistant (CNA) or trainee nurse. Eligible potential participants were purposively selected based on organisation, educational level, years of work experience, gender and availability (in this order) to ensure maximum variation. A total of two focus groups (90 minutes each) were – due to national Covid-19 restrictions – held online, using Microsoft Teams, by the research team (moderator: LvB observers: KP and AvL) in the period January – February 2022. Data analysis Using the quantitative dataset of suspected UTI cases of the ANNA study, we first analyzed whether or not urine dipstick test use was in accordance with the UTI guideline of the Dutch Association of Elderly Care Physicians (Verenso). 15 This implies that urine dipstick test use is considered guideline-accordant in case of: 1) presence of UTI-related S&S (i.e., two or more, one bothersome, combined with systemic S&S and/or combined with costovertebral angle pain/tenderness or suprapubic pain) or, 2) costovertebral angle pain/tenderness combined with systemic S&S. Next, univariate logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (CIs) were conducted to examine possible associations between various patient characteristics and guideline-accordant urine dipstick use (yes/no). The group ‘guideline-accordant urine dipstick test use’ is used as a reference group. In the multivariate logistic regression analysis, variables with a p value of α < 0.10 demonstrated in the univariate analysis were included and adjusted for age and gender. The level of statistical significance was considered at α < 0.05. Analyses were done with IBM SPSS Statistics (version 28). For the qualitative analysis, first, focus groups interviews were transcribed verbatim and pseudonymised. ‘KP’ and ‘LvB’ independently coded the transcripts and developed a codebook of themes based on consensus, using MAXQDA (2022). The findings were discussed within the project group and an analytical framework of main and subthemes was created. Second, (sub)themes derived from the interviews of the ANNA studies were integrated in the analytical framework. From both sources (i.e., focus groups and interviews), verbatim quotes, illustrating the derived themes, were translated by a native speaker. In the conduction and reporting of the focus groups, we adhered to the COREQ guidelines. 16 Ethical considerations The Medical Ethics Review Committee of the Amsterdam University Medical Center, location VUmc, approved the study protocol from the ANNA-study on December 27, 2018. On February 26, 2019, the ANNA-study was registered in the Netherlands Trial Register under number NL7555. The Medical Ethics Review Committee of the Amsterdam University Medical Center, location AMC, reviewed the study protocol of the current study and judged that this study was exempted from ethical review (reference number FWA00017598). Written informed consent was obtained from all study participants or their representatives. Results Quantitative analysis of suspected UTI cases A total of 294 cases of suspected UTI was analyzed. The mean age of included residents was 86 years, the majority was female (79%), and comorbidities were common. 12 Of the suspected UTI cases, 51 were in residents with an indwelling urinary catheter. In these cases, urine dipstick test use is not indicated according to guidelines. A urine dipstick test was nonetheless performed in 7/51 (13.7%) of these cases. Urine dipstick test use Of the 243 suspected UTI cases without an indwelling catheter, a urine dipstick test was performed in 149 cases (61.3%) (see Table 1 ). Table 1 Characteristics and symptomatology of suspected UTI cases in whom a urine dipstick test was performed, divided into guideline-accordant and guideline non-accordant dipstick test use, and including results of univariate and adjusted multivariate analyses. Urine dipstick test performed Total Guideline-accordant Non guideline-accordant Univariate Multivariate * Characteristics, comorbidities, risk factors (N = 149), % (n/N) (N = 82), % (n/N) (N = 67, % (n/N) OR (95% CI) OR (95% CI) Age, y (Mean, St dev.) 85.6 (σ6.79) 84.9 (σ7.10) 86.4 (σ6.36) 0.97 (0.92─1.02) Gender (female) 87.2 (130/149) 86.6 (71/82) 88.1 (59/67) 1.14 (0.43─3.03) Residence on department for psychogeriatric illness 77.2 (115/149) 72.0 (59/82) 83.6 (56/67) 0.50 (0.23─1.13) 0.57 (0.18─1.78) Dementia 60.7 (88/145) 53.2 (42/79) 69.7 (46/66) 0.49 (0.25─0.98) 0.63 (0.25─1.61) Cardiovascular disease 47.0 (77/149) 46.3 (38/82) 47.8 (32/67) 0.95 (0.49─1.80) Pulmonary disease 15.4 (23/149) 17.1 (14/82) 13.4 (9/67) 1.33 (0.54─3.29) Diabetes mellitus 25.5 (38/149) 22.0 (18/82) 29.9 (20/67) 0.66 (0.32─1.39) Urine inontinence 34.9 (52/149) 31.7 (26/82) 38.8 (26/67) 0.73 (0.37─1.44) Recurrent UTI 31.5 (47/149) 30.5 (25/82) 32.8 (22/67) 0.89 (0.45─1.79) Renal or urinary tract abnormalities 12.8 (19/149) 7.3 (6/82) 19.4 (13/67) 0.33 (0.12─0.92) 0.29 (0.09─0.96) UTI related signs and symptoms Recent onset of dysuria 28.9 (43/149) 47.6 (39/82) 2.7 (4/67) 0.94 (0.62─1.44) Urgency (new/worsening) 36.2 (54/149) 64.4 (53/82) 1.5 (1/67) 1.48 (0.96─2.29) 1.69 (0.86─3.34) Frequency (new/worsening) 34.2 (51/149) 62.2 (51/82) 0 1.45 (0.96─2.21) 1.28 (0.67─2.45) Urine incontinence (new/worsening) 10.7 (16/149) 15.9 (13/82) 4.5 (3/67) 1.41 (0.82─2.41) (Visible) urethral purulence 1.3 (2/149) 2.4 (2/82) 0 1.42 (0.76─2.65) Non-specific signs and symptoms Agitation 22.8 (51/149) 18.3 (15/82) 28.4 (19/67) 0.57 (0.26─1.22) Mental status change symptoms other than delirium 34.2 (51/149) 26.8 (22/82) 43.3 (29/67) 0.48 (0.24─0.96) 0.34 (0.15–0.77) Not being him/herself 41.6 (62/149) 34.1 (28/82) 50.7 (34/67) 0.50 (0.26─0.98) 0.59 (0.28–1.29) Urinary output decrease 3.4 (5/149) 4.9 (4/82) 1.5 (1/67) 3.39 (0.39─11.24) Urinary retention 4.7 (7/149) 6.1 (5/82) 3.0 (2/67) 2.11 (0.87─1.57) Cloudy urine, urine color change, urine odor change 32.9 (49/149) 39.0 (32/82) 25.4 (17/67) 1.88 (0.93─3.82) 2.47 (1.06─5.73) Macroscopic hematuria 4.0 (6/149) 4.9 (4/82) 3.0 (2/67) 1.67 (0.29─9.39) General malaise or weakness 39.6 (59/149) 43.9 (36/82) 34.3 (23/67) 1.49 (0.77─2.92) Decreased functional status/ADL, decreased mobility 26.2 (39/149) 22.0 (18/82) 31.3 (21/67) 0.62 (0.29─1.28) Systemic S&S Fever 14.1 (21/149) 18.4 (15/82) 9.0 (6/67) 1.12 (0.82─1.53) Rigors 1.3 (2/149) 2.4 (2/82) 0 1.99 (0.60─6.64) Delirium (clear-cut) 16.8 (25/149) 18.3 (15/82) 14.9 (10/67) 1.17 (0.87─1.57) Other non-patient factors Consulting during evenings/weekends 14.8 (22/149) 17.1 (14/82) 11.9 (8/67) 1.52 (0.59─3.87) Physician spoke to the resident himself 44.3 (66/149) 57.3 (47/82) 53.7 (36/67) 1.156 (0.60─2.21) * Variables with a p value of α < 0.10 demonstrated in the univariate analysis were included and adjusted for age and gender in the multivariate logistic regression: residence on department for psychogeriatric illness, dementia, renal or urinary tract abnormalities (e.g., urinary retention, severe renal insufficiency (eGFR less than 30) or kidney stones), urgency, frequency, mental status change symptoms other than delirium, not being him/herself, and having cloudy urine, urine color change, and/or urine odor change. (Non) guideline/accordant urine dipstick test use In 45% of the 149 cases a urine dipstick test was not performed in accordance with the guideline. In the adjusted multivariate analyses, renal or urinary tract abnormalities (OR 0.29, 95% CI 0.09─0.96) and mental status change symptoms other than delirium (OR 0.34, 95% CI 0.15–0.77) were associated with more guideline non-accordant dipstick use. Having cloudy urine, urine color change and/or urine odor change (OR 2.47, 95% CI 1.06─5.73) was associated with more guideline-accordant urine dipstick test use (see Table 1 .). Interviews and focus groups Whereas a total of 53 nursing staff members had registered for participation in the focus groups, during sampling a large number turned out to be unavailable to participate and almost everyone turned out to be female. Consecutive sampling was therefore applied instead of the intended purposive selection. In total, two focus groups were conducted with a total of 14 nursing staff members (8 in focus group #1, 6 in focus group #2) from 10 different NHs. See Table 2 for characteristics of nursing staff participating in the focus groups (and ANNA study interviews). 1 , 2 Table 2 Characteristics of nursing staff participating in the ANNA study interviews and focus groups. Characteristics Interviews * Focus groups N = 9 N = 14 Gender Female 8 13 Educational level Nurse practitioner (NP) 1 Registered nurse (RN) 5 8 Certified nurse assistant (CNA) 4 3 Trainee nurse 2 Years of work experience Not asked 20y 3 Employed on department for Psychogeriatric illness 4 4 Somatic illness 2 6 (Mixed) psychogeriatric and somatic illness 3 4 * Interviews conducted in the ANNA study. Three main themes emerged from the analysis of the qualitative data (i.e., focus groups and ANNA study interviews): 1) urine dipstick test work processes, 2) knowledge and perceptions regarding urine dipstick testing, and 3) points for improvement. A description of the findings for each theme and the identified subthemes (indicated in italic) is presented below. Representative quotes are numbered and presented in Table 3 (q1–18). Table 3 Illustrative quotes for each (sub)theme. Illustrative quotes for each theme Participant identifiers: I = ANNA Interview, FG1 = Focus group 1, FG2 = Focus group 2, R = Registered nurse, CNA = Certified nurse assistant, TN = trainee nurse Nr. Quote Theme 1: The process of urine dipsticking 1 Then I think to myself… it’s also a matter of taking the family seriously… that the least you can do is test the urine. RN1_FG2 2 With us, in principle this has to go through the elderly care physician, but well, we have many stubborn old-fashioned nurses, who often do not wait it out. Officially, it must be at the request of the doctor. Ahm, but you also see that we do it ourselves in the first instance. Ahm, and we have already discussed that with the physician and the nurse specialist, like well, you know, if we notice that the behaviour is really different, then they also say ‘you can do it’. Ahm, but yes, officially the rules are that the physician has to give permission to do a stick test. But that's not how it happens [laughs]. CNA1_FG1 3 Then we always check whether only the leukos are discolored, or also the nitrite. Because people often say that if the leukos are discolored there is a urinary tract infection, well, we say well, then the nitrite must