VANDERBILT UNIVERSITY MEDICAL CENTER
POINT OF CARE TESTING
MULTISTIX 10 SG URINE REAGENT STRIP
VISUAL PROCEDURE
MULTISTIX10 SG test for Glucose, Bilirubin, Ketone (Acetoacetic Acid), Specific
Gravity, Blood, pH, Protein, Urobilinogen, Nitrite, and Leukocytes in Urine.
The Point of Care Testing (POCT) program at Vanderbilt University Medical Center
(VUMC) is overseen and coordinated by the POCT Steering Committee as chartered by
the Medical Center Medical Board. The POCT Steering Committee administers the
program with the primary goal of meeting clinical need in the most cost-effective manner
possible. In order to provide for both regulatory compliance and appropriate utilization
of POCT, any clinical area wishing to perform POCT must be approved by the POCT
Steering Committee and must maintain acceptable performance according to criteria set
forth in Hospital Policy 20-23.
I.
PRINCIPLES:
The reaction of Siemens Multistix 10 SG test strips depends on color development as
an indicator of the concentration of the following test reactions.

The pH test reaction uses methyl red/bromthymol blue indicator system, which
provides pH readings from 5.0 - 8.5. The color of the test pad changes from orange
to green to blue in this range of pH.

The glucose test is based on a double sequential enzyme reaction, which requires
glucose oxidase, peroxidase, and potassium iodide. A glucose specific enzyme,
glucose oxidase, catalyzes the formation of gluconic acid and H 202 from the
oxidation of glucose. The enzyme peroxidase catalyzes the reaction of H 202 with a
potassium iodide chromogen to oxidize the chromogen to colors ranging from green
to brown.

The protein reaction uses tetrabromophenol blue reagent buffered at a pH of 3.
This colorimetric method is based on a concept known as the “protein error of
indicators,” where the point of color change of certain buffered pH indicators is
different in the presence or absence of protein. Colors range from yellow (negative)
through yellow-green, green, and blue-green, as positivity increases. The protein
test pad is more sensitive to albumin than globulins (such as gamma-globulin, Bence
Jones, hemoglobin, and mucoprotein), and a negative result does not necessarily
rule out the presence of these other proteins

The ketone reaction uses sodium nitroprusside reagent, which, in the presence of
acetoacetic acid produces a color change from buff-pink (negative) to purple as
ketone concentration increases. Acetone and B-hydroxybutyric acid are not
detected with this method.

The bilirubin reaction occurs when bilirubin reacts with diazonium salt (2,4
dichloroaniline) to form a tan color.
Multistix Visual Urinalysis Proc 2-2006
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VANDERBILT UNIVERSITY MEDICAL CENTER
POINT OF CARE TESTING
MULTISTIX 10 SG URINE REAGENT STRIP
VISUAL PROCEDURE

Urobilinogen reaction is due to the reaction of urobilinogen with
diethylaminobenzaldehyde, (in an acid medium), producing a pink-red color.

Leukocyte Esterase reaction is due to derivatized pyrrole amino acid ester and
diazonium salt. Leukocytes of the granulocyte series contain the enzyme, esterase,
in their granules. This enzyme catalyzes the hydrolysis of the amino acid ester to
liberate the pyrrole compound, in turn reacting with the diazonium salt, resulting in a
purple color.

Nitrite reaction occurs when Nitrite reacts with p-arsanilic acid yielding a diazonium
compound which, in turn, couples with a quinolin reagent to produce a uniform pink
color. Pink spots or edges should not be interpreted as positive.

The Specific Gravity test reaction is based on apparent pka change of certain
pretreated polyelectrolytes in relation to ionic concentration. In the presence of an
indicator, color ranges from deep blue-green in urine of low ionic concentration
through green and yellow-green in urines by increasing ionic concentration. This
reaction employs 2.8% w/w bromthymol blue, 68.8% w/w/ poly (methyl vinyl
ether/maleic anhydride); 28.4% w/w/ sodium hydroxide.

Blood reaction is based on the peroxidase-like activity of hemoglobin, which
catalyzes the reaction of diisopropylbenzene dihydroperoxide and uses 3, 3’5, 5’ tetramethylbenzidine. Blood is detected as intact red cells or as free hemoglobin,
although the reagent pad is much more sensitive to the latter. The reaction is based
on the liberation of oxygen from peroxide by the peroxidase-like activity of heme. In
this test a benzidine compound is oxidized to a colored product ranging from orange
to green to dark blue.
II.
p-
SCOPE OF PRACTICE:
Urine reagent strip testing may be performed by VUMC RN’s, LPN’s, Patient Care
Partners/Technicians, Operating Room Technicians, and Nursing Externs working in
areas/units approved by the POCT Steering Committee to perform point of care urine
reagent strip testing. To maintain this privilege, testing must be performed in
accordance with VUMC hospital POCT policy. All staff performing testing must attend
POCT orientation, annual proficiency testing, and follow established testing protocol.
Multistix Visual Urinalysis Proc 2-2006
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VANDERBILT UNIVERSITY MEDICAL CENTER
POINT OF CARE TESTING
MULTISTIX 10 SG URINE REAGENT STRIP
VISUAL PROCEDURE
III.
PURPOSE:
Siemens Multistix 10 SG and other various Siemens reagent test strips are used as a
screening procedure to monitor carbohydrate metabolism, kidney and liver function,
acid-base balance and urinary tract functions. It is recommended that a confirmation
microscopic exam be performed on the original sample if any of the following are
positive:

Blood, Protein, Nitrite, Leukocyte
Further evaluation or tests may be performed on the original sample if the following are
positive:

Bilirubin, Ketones
IV.
SPECIMEN COLLECTION:
A. Conditions for Patient Preparation
 Follow Patient Preparation and Collection Procedure for Point of Care Testing
policy.
B. Specimen Type
 At least 12mls of urine (first morning urine recommended)
C. Handling Conditions
 Use Standard Precautions
 Collect in a clean, dry container.
 Do not centrifuge
 Use of preservatives is not recommended.
 Test urine immediately. Refrigerate if testing cannot be performed within one
hour of voiding and let it return to room temperature before testing.
 Urine with prolonged exposure to room temperature and light may yield
altered results for bilirubin, urobilinogen, pH, glucose, and nitrite tests.
V. REAGENTS/SUPPLIES:
Siemens Multistix 10 SG reagent test strips (based on dry weight at time of
impregnation)
 Glucose: 2.2% w/w glucose oxidase;1.0% w/w peroxidase; 8.1% w/w
potassium iodide; 69.8% w/w buffer; 18.9% w/w nonreactive ingredients
 Bilirubin: 0.4% w/w 2,4-dichloroaniline diazonium salt; 37.3% w/w buffer;
62.3% w/w nonreactive ingredients
 Ketone: 7.1% w/w sodium nitroprusside; 92.9 % w/w buffer
 Specific Gravity: 2.8% w/w bromthymol blue; 68.8% w/w poly(methyl
vinyl ether/maleic anhydride); 28.4%w/w sodium hydroxide
Multistix Visual Urinalysis Proc 2-2006
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VANDERBILT UNIVERSITY MEDICAL CENTER
POINT OF CARE TESTING
MULTISTIX 10 SG URINE REAGENT STRIP
VISUAL PROCEDURE

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


Blood: 6.8% w/w diisopropylbenzene dihydroperoxide; 4.0% w/w 3,3’,5,tetramethylbenzidine; 48.0% w/w buffer; 41.2% non-reactive ingredients
pH: 0.2% w/w methyl red; 2.8% w/w bromthymol blue; 97.0% w/w inactive
ingredients
protein: 0.3% w/w tetrabromphenol blue; 97.3% w/w buffer; 2.4% w/w
nonreactive ingredients
Urobilinogen: 0.2% w/w p-diethylaminobenzaldehyde; 99.8% w/w
nonreactive ingredients
Nitrite: 1.4% w/w p-arsanilic acid; 1.3% w/w 1,2,3,4-tetrahydrobenzo(h)quinolin-3-ol; 10.8% w/w buffer; 86.5% w/w nonreactive ingredients.
Leukocytes: 0.4% w/w derivatized pyrrole amino acid ester; 0.2% w/w
diazonium salt; 40.9% w/w buffer; 58.8% w/w nonreactive ingredients
BIO-RAD Control System - Urine control Level I and Level II : Human
erythrocytes, constituents of animal origin, chemicals, and preservatives.
VI.
STORAGE AND STABILITY:



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
VII.
Reagent strips must be stored in the original capped vial at room temperature
(below 85 degrees F/ 30 degrees C). Replace cap immediately after removing
test strip.
Opened reagent strips may be used until the printed expiration date on the
vial if quality control testing is acceptable.
BIO-RAD qUAntify control Levels 1 and 2 will be stable until the
manufacturer’s expiration date when unopened controls are stored at 2-8°C
(36-46°F).
Vials of BIO-RAD qUAntify control Levels 1 and 2 once opened will be stable
for 31 days when stored tightly capped at 2-25°C (refrigerated or room
temperature).
All reagent strips and quality control (QC) must be labeled with staff initials
and a valid expiration date.
Do not freeze control solution
Do not store reagent strips in direct sunlight
CALIBRATION:
N/A
VIII.