also be positive. If both the leukos and nitrite are positive, especially if the nitrite is really positive, then it really is a urinary tract infection. In practice you often only see leukos that are positive. If the nitrite is positive then it is really positive and there is a UTI. RN1_FG1 4 A few days ago, a client was reported to have had very pungent smelling urine for a few days already. Well yes, I thought, I’m not surprised. That lady is sitting in the hall all day and so she misses every coffee and tea round. So I really wonder if this lady is drinking enough. In the past I think we would have done a dipstick test right away, but now we go and bring her coffee and tea in the hall. And then the problem appears to be solved already. RN3_FG2 5 I noticed early when I first came to work here that urine was sticked pretty quickly, if people were even slightly confused or ahm, yeah that sort of thing. I now notice that yes, we often ask Goh's doctor ourselves, can we stick because I notice a change. Yes, and someone's behavior, but that the doctors soon become very reluctant, like let's just wait and take the temperature, things like that, and then start sticking. RN4_I 6 Okay, so I've been in health care since 1984, right. In the past, we used to do a urine test at the drop of a hat, and if you were lucky you got antibiotics right away too. That is really very different now. CNA2_FG2 7 We used to do it ourselves quickly, and now it's actually more like asking the doctor for permission first CNA1_I 8 […] that we simply removed the urine dipstick tests from the department. I think that in itself was a good start. CNA2_I Theme 2: Knowledge and perceptions about urine dipstick testing 9 In fact, it is important that the elderly care physician or the Nurse practitioner share the information of the guidelines. We basically don't know much about it. […] It's the physician’s responsibility to share this information RN3_FG2 10 To measure is to know, it is nice to go to the physician with a ‘complete story’, where, in addition to a description of the symptoms, the vital checks and urine dipstick results can also be passed on immediately. RN2_FG1 Theme 3: Suggestions for improvement 11 It takes a long time. You have to get all the long-term employees on board too. For them, it’s so natural to just do a dipstick test. So I think you should keep having to discuss it. TN_FG1 12 It simply starts with continuous communication, also with the long-term employees. It all comes down to your communication with the team and what you discuss. RN1_FG1 Urine dipstick test work processes Indications for performing a urine dipstick test , as mentioned by nursing staff, include the presence of UTI-related S&S, the presence of non-UTI related S&S (e.g., behavior change), the presence of S&S that were previously attributed to UTI (referred to as a ‘recurrent UTI’), a request of the residents’ family, and continuation of S&S after antibiotic treatment. With regard to a residents’ family request as a reason to perform a urine dipstick test, a motivation that was mentioned was that one should ‘take the family seriously’ (q1). It differs between NH organizations who decides that a dipstick test should be performed . In some NHs, nursing staff takes the initiative, whereas in other NHs physicians order urine dipstick tests. In the latter case, the agreement that nursing staff should await physicians’ orders is not always acted upon in practice (q2). It also differs per NH organization from which educational level nursing staff is allowed to perform a dipstick test ; in the one organization this is done by CNAs whereas in the other only RNs are allowed to perform the test. The urine dipstick test appeared to be well- accessible in the organizations of all participants, however, the storage location differed between NHs (e.g., this can be a nurse station, medication room or medicine cart). As for the interpretation of the test results , it was mentioned that in practice there are sometimes discussions about which results indicate a UTI (i.e., increased leukocyte esterase, presence of nitrite, or both). In addition, the colors on the dipstick test can be interpreted differently by different persons, leading to different conclusions (q3). Test results are communicated to the physician. It was mentioned that, in case of a positive dipstick test, action of the physician was expected by nursing staff, and often indeed undertaken. Here, ‘action’ can be ordering a urine culture, initiation of antibiotic treatment, or not starting antibiotic treatment but instead initiating other actions (e.g., stimulation of intake, consultation of a psychologist in case of behavior change). The participants mentioned that there have been changes in the work processes regarding urine dipstick test use in recent years. For example, unlike before, other causes are more often considered by nursing staff when a resident presents with non UTI-related S&S (q4). It was also mentioned that physicians have become more reluctant to order urine dipstick tests (q5), and also more reluctant to start antibiotic treatment in case of positive urine dipstick test results (q6). Further, it was mentioned that permission of a physician is more commonly required to perform a dipstick test (q7), and that dipstick tests are less wide-spread available within the NH (q8). Knowledge and perceptions regarding urine dipstick testing Nursing staff mentioned that most knowledge regarding urine dipstick testing is acquired at training institutes for nursing staff, whereas the practical procedures are generally learnt in practice. Among the participants, there was little knowledge of current guidelines stating that urinalysis should no longer be used to confirm a UTI diagnosis. Physicians are considered to be responsible for transferring new knowledge regarding this topic to nursing staff (q9). Finally, it was mentioned that the urine dipstick test is embedded in daily practice and is therefore used routinely as a habit. The urine dipstick test itself is perceived by nursing staff as “easy accessible” and “non-invasive for NH residents.” It was also mentioned that performing the test gives a ‘sense of control’. Further, nursing staff mentioned to appreciate having a tangible tool that provides quick results in recognition of UTI, and that enables them to get a ‘complete patients’ story’ for the physician (q10). Regarding perceptions on urine dipstick test work processes, the absence of a physician in the NH was considered a limitation of only performing a urine dipstick test after permission of a physician (i.e., it takes time to consult the physician). Other nursing staff members consider it an advantage to only perform a dipstick test after permission, as this prevents overuse of urine dipstick tests. Points for improvement Nursing staff indicates that the use of urine dipstick tests is ‘very much embedded’ in everyday practice, and that it therefore requires time to bring about change. In addition, they mention that repeatedly offering of the new knowledge is important (q11). This knowledge should be offered both during nursing education and in practice. Communication regarding the reason for change and the involvement of nursing teams are also considered important factors in bringing about change (q12). Several practical suggestions are made by the participants to promote guideline-accordant use of urine dipstick testing. First, as it can be perceived by nursing staff that something ‘tangible’ is being taken away from them, it may be considered to replace the urine dipstick test by other tangible tools , such as fluid intake lists or observation lists. Second, restricting access to the urine dipstick tests can prevent overuse. Finally, they mention the use or development of (educational) tools that promote knowledge regarding guideline-accordant urine dipstick test use, such as posters, e-learnings and educational sessions. Discussion In this study, we assessed the degree of guideline non-accordant urine dipstick test use and associated factors in NHs, and explored current processes and perceptions regarding urine dipstick test use among nursing staff. We found that the urine dipstick test is still used in two-thirds of UTI suspicions, and that almost half of these urine dipstick tests are not according current guidelines. 3 15 In addition, we gained in-depth insight in the work processes, knowledge and perceptions regarding urine dipstick use, and in opportunities to improve guideline-accordant urine dipstick use. Remarkably, we found that the urine dipstick test was used in a considerable number of suspected UTI cases in which a indwelling urinary catheter was present, while it has been known for decades that biofilm formation along the catheter surface causes bacteriuria, making the urine dipstick test a futile diagnostic tool in these patients 17 . For residents without an indwelling urinary catheter, we found that mental status change (other than delirium) and renal and urinary tract abnormalities are associated with more guideline non-accordant dipstick test use. It is striking that In line with previous literature, comorbidities such as renal or urinary tract abnormalities make it difficult to recognize UTI-related S&S. 18 – 20 As for mental status change, this is known as an important trigger for UTI suspicion in the older population, irrespective of the presence of UTI-specific S&S. 21 22 If a urine dipstick test is subsequently performed en found to be positive, a UTI may be incorrectly diagnosed and the many other possible causes for mental status change may be overlooked (and not addressed). It appears that the paradigm of atypical disease presentation is still present. Finally, having cloudy urine, urine color change, and/or urine odor change are associated with more guideline-accordant use of the urine dipstick test. This result is not in line with previous research observing that nursing staff members associate these symptoms with a UTI, 23 urging them to dipstick use (guideline non-accordant). Based on the qualitative study findings, improving guideline-accordant urine dipstick test use requires improved work processes, and knowledge and skills among nursing staff members. Clear work processes may contribute to more guideline-accordant urine dipstick test use, for instance with regard to agreements about who takes the initiative to use the test, who is allowed to perform the test, and the accessibility of the test. Knowledge gaps appeared to exist with regard to which S&S are indicative of UTI, the role of the urine dipstick test in UTI diagnosis (i.e., not to confirm, but to rule out), and possible alternatives for performing a urine dipstick test in case of non-UTI related S&S (e.g., ‘watchfull waiting’). Finally, improved skills are needed with regard to the interpretation of urine dipstick test results, mapping UTI-related S&S in NH residents, and dealing with urinalysis requests of residents or their relatives. From the interviews and focus groups, we can learn conditions for bringing about change towards more guideline-accordant urine dipstick test use. First, given that urine dipstick test use is very much embedded in daily routine practice, sufficient time should be allowed for the change process. Second, clear and repeated communication seems to be crucial: what should be changed? What is the reason hereford? And what is expected from nursing staff? Finally, to facilitate support for change, involvement of nursing teams is considered important in the change process given their central role in UTI diagnosis. 2425, 26 In addition to the abovementioned conditions, the identified perceptions of nursing staff regarding the urine dipstick test are important to bear in mind and address throughout the change process. Based on our qualitative findings, the urine dipstick test is a tool that brings a sense of ‘control’, and is perceived as ‘easy-accessible’, ‘easy-to-use’ and ‘non-invasive’. In the change process, instead of communicating that ‘something is being taken away’ from the nursing staff, if may therefore be better to focus on ‘something that is changing’ for nursing staff, and thereby to emphasize the important role that nursing staff plays in the recognition of UTI-related S&S. Finally, as nursing staff members appreciate the ‘tangible’ nature of the urine dipstick test, it may be beneficial to look for other ‘tangible’ tools as replacements, such as fluid intake registration lists or a previously developed observation checklist for UTI-related S&S in NH residents with impaired awareness or ability to communicate S&S. 27 Strengths & Limitations A strength of this study is the use of mixed-methods, with qualitative data in-depth complementing the quantitative results. Another strength is the combination of interviews, with nursing staff expressing their personal views, with focus groups, in which there was interaction between the participants. A limitation of this study is that two focus groups were held, more focus groups might have provided additional information. A second limitation of this study is that in the ANNA study cases were included at the level of a UTI-diagnosis as stated by the physician, and not at the level of a performed urine dipstick test (e.g., a dipstick test may have been performed by nursing staff, but the physician did not register the patient as he/she did not suspect a UTI). This may have led to an underestimation of the percentage guideline-non accordant urine dipstick tests. Conclusions This study shows that guideline non-accordant use of urine dipstick tests is common in NHs. Our findings can inform future strategies to improve guideline-accordant urine dipstick use. To this end, improved knowledge and skills of nursing staff is required, as well as clear work processes. As the use of the urine dipstick test is very much embedded in everyday practice, the change process requires sufficient time, clear and repeated communication, and involvement of nursing staff. Finally, the identified perceptions of nursing staff regarding urine dipstick test use are important to consider and address throughout the change process. Abbreviations (ASB) Asymptomatic Bacteriuria (CI) Confidence Interval (CNA) Certified Nurse Assistant (cRCT) cluster Randomized Controlled Trial (EHR) Electronic Health Record (NP) Nurse Practitioner (NH) Nursing Home (OR) Odds Ratio (RN) Registered Nurse (S&S) Signs and Symptoms (UTI) Urinary Tract Infection Declarations Ethics approval and consent to participate The Medical Ethics Review Committee of the Amsterdam University Medical Center, location VUmc, approved the study protocol from the ANNA-study on December 27, 2018. On February 26, 2019, the ANNA-study was registered in the Netherlands Trial Register under number NL7555. The Medical Ethics Review Committee of the Amsterdam University Medical Center, location AMC, reviewed the study protocol of the current study and judged that this study was exempted from ethical review (reference number FWA00017598). Written informed consent was obtained from all study participants or their representatives. Consent for publication Not applicable Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by Antibiotic Resistance Healthcare Network (ABR Zorgnetwerk), grant P5C. The funding body (ie, Antibiotic Resistance Healthcare Network, Netherlands [ABR Zorgnetwerk]) had no role in study design, methods, subject recruitment, data collection, analysis, and preparation of this article. Authors’ contributions Study concept and design: all authors Acquisition of data: KP, JR, and LvB Analysis and interpretation of data: all authors Drafting of the manuscript: KP and LvB Critical revision of the manuscript for important intellectual content: all authors Acknowledgments We thank the participating nursing staff members for their participation in this study. References Nicolle LE. Urinary tract infections in long-term-care facilities. Infect Control Hosp Epidemiol. 2001;22(3):167–75. 10.1086/501886 . (In eng). van Buul LW, van der Steen JT, Veenhuizen RB, et al. Antibiotic use and resistance in long term care facilities. J Am Med Dir Assoc. 2012;13(6):e5681–13. 10.1016/j.jamda.2012.04.004 . (In eng). van Buul LW, Veenhuizen RB, Achterberg WP, et al. Antibiotic prescribing in Dutch nursing homes: how appropriate is it? J Am Med Dir Assoc. 2015;16(3):229–37. 10.1016/j.jamda.2014.10.003 . (In eng). Holmes AH, Moore LS, Sundsfjord A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387(10014):176–87. 10.1016/s0140-6736(15)00473-0 . (In eng). Global burden of bacterial antimicrobial resistance. in 2019: a systematic analysis. Lancet. 2022;399(10325):629–55. 10.1016/s0140-6736(21)02724-0 . (In eng). Ashraf MS, Gaur S, Bushen OY, et al. Diagnosis, treatment, and prevention of urinary tract infections in post-acute and long-term care settings: A consensus statement from AMDA's Infection Advisory Subcommittee. J Am Med Dir Assoc. 2020;21(1):12–24. e2. Biggel M, Heytens S, Latour K, Bruyndonckx R, Goossens H, Moons P. Asymptomatic bacteriuria in older adults: the most fragile women are prone to long-term colonization. BMC Geriatr. 2019;19(1):1–11. Hedin K, Petersson C, Widebäck K, Kahlmeter G, Mölstad S. Asymptomatic bacteriuria in a population of elderly in municipal institutional care. Scand J Prim Health Care. 2002;20(3):166–8. Juthani-Mehta M. Asymptomatic bacteriuria and urinary tract infection in older adults. Clin Geriatr Med. 2007;23(3):585–94. Lin Y-T, Chen L-K, Lin M-H, Hwang S-J. Asymptomatic bacteriuria among the institutionalized elderly. J Chin Med Association. 2006;69(5):213–7. Aliyu S, Travers JL, Heimlich SL, Ifill J, Smaldone A. Antimicrobial stewardship interventions to optimize treatment of infections in nursing home residents: a systematic review and meta-analysis. J Appl Gerontol. 2022;41(3):892–901. Rutten JJS, van Buul LW, Smalbrugge M, et al. An Electronic Health Record Integrated Decision Tool and Supportive Interventions to Improve Antibiotic Prescribing for Urinary Tract Infections in Nursing Homes: A Cluster Randomized Controlled Trial. J Am Med Dir Assoc. 2022;23(3):387–93. 10.1016/j.jamda.2021.11.010 . (In eng). Rutten JJS, Smalbrugge M, van Buul LW, et al. A Process Evaluation of an Antibiotic Stewardship Intervention for Urinary Tract Infections in Nursing Homes. J Am Med Dir Assoc. 2024;25(1):146–e1549. 10.1016/j.jamda.2023.09.016 . (In eng). Rutten JJS, van Buul LW, Smalbrugge M, et al. Antibiotic prescribing and non-prescribing in nursing home residents with signs and symptoms ascribed to urinary tract infection (ANNA): study protocol for a cluster randomized controlled trial. BMC Geriatr. 2020;20(1):341. 10.1186/s12877-020-01662-0 . (Verenso) DAoECP. Guideline: urinary tract infections in frail older adults [Dutch]. 2018. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. 10.1093/intqhc/mzm042 . Stickler DJ. Bacterial biofilms in patients with indwelling urinary catheters. Nat Clin Pract Urol. 2008;5(11):598–608. 10.1038/ncpuro1231 . (In eng). Nicolle LE. Urinary Tract Infections in the Older Adult. Clin Geriatr Med. 2016;32(3):523–38. 10.1016/j.cger.2016.03.002 . (In eng). High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;48(2):149–71. Nicolle LE, Committee SL-TC. Urinary tract infections in long-term–care facilities. Infect Control Hosp Epidemiol. 2001;22(3):167–75. Latour K, De Lepeleire J, Catry B, Buntinx F. Nursing home residents with suspected urinary tract infections: a diagnostic accuracy study. BMC Geriatr. 2022;22(1):187. 10.1186/s12877-022-02866-2 . Hartman EAR, Groen WG, Heltveit-Olsen SR, et al. Decisions on antibiotic prescribing for suspected urinary tract infections in frail older adults: a qualitative study in four European countries. Age Ageing. 2022;51(6). 10.1093/ageing/afac134 . (In eng). Trautner BW, Greene MT, Krein SL, et al. Infection Prevention and Antimicrobial Stewardship Knowledge for Selected Infections Among Nursing Home Personnel. Infect Control Hosp Epidemiol. 2017;38(1):83–8. 10.1017/ice.2016.228 . (In eng). Broom A, Broom J, Kirby E, Scambler G. Nurses as Antibiotic Brokers: Institutionalized Praxis in the Hospital. Qual Health Res. 2017;27(13):1924–35. 10.1177/1049732316679953 . (In eng). Gbinigie OA, Ordóñez-Mena JM, Fanshawe TR, Plüddemann A, Heneghan C. Diagnostic value of symptoms and signs for identifying urinary tract infection in older adult outpatients: Systematic review and meta-analysis. J Infect. 2018;77(5):379–90. 10.1016/j.jinf.2018.06.012 . (In eng). Midthun SJ, Paur R, Lindseth G. Urinary tract infections. Does the smell really tell? J Gerontol Nurs. 2004;30(6):4–9. 10.3928/0098-9134-20040601-04 . (In eng). van Eijk J, Rutten JJS, Hertogh C, Smalbrugge M, van Buul LW. Observation of urinary tract infection signs and symptoms in nursing home residents with impaired awareness or ability to communicate signs and symptoms: The development of supportive tools. Int J Older People Nurs. 2023;18(5):e12560. 10.1111/opn.12560 . (In eng). Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. 10.1186/1471-2288-13-117 . (In eng). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4467344","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317801029,"identity":"84ba84d7-d514-4965-9939-629a79d5fe10","order_by":0,"name":"Kelly C. Paap","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYBACCRiDH0ozNkAZMgS1SIKUHkDSwkNQi8EBYrVINjA/YC6oscszPn46+fOHinuy/dPOmG74wXAHpxZpBjYD5hnHkovNzuRukzhwpth4xu0cs5s9DM9wapEDOoCZh405cduB3G0MB9sSEhuAWm4zMBwmoOVffeLm/rebPxz8l5A4n5AWaZAW3rbDiRskcjdIHGxISNxASItkM5vB4Zl9x4slbrzdJnHmWILxxttpZTd7DHBrkTje/PBxwbfqPP7+3M0fKmoSZOfdTt5240fFYTlcWhiYgW4AUglowgY4NcB0YWgZBaNgFIyCUYAAALRAWzGhpjrKAAAAAElFTkSuQmCC","orcid":"","institution":"Amsterdam University Medical Centers","correspondingAuthor":true,"prefix":"","firstName":"Kelly","middleName":"C.","lastName":"Paap","suffix":""},{"id":317801030,"identity":"c002d21d-4a11-49b1-8981-4f02af6106c3","order_by":1,"name":"Jeanine J.J.S. Rutten","email":"","orcid":"","institution":"Amsterdam University Medical Centers","correspondingAuthor":false,"prefix":"","firstName":"Jeanine","middleName":"J.J.S.","lastName":"Rutten","suffix":""},{"id":317801031,"identity":"fa1edc3a-3326-417e-a989-0d8faf55fbc9","order_by":2,"name":"Anouk M. van Loon","email":"","orcid":"","institution":"Amsterdam University Medical Centers","correspondingAuthor":false,"prefix":"","firstName":"Anouk","middleName":"M. van","lastName":"Loon","suffix":""},{"id":317801032,"identity":"c1c991eb-c000-42d5-b7f5-5b6ef29ea434","order_by":3,"name":"Cees M.P.M. Hertogh","email":"","orcid":"","institution":"Amsterdam University Medical Centers","correspondingAuthor":false,"prefix":"","firstName":"Cees","middleName":"M.P.M.","lastName":"Hertogh","suffix":""},{"id":317801033,"identity":"145fcca6-acdc-4aa1-9b0b-7248dddeb83e","order_by":4,"name":"Martin Smalbrugge","email":"","orcid":"","institution":"Amsterdam University Medical Centers","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Smalbrugge","suffix":""},{"id":317801034,"identity":"923bea3b-9636-48e2-b878-358ec935d17a","order_by":5,"name":"Laura W. van Buul","email":"","orcid":"","institution":"Amsterdam University Medical Centers","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"W. van","lastName":"Buul","suffix":""}],"badges":[],"createdAt":"2024-05-23 13:59:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4467344/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4467344/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62930651,"identity":"d587f915-5474-442c-9e69-57773e52ab0c","added_by":"auto","created_at":"2024-08-21 07:44:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":879535,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4467344/v1/64f5e1be-ab5f-4bec-bb86-2a3dcc75d1da.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Urine dipstick test use in Dutch nursing homes: a mixed-methods study to inform strategies for improved guideline-accordance","fulltext":[{"header":"Background","content":"\u003cp\u003eUrinary tract infections (UTIs) represent the most commonly diagnosed type of infection among nursing home (NH) residents.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e In many cases, however, this diagnosis is incorrect, leading to unnecessary antibiotic prescribing. One third of the antibiotic prescriptions for suspected UTIs has been reported to be inappropriate in the NH setting.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Inappropriate antibiotic prescribing should be avoided as it unnecessarily poses residents at risk of adverse events and is an important contributor to antibiotic resistance development.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA substantial part of inappropriate antibiotic prescribing for UTIs includes prescribing in response to positive urine dipstick test results.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e A urine dipstick test indicates the presence of bacteria (i.e., bacteriuria), and an inflammatory response (i.e., leukocyturia). Until recently, a positive urine dipstick test was considered a confirmation of a UTI in NH residents. However, a substantial part of older adults was found to have bacteriuria without the presence of (relevant) signs and symptoms (S\u0026amp;S): asymptomatic bacteriuria (ASB). Therefore, current guidelines state that urinalysis should no longer be used to confirm a UTI diagnosis. Instead, this diagnosis should be merely based on the presence of UTI-related S\u0026amp;S, such as dysuria and urgency.\u003csup\u003e\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e If such S\u0026amp;S are present, a urine dipstick test may be used to rule out a UTI diagnosis (i.e., an infection is unlikely if no nitrite and leukocytes are present).\u003c/p\u003e \u003cp\u003eThis implies that urine dipstick tests in NHs should only by performed when a physician considers a UTI based on the presence of UTI-related S\u0026amp;S in a resident. In current NH practice, however, urine dipstick tests are still frequently used by nursing staff in response to a broad array of \u0026ndash; often non-UTI related \u0026ndash; S\u0026amp;S, and a common reason to consult a physician.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e To improve guideline-accordant urine dipstick test use, it is important to first understand current processes and perceptions regarding urine dipstick test use.\u003c/p\u003e \u003cp\u003e In the current study, we therefore first quantified guideline non-accordant urine dipstick tests use, using an existing dataset of NH residents with suspected UTI, and assessed factors associated with guideline non-accordance. In addition, using qualitative methods, we in-depth explored current processes and perceptions regarding urine dipstick test use among nursing staff.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and population\u003c/h2\u003e \u003cp\u003eIn this mixed-methods study, we used a quantitative dataset of NH residents with suspected UTI, from a previous study (ANNA study),\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e to assess the degree of guideline non-accordant cases of urine dipstick test use and associated factors. To explore current processes and perceptions regarding urine dipstick test use among nursing staff in NHs, data from semi-structured interviews with nine nursing staff members, previously conducted as part of the aforementioned ANNA study, were used and complemented with newly conducted focus groups with 14 nursing staff members.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSampling and data collection\u003c/h2\u003e \u003cp\u003eThe ANNA study, from which the quantitative dataset was reused in the current study, was a cluster randomized controlled trial (cRCT) conducted in the period March 2019 \u0026ndash; March 2020.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e In this study, the appropriateness of treatment decisions for 295 cases of 'suspected UTI' (i.e, based on discretion of the physician) - was evaluated among residents of 16 Dutch NHs. In the intervention group (10 NHs), an electronic health record (EHR) integrated decision tool for the treatment of residents with suspected UTI, and supportive interventions, were implemented. In the control group (6 NHs), usual care was provided. For the current study, data of 294 cases of suspected UTIs (both control and intervention group data) with available data on urine dipstick test use were analyzed, including: patient characteristics, comorbidities, risk factors for UTI (i.e., recurrent UTI, renal or urinary tract abnormalities, diabetes mellitus, or compromised immunity (e.g., due to radiation therapy or use of immunosuppressive medication)), UTI related S\u0026amp;S, nonspecific S\u0026amp;S and other factors (i.e., consultation during evenings/weekends and whether the physician spoke to the resident in person).\u003c/p\u003e \u003cp\u003eWe also reused transcripts of semi-structured interviews with 9 nursing staff members, conducted as part of a process evaluation of the ANNA study in the period February \u0026ndash; April 2020.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Details on the methods regarding the conduction of these interviews can be found elsewhere.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e For the current study, transcript fragments coded with the labels \u0026lsquo;working method regarding urinalysis\u0026rsquo; and \u0026lsquo;influence of the ANNA study on the working method regarding urinalysis\u0026rsquo; were extracted by LvB, and subthemes were identified.\u003c/p\u003e \u003cp\u003eThe subthemes derived from the ANNA study interviews informed the development of the semi-structured topic (Additional file 1.) for the focus groups conducted in the current study. The focus group meetings started with an in-depth exploration of the work processes and perceptions regarding urine dipstick test use. Next, current evidence and guidelines on urine dipstick test use in NH residents was presented and reflected upon with the participants. Finally, possible opportunities for improvement of urine dipstick test use were explored with the participants.\u003c/p\u003e \u003cp\u003eFocus group participants were recruited though regional and national online communication channels of organisations active in the care for older people. Participants were eligible for participation if they were working in a NH as nurse practitioner (NP), registered nurse (RN), certified nurse assistant (CNA) or trainee nurse. Eligible potential participants were purposively selected based on organisation, educational level, years of work experience, gender and availability (in this order) to ensure maximum variation. A total of two focus groups (90 minutes each) were \u0026ndash; due to national Covid-19 restrictions \u0026ndash; held online, using Microsoft Teams, by the research team (moderator: LvB observers: KP and AvL) in the period January \u0026ndash; February 2022.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eUsing the quantitative dataset of suspected UTI cases of the ANNA study, we first analyzed whether or not urine dipstick test use was in accordance with the UTI guideline of the Dutch Association of Elderly Care Physicians (Verenso).\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e This implies that urine dipstick test use is considered guideline-accordant in case of: 1) presence of UTI-related S\u0026amp;S (i.e., two or more, one bothersome, combined with systemic S\u0026amp;S and/or combined with costovertebral angle pain/tenderness or suprapubic pain) or, 2) costovertebral angle pain/tenderness combined with systemic S\u0026amp;S. Next, univariate logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (CIs) were conducted to examine possible associations between various patient characteristics and guideline-accordant urine dipstick use (yes/no). The group \u0026lsquo;guideline-accordant urine dipstick test use\u0026rsquo; is used as a reference group. In the multivariate logistic regression analysis, variables with a \u003cem\u003ep\u003c/em\u003e value of α\u0026thinsp;\u0026lt;\u0026thinsp;0.10 demonstrated in the univariate analysis were included and adjusted for age and gender. The level of statistical significance was considered at α\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Analyses were done with IBM SPSS Statistics (version 28).\u003c/p\u003e \u003cp\u003eFor the qualitative analysis, first, focus groups interviews were transcribed verbatim and pseudonymised. \u0026lsquo;KP\u0026rsquo; and \u0026lsquo;LvB\u0026rsquo; independently coded the transcripts and developed a codebook of themes based on consensus, using MAXQDA (2022). The findings were discussed within the project group and an analytical framework of main and subthemes was created. Second, (sub)themes derived from the interviews of the ANNA studies were integrated in the analytical framework. From both sources (i.e., focus groups and interviews), verbatim quotes, illustrating the derived themes, were translated by a native speaker. In the conduction and reporting of the focus groups, we adhered to the COREQ guidelines.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e The Medical Ethics Review Committee of the Amsterdam University Medical Center, location VUmc, approved the study protocol from the ANNA-study on December 27, 2018. On February 26, 2019, the ANNA-study was registered in the Netherlands Trial Register under number NL7555. The Medical Ethics Review Committee of the Amsterdam University Medical Center, location AMC, reviewed the study protocol of the current study and judged that this study was exempted from ethical review (reference number FWA00017598). Written informed consent was obtained from all study participants or their representatives.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative analysis of suspected UTI cases\u003c/h2\u003e \u003cp\u003eA total of 294 cases of suspected UTI was analyzed. The mean age of included residents was 86 years, the majority was female (79%), and comorbidities were common.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Of the suspected UTI cases, 51 were in residents with an indwelling urinary catheter. In these cases, urine dipstick test use is not indicated according to guidelines. A urine dipstick test was nonetheless performed in 7/51 (13.7%) of these cases.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eUrine dipstick test use\u003c/h2\u003e \u003cp\u003eOf the 243 suspected UTI cases without an indwelling catheter, a urine dipstick test was performed in 149 cases (61.3%) (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics and symptomatology of suspected UTI cases in whom a urine dipstick test was performed, divided into guideline-accordant and guideline non-accordant dipstick test use, and including results of univariate and adjusted multivariate analyses.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUrine dipstick test performed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGuideline-accordant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon guideline-accordant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnivariate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMultivariate\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristics, comorbidities, risk factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;149), % (n/N)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;82), % (n/N)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;67, % (n/N)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, y (Mean, St dev.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.6 (σ6.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.9 (σ7.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86.4 (σ6.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.97 (0.92─1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87.2 (130/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.6 (71/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88.1 (59/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.14 (0.43─3.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence on department for psychogeriatric illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.2 (115/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.0 (59/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83.6 (56/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.50 (0.23─1.13)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.57 (0.18─1.78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDementia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.7 (88/145)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.2 (42/79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69.7 (46/66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.49 (0.25─0.98)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.63 (0.25─1.61)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47.0 (77/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.3 (38/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.8 (32/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.95 (0.49─1.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.4 (23/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.1 (14/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.4 (9/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.33 (0.54─3.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.5 (38/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.0 (18/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.9 (20/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.66 (0.32─1.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrine inontinence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.9 (52/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.7 (26/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.8 (26/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.73 (0.37─1.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrent UTI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.5 (47/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.5 (25/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.8 (22/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.89 (0.45─1.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal or\u0026nbsp;urinary tract\u0026nbsp;abnormalities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.8 (19/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.3 (6/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.4 (13/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.33 (0.12─0.92)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.29 (0.09─0.96)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUTI related signs and symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecent onset of dysuria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.9 (43/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.6 (39/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.7 (4/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.94 (0.62─1.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrgency (new/worsening)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.2 (54/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.4 (53/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5 (1/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e1.48 (0.96─2.29)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.69 (0.86─3.34)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency (new/worsening)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.2 (51/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.2 (51/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e1.45 (0.96─2.21)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.28 (0.67─2.45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrine incontinence (new/worsening)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.7 (16/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.9 (13/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.5 (3/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.41 (0.82─2.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Visible) urethral purulence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3 (2/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.4 (2/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.42 (0.76─2.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNon-specific signs and symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.8 (51/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.3 (15/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.4 (19/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.57 (0.26─1.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental status change symptoms other than delirium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.2 (51/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.8 (22/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.3 (29/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.48 (0.24─0.96)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.34 (0.15\u0026ndash;0.77)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot being him/herself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.6 (62/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.1 (28/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.7 (34/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.50 (0.26─0.98)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.59 (0.28\u0026ndash;1.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary output decrease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.4 (5/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.9 (4/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5 (1/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.39 (0.39─11.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary retention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.7 (7/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.1 (5/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.0 (2/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.11 (0.87─1.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCloudy urine, urine color change, urine odor change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.9 (49/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.0 (32/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.4 (17/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e1.88 (0.93─3.82)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e2.47 (1.06─5.73)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMacroscopic hematuria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.0 (6/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.9 (4/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.0 (2/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.67 (0.29─9.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral malaise or weakness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.6 (59/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.9 (36/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.3 (23/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.49 (0.77─2.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecreased functional status/ADL, decreased mobility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.2 (39/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.0 (18/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.3 (21/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.62 (0.29─1.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSystemic S\u0026amp;S\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.1 (21/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.4 (15/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.0 (6/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.12 (0.82─1.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRigors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3 (2/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.4 (2/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.99 (0.60─6.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelirium (clear-cut)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.8 (25/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.3 (15/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.9 (10/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.17 (0.87─1.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther non-patient factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsulting during evenings/weekends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.8 (22/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.1 (14/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.9 (8/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.52 (0.59─3.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysician spoke to the resident himself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.3 (66/149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.3 (47/82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.7 (36/67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.156 (0.60─2.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e*\u003c/sup\u003e Variables with a p value of α\u0026thinsp;\u0026lt;\u0026thinsp;0.10 demonstrated in the univariate analysis were included and adjusted for age and gender in the multivariate logistic regression: residence on department for psychogeriatric illness, dementia, renal or urinary tract abnormalities (e.g., urinary retention, severe renal insufficiency (eGFR less than 30) or kidney stones), urgency, frequency, mental status change symptoms other than delirium, not being him/herself, and having cloudy urine, urine color change, and/or urine odor change.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e(Non) guideline/accordant urine dipstick test use\u003c/h2\u003e \u003cp\u003e In 45% of the 149 cases a urine dipstick test was not performed in accordance with the guideline. In the adjusted multivariate analyses, renal or urinary tract abnormalities (OR 0.29, 95% CI 0.09─0.96) and mental status change symptoms other than delirium (OR 0.34, 95% CI 0.15\u0026ndash;0.77) were associated with more guideline non-accordant dipstick use. Having cloudy urine, urine color change and/or urine odor change (OR 2.47, 95% CI 1.06─5.73) was associated with more guideline-accordant urine dipstick test use (see Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInterviews and focus groups\u003c/h2\u003e \u003cp\u003eWhereas a total of 53 nursing staff members had registered for participation in the focus groups, during sampling a large number turned out to be unavailable to participate and almost everyone turned out to be female. Consecutive sampling was therefore applied instead of the intended purposive selection. In total, two focus groups were conducted with a total of 14 nursing staff members (8 in focus group #1, 6 in focus group #2) from 10 different NHs. See Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for characteristics of nursing staff participating in the focus groups (and ANNA study interviews).\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of nursing staff participating in the ANNA study interviews and focus groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterviews\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFocus groups\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;14\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse practitioner (NP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegistered nurse (RN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCertified nurse assistant (CNA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrainee nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of work experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot asked\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5-20y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;20y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed on department for\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychogeriatric illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomatic illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Mixed) psychogeriatric and somatic illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* Interviews conducted in the ANNA study.\u003c/p\u003e \u003cp\u003eThree main themes emerged from the analysis of the qualitative data (i.e., focus groups and ANNA study interviews): 1) urine dipstick test work processes, 2) knowledge and perceptions regarding urine dipstick testing, and 3) points for improvement. A description of the findings for each theme and the identified subthemes (indicated in italic) is presented below. Representative quotes are numbered and presented in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e (q1\u0026ndash;18).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIllustrative quotes for each (sub)theme.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eIllustrative quotes for each theme\u003c/p\u003e \u003cp\u003eParticipant identifiers: I\u0026thinsp;=\u0026thinsp;ANNA Interview, FG1\u0026thinsp;=\u0026thinsp;Focus group 1, FG2\u0026thinsp;=\u0026thinsp;Focus group 2, R\u0026thinsp;=\u0026thinsp;Registered nurse, CNA\u0026thinsp;=\u0026thinsp;Certified nurse assistant, TN\u0026thinsp;=\u0026thinsp;trainee nurse\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNr.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuote\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 1: The process of urine dipsticking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThen I think to myself\u0026hellip; it\u0026rsquo;s also a matter of taking the family seriously\u0026hellip; that the least you can do is test the urine. \u003cb\u003eRN1_FG2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith us, in principle this has to go through the elderly care physician, but well, we have many stubborn old-fashioned nurses, who often do not wait it out. Officially, it must be at the request of the doctor. Ahm, but you also see that we do it ourselves in the first instance. Ahm, and we have already discussed that with the physician and the nurse specialist, like well, you know, if we notice that the behaviour is really different, then they also say \u0026lsquo;you can do it\u0026rsquo;. Ahm, but yes, officially the rules are that the physician has to give permission to do a stick test. But that's not how it happens [laughs]. \u003cb\u003eCNA1_FG1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThen we always check whether only the leukos are discolored, or also the nitrite. Because people often say that if the leukos are discolored there is a urinary tract infection, well, we say well, then the nitrite must also be positive. If both the leukos and nitrite are positive, especially if the nitrite is really positive, then it really is a urinary tract infection. In practice you often only see leukos that are positive. If the nitrite is positive then it is really positive and there is a UTI. \u003cb\u003eRN1_FG1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA few days ago, a client was reported to have had very pungent smelling urine for a few days already. Well yes, I thought, I\u0026rsquo;m not surprised. That lady is sitting in the hall all day and so she misses every coffee and tea round. So I really wonder if this lady is drinking enough. In the past I think we would have done a dipstick test right away, but now we go and bring her coffee and tea in the hall. And then the problem appears to be solved already. \u003cb\u003eRN3_FG2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI noticed early when I first came to work here that urine was sticked pretty quickly, if people were even slightly confused or ahm, yeah that sort of thing. I now notice that yes, we often ask Goh's doctor ourselves, can we stick because I notice a change. Yes, and someone's behavior, but that the doctors soon become very reluctant, like let's just wait and take the temperature, things like that, and then start sticking. \u003cb\u003eRN4_I\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOkay, so I've been in health care since 1984, right. In the past, we used to do a urine test at the drop of a hat, and if you were lucky you got antibiotics right away too. That is really very different now. \u003cb\u003eCNA2_FG2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWe used to do it ourselves quickly, and now it's actually more like asking the doctor for permission first \u003cb\u003eCNA1_I\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[\u0026hellip;] that we simply removed the urine dipstick tests from the department. I think that in itself was a good start. \u003cb\u003eCNA2_I\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 2: Knowledge and perceptions about urine dipstick testing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn fact, it is important that the elderly care physician or the Nurse practitioner share the information of the guidelines. We basically don't know much about it. [\u0026hellip;] It's the physician\u0026rsquo;s responsibility to share this information \u003cb\u003eRN3_FG2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo measure is to know, it is nice to go to the physician with a \u0026lsquo;complete story\u0026rsquo;, where, in addition to a description of the symptoms, the vital checks and urine dipstick results can also be passed on immediately. \u003cb\u003eRN2_FG1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 3: Suggestions for improvement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIt takes a long time. You have to get all the long-term employees on board too. For them, it\u0026rsquo;s so natural to just do a dipstick test. So I think you should keep having to discuss it. \u003cb\u003eTN_FG1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIt simply starts with continuous communication, also with the long-term employees. It all comes down to your communication with the team and what you discuss. \u003cb\u003eRN1_FG1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eUrine dipstick test work processes\u003c/h2\u003e \u003cp\u003e \u003cem\u003eIndications for performing a urine dipstick test\u003c/em\u003e, as mentioned by nursing staff, include the presence of UTI-related S\u0026amp;S, the presence of non-UTI related S\u0026amp;S (e.g., behavior change), the presence of S\u0026amp;S that were previously attributed to UTI (referred to as a \u0026lsquo;recurrent UTI\u0026rsquo;), a request of the residents\u0026rsquo; family, and continuation of S\u0026amp;S after antibiotic treatment. With regard to a residents\u0026rsquo; family request as a reason to perform a urine dipstick test, a motivation that was mentioned was that one should \u0026lsquo;take the family seriously\u0026rsquo; (q1). It differs between NH organizations \u003cem\u003ewho decides that a dipstick test should be performed\u003c/em\u003e. In some NHs, nursing staff takes the initiative, whereas in other NHs physicians order urine dipstick tests. In the latter case, the agreement that nursing staff should await physicians\u0026rsquo; orders is not always acted upon in practice (q2). It also differs per NH organization \u003cem\u003efrom which educational level nursing staff is allowed to perform a dipstick test\u003c/em\u003e; in the one organization this is done by CNAs whereas in the other only RNs are allowed to perform the test. The urine dipstick test appeared to be well-\u003cem\u003eaccessible\u003c/em\u003e in the organizations of all participants, however, the storage location differed between NHs (e.g., this can be a nurse station, medication room or medicine cart). As for the \u003cem\u003einterpretation of the test results\u003c/em\u003e, it was mentioned that in practice there are sometimes discussions about which results indicate a UTI (i.e., increased leukocyte esterase, presence of nitrite, or both). In addition, the colors on the dipstick test can be interpreted differently by different persons, leading to different conclusions (q3). Test results are communicated to the physician. It was mentioned that, in case of a positive dipstick test, action of the physician was \u003cem\u003eexpected\u003c/em\u003e by nursing staff, and often indeed undertaken. Here, \u0026lsquo;action\u0026rsquo; can be ordering a urine culture, initiation of antibiotic treatment, or not starting antibiotic treatment but instead initiating other actions (e.g., stimulation of intake, consultation of a psychologist in case of behavior change).\u003c/p\u003e \u003cp\u003eThe participants mentioned that there have been \u003cem\u003echanges in the work processes\u003c/em\u003e regarding urine dipstick test use in recent years. For example, unlike before, other causes are more often considered by nursing staff when a resident presents with non UTI-related S\u0026amp;S (q4). It was also mentioned that physicians have become more reluctant to order urine dipstick tests (q5), and also more reluctant to start antibiotic treatment in case of positive urine dipstick test results (q6). Further, it was mentioned that permission of a physician is more commonly required to perform a dipstick test (q7), and that dipstick tests are less wide-spread available within the NH (q8).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge and perceptions regarding urine dipstick testing\u003c/h2\u003e \u003cp\u003eNursing staff mentioned that most \u003cem\u003eknowledge\u003c/em\u003e regarding urine dipstick testing is acquired at training institutes for nursing staff, whereas the practical procedures are generally learnt in practice. Among the participants, there was little knowledge of current guidelines stating that urinalysis should no longer be used to confirm a UTI diagnosis. Physicians are considered to be responsible for transferring new knowledge regarding this topic to nursing staff (q9). Finally, it was mentioned that the urine dipstick test is embedded in daily practice and is therefore used routinely as a habit.\u003c/p\u003e \u003cp\u003eThe urine dipstick test itself is \u003cem\u003eperceived\u003c/em\u003e by nursing staff as \u0026ldquo;easy accessible\u0026rdquo; and \u0026ldquo;non-invasive for NH residents.\u0026rdquo; It was also mentioned that performing the test gives a \u0026lsquo;sense of control\u0026rsquo;. Further, nursing staff mentioned to appreciate having a tangible tool that provides quick results in recognition of UTI, and that enables them to get a \u0026lsquo;complete patients\u0026rsquo; story\u0026rsquo; for the physician (q10).\u003c/p\u003e \u003cp\u003eRegarding perceptions on urine dipstick test work processes, the absence of a physician in the NH was considered a limitation of only performing a urine dipstick test after permission of a physician (i.e., it takes time to consult the physician). Other nursing staff members consider it an advantage to only perform a dipstick test after permission, as this prevents overuse of urine dipstick tests.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePoints for improvement\u003c/h2\u003e \u003cp\u003eNursing staff indicates that the use of urine dipstick tests is \u0026lsquo;very much embedded\u0026rsquo; in everyday practice, and that it therefore requires \u003cem\u003etime\u003c/em\u003e to bring about change. In addition, they mention that \u003cem\u003erepeatedly offering of the new knowledge\u003c/em\u003e is important (q11). This knowledge should be offered both during nursing education and in practice. \u003cem\u003eCommunication regarding the reason for change\u003c/em\u003e and the \u003cem\u003einvolvement of nursing teams\u003c/em\u003e are also considered important factors in bringing about change (q12).\u003c/p\u003e \u003cp\u003e Several practical suggestions are made by the participants to promote guideline-accordant use of urine dipstick testing. First, as it can be perceived by nursing staff that something \u0026lsquo;tangible\u0026rsquo; is being taken away from them, it may be considered to \u003cem\u003ereplace the urine dipstick test by other tangible tools\u003c/em\u003e, such as fluid intake lists or observation lists. Second, \u003cem\u003erestricting access\u003c/em\u003e to the urine dipstick tests can prevent overuse. Finally, they mention the \u003cem\u003euse or development of (educational) tools that promote knowledge\u003c/em\u003e regarding guideline-accordant urine dipstick test use, such as posters, e-learnings and educational sessions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e In this study, we assessed the degree of guideline non-accordant urine dipstick test use and associated factors in NHs, and explored current processes and perceptions regarding urine dipstick test use among nursing staff. We found that the urine dipstick test is still used in two-thirds of UTI suspicions, and that almost half of these urine dipstick tests are not according current guidelines.\u003csup\u003e3 15\u003c/sup\u003e In addition, we gained in-depth insight in the work processes, knowledge and perceptions regarding urine dipstick use, and in opportunities to improve guideline-accordant urine dipstick use.\u003c/p\u003e \u003cp\u003eRemarkably, we found that the urine dipstick test was used in a considerable number of suspected UTI cases in which a indwelling urinary catheter was present, while it has been known for decades that biofilm formation along the catheter surface causes bacteriuria, making the urine dipstick test a futile diagnostic tool in these patients\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. For residents without an indwelling urinary catheter, we found that mental status change (other than delirium) and renal and urinary tract abnormalities are associated with more guideline non-accordant dipstick test use. It is striking that In line with previous literature, comorbidities such as renal or urinary tract abnormalities make it difficult to recognize UTI-related S\u0026amp;S.\u003csup\u003e\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e As for mental status change, this is known as an important trigger for UTI suspicion in the older population, irrespective of the presence of UTI-specific S\u0026amp;S. \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e If a urine dipstick test is subsequently performed en found to be positive, a UTI may be incorrectly diagnosed and the many other possible causes for mental status change may be overlooked (and not addressed). It appears that the paradigm of atypical disease presentation is still present. Finally, having cloudy urine, urine color change, and/or urine odor change are associated with more guideline-accordant use of the urine dipstick test. This result is not in line with previous research observing that nursing staff members associate these symptoms with a UTI, \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e urging them to dipstick use (guideline non-accordant).\u003c/p\u003e \u003cp\u003e Based on the qualitative study findings, improving guideline-accordant urine dipstick test use requires improved work processes, and knowledge and skills among nursing staff members. Clear work processes may contribute to more guideline-accordant urine dipstick test use, for instance with regard to agreements about who takes the initiative to use the test, who is allowed to perform the test, and the accessibility of the test. Knowledge gaps appeared to exist with regard to which S\u0026amp;S are indicative of UTI, the role of the urine dipstick test in UTI diagnosis (i.e., not to confirm, but to rule out), and possible alternatives for performing a urine dipstick test in case of non-UTI related S\u0026amp;S (e.g., \u0026lsquo;watchfull waiting\u0026rsquo;). Finally, improved skills are needed with regard to the interpretation of urine dipstick test results, mapping UTI-related S\u0026amp;S in NH residents, and dealing with urinalysis requests of residents or their relatives.\u003c/p\u003e \u003cp\u003e From the interviews and focus groups, we can learn conditions for bringing about change towards more guideline-accordant urine dipstick test use. First, given that urine dipstick test use is very much embedded in daily routine practice, sufficient time should be allowed for the change process. Second, clear and repeated communication seems to be crucial: what should be changed? What is the reason hereford? And what is expected from nursing staff? Finally, to facilitate support for change, involvement of nursing teams is considered important in the change process given their central role in UTI diagnosis.\u003csup\u003e2425,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn addition to the abovementioned conditions, the identified perceptions of nursing staff regarding the urine dipstick test are important to bear in mind and address throughout the change process. Based on our qualitative findings, the urine dipstick test is a tool that brings a sense of \u0026lsquo;control\u0026rsquo;, and is perceived as \u0026lsquo;easy-accessible\u0026rsquo;, \u0026lsquo;easy-to-use\u0026rsquo; and \u0026lsquo;non-invasive\u0026rsquo;. In the change process, instead of communicating that \u0026lsquo;something is being taken away\u0026rsquo; from the nursing staff, if may therefore be better to focus on \u0026lsquo;something that is changing\u0026rsquo; for nursing staff, and thereby to emphasize the important role that nursing staff plays in the recognition of UTI-related S\u0026amp;S. Finally, as nursing staff members appreciate the \u0026lsquo;tangible\u0026rsquo; nature of the urine dipstick test, it may be beneficial to look for other \u0026lsquo;tangible\u0026rsquo; tools as replacements, such as fluid intake registration lists or a previously developed observation checklist for UTI-related S\u0026amp;S in NH residents with impaired awareness or ability to communicate S\u0026amp;S.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStrengths \u0026amp; Limitations\u003c/h2\u003e \u003cp\u003eA strength of this study is the use of mixed-methods, with qualitative data in-depth complementing the quantitative results. Another strength is the combination of interviews, with nursing staff expressing their personal views, with focus groups, in which there was interaction between the participants.\u003c/p\u003e \u003cp\u003eA limitation of this study is that two focus groups were held, more focus groups might have provided additional information. A second limitation of this study is that in the ANNA study cases were included at the level of a UTI-diagnosis as stated by the physician, and not at the level of a performed urine dipstick test (e.g., a dipstick test may have been performed by nursing staff, but the physician did not register the patient as he/she did not suspect a UTI). This may have led to an underestimation of the percentage guideline-non accordant urine dipstick tests.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003e This study shows that guideline non-accordant use of urine dipstick tests is common in NHs. Our findings can inform future strategies to improve guideline-accordant urine dipstick use. To this end, improved knowledge and skills of nursing staff is required, as well as clear work processes. As the use of the urine dipstick test is very much embedded in everyday practice, the change process requires sufficient time, clear and repeated communication, and involvement of nursing staff. Finally, the identified perceptions of nursing staff regarding urine dipstick test use are important to consider and address throughout the change process.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e(ASB) Asymptomatic Bacteriuria\u003c/p\u003e\n\u003cp\u003e(CI) Confidence Interval\u003c/p\u003e\n\u003cp\u003e(CNA) Certified Nurse Assistant\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(cRCT) cluster Randomized Controlled Trial\u003c/p\u003e\n\u003cp\u003e(EHR) Electronic Health Record\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(NP) Nurse Practitioner\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(NH) Nursing Home\u003c/p\u003e\n\u003cp\u003e(OR) Odds Ratio\u003c/p\u003e\n\u003cp\u003e(RN) Registered Nurse\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(S\u0026amp;S) Signs and Symptoms\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(UTI) Urinary Tract Infection\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Medical Ethics Review Committee of the Amsterdam University Medical Center, location VUmc,\u0026nbsp;approved the study protocol from the ANNA-study on December 27, 2018. On February 26, 2019, the ANNA-study was registered in the Netherlands Trial Register under number NL7555.\u0026nbsp;The Medical Ethics Review Committee of the Amsterdam University Medical Center, location AMC, reviewed the study protocol of the current study and judged that this study was exempted\u0026nbsp;from\u0026nbsp;ethical review\u0026nbsp;(reference number FWA00017598). Written informed consent was obtained from all study participants or their representatives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Antibiotic Resistance Healthcare Network (ABR Zorgnetwerk), grant P5C. The funding body (ie, Antibiotic Resistance Healthcare Network, Netherlands [ABR Zorgnetwerk]) had no role in study design, methods, subject recruitment, data collection, analysis, and preparation of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy concept and design: all authors\u003c/p\u003e\n\u003cp\u003eAcquisition of data: KP, JR, and LvB\u003c/p\u003e\n\u003cp\u003eAnalysis and interpretation of data: all authors\u003c/p\u003e\n\u003cp\u003eDrafting of the manuscript: KP and LvB\u003c/p\u003e\n\u003cp\u003eCritical revision of the manuscript for important intellectual content: all authors\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the participating nursing staff members for their participation in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNicolle LE. 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(In eng).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Nursing home, urinary tract infection, urine dipstick, urinalysis, guideline-accordance","lastPublishedDoi":"10.21203/rs.3.rs-4467344/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4467344/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Current guidelines stated that urinalysis should no longer be used to confirm a urinary tract infection (UTI) diagnosis in nursing home (NH) residents, urine dipstick tests are still frequently used by nursing staff in response to a broad array of – often non-UTI related – S\u0026amp;S. This study gain insight into factors associated with guideline non-accordant urine dipstick test use in NHs, and explore the current processes and perceptions regarding urine dipstick test use among nursing staff.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Mixed-methods study in Dutch NHs.\u003c/p\u003e\n\u003cp\u003eParticipants: NH residents with a suspected UTI and nursing staff members. \u003cbr\u003e\n Measurements: In an existing dataset of 294 cases of suspected UTI, we compared patient characteristics between guideline-accordant and non-accordant urine dipstick test use. We additionally explored processes and perceptions regarding urine dipstick test use, using data from previously conducted interviews with 9 nursing staff members complemented with 2 newly conducted focus groups with 14 nursing staff members.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A urine dipstick test was performed in 13.7% of 51 residents with an indwelling urinary catheter. A urine dipstick test was performed in 61.3% of 243 suspected cases without an indwelling catheter, 45% of which was not guideline-accordant. Renal or urinary tract abnormalities [OR 0.29, 95% CI 0.09─0.96] and mental status change other than delirium (OR 0.34, 95% CI 0.15─0.77) were associated with more guideline non-accordant dipstick use. Having cloudy urine, urine color change and/or urine odor change (OR 2.47, 95% CI 1.06─5.73) was associated with more guideline-accordant urine dipstick test use. The qualitative findings provided in-depth insight into current work processes regarding the urine dipstick test, knowledge and perceptions, and points for improvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Guideline non-accordant urine dipstick test use is common in NHs. Improved knowledge and skills of nursing staff is needed, as well as clear work processes. As the urine dipstick test is very much embedded in everyday practice, the change process requires sufficient time, clear and repeated communication, and involvement of nursing staff. Throughout the change process, the perceptions of nursing staff identified in this study are important to consider and address.\u003c/p\u003e","manuscriptTitle":"Urine dipstick test use in Dutch nursing homes: a mixed-methods study to inform strategies for improved guideline-accordance","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-26 09:53:42","doi":"10.21203/rs.3.rs-4467344/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6631c8ab-2ed7-463f-a76d-93f2aa9b5682","owner":[],"postedDate":"June 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-21T07:36:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-26 09:53:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4467344","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4467344","identity":"rs-4467344","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}