QUALITY CONTROL (QC):
Control systems evaluate the accuracy of testing technique, as well as the
function and stability of the products used.
Multistix Visual Urinalysis Proc 2-2006
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
VANDERBILT UNIVERSITY MEDICAL CENTER
POINT OF CARE TESTING
MULTISTIX 10 SG URINE REAGENT STRIP
VISUAL PROCEDURE
Quality Control (Level I –negative and Level II-positive) must be tested every 24
hours on each open bottle of Multistix 10SG reagent strips that are being used
for patient testing.
Quality Control Testing Procedure:
1. Check the expiration date on the control bottle—(expires 1 month after
opening) and verify the lot # of the Control Package Insert matches the lot
# of the control solution.
2. Allow control solution to reach room temperature (15-30 minutes). Verify
the reagent strips are in-date for use.
3. Remove reagent strip and immediately recap the vial.
4. Shake control bottle gently, to mix and remove dropper cap.
5. Invert control bottle and apply control material directly across each pad by
gently squeezing the bottle, making sure not to touch tip of bottle to test
strip pads and each pad is wet. Wipe bottle tip and replace cap.
6. Remove excess control by tilting the reagent strip on its edge to blot.
(This will prevent color pads from running together)
7. Read the color reactions by comparing each pad to the corresponding test
on the label’s color chart. Each test should be read at the manufacturer’s
designated times printed on the label.
8. Record each test result as it is read. Compare results to the Control
Package Insert written on POCT QC log.
 Quality Control Results must be within expected ranges (acceptable)
before performing patient testing.
 The Control Package Insert is included with each bottle of control delivered to the
patient care area and must be posted in the area where reagent strip control testing
is performed and recorded.
 The results you obtain when running the control must match the insert.
 Always replace the insert when new lot # of control is placed into use.
Multistix Visual Urinalysis Proc 2-2006
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VANDERBILT UNIVERSITY MEDICAL CENTER
POINT OF CARE TESTING
MULTISTIX 10 SG URINE REAGENT STRIP
VISUAL PROCEDURE
QUALITY CONTROL PACKAGE INSERT (Expected Results)
VISUAL
LEVEL II
ANALYTE
*This lot # will change. Control

* LOT # A2502
values may vary from lot to lot.
ALWAYS make sure that the lot
GLUCOSE
250-500 mg/dl
# on the Control Package Insert
BILIRUBIN
Small - Moderate
Matches the lot # on the Urine
KEYTONE
15 - 40 mg/dl
control bottle. This Control
SPECIFIC
1.010 - 1.020
Package Insert is inside each
GRAVITY
box of Controls
BLOOD
Moderate - Large
pH
7.0 - 8.5
PROTEIN
30 - 100 mg./dl
UROBILINOGEN
2 - 4 EU/dl
NITRITE
Positive
LEUKOCYTES
Trace - Small
 IF CONTROL IS NOT WITHIN EXPECTED RANGES follow the corrective action
steps outlined below
B.
Corrective Action
1. Check expiration dates on control bottle and urine reagent strips. If supplies
are "out of date", obtain new supplies. If supplies are "in date", repeat test.
2. If control is still out of range, replace bottle of control and rerun.
3. If control is still out of range, replace vial of reagent strips and rerun.
4. If control is still out of range, call the POCT Center at 3-5707 or 3-8416
IX.
PATIENT TEST PROCEDURE
 Observe Standard Precautions
1.
2.
3.
Mix urine well before immediately before testing.
Remove one strip from reagent strip bottle and replace cap. Immerse test
strip in urine (all reagent pads should be wet), then remove immediately.
Remove excess urine by dragging the edge of the strip across the top of
the specimen container, then blot reagent strip by tilting on its edge onto
paper towel.
Multistix Visual Urinalysis Proc 2-2006
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VANDERBILT UNIVERSITY MEDICAL CENTER
POINT OF CARE TESTING
MULTISTIX 10 SG URINE REAGENT STRIP
VISUAL PROCEDURE
4.
Compare reagent pads to the corresponding Color Chart on the bottle
label at the specified times. Record results as they are read. Since some
color reactions develop over time it is important to read reactions at the
recommended times.
5.
It is recommended that a microscopic exam on the original sample be
performed when any of the following analytes are positive: Blood, Protein,
Nitrite, or Leukocyte esterase. Additional tests may be performed if
bilirubin or ketone tests are positive.
Recommended Test Strip Read Times:
Glucose
30 seconds
Bilirubin
30 seconds
Ketones
40 seconds
Specific Gravity
45 seconds
Blood
60 seconds
pH
60 seconds (can read immediately)
Protein
60 seconds
Urobilinogen
60 seconds
Nitrite
60 seconds
Leukocyte esterase
60 seconds (Pos.)-120 seconds (Neg.)
X.
RESULT REPORTING:
Test result names may be abbreviated as shown below. You must include the units for
each result where applicable, when reporting patient test results in permanent medical
record. The use of symbols ( + / - ) are not acceptable when reporting out patient or QC
results.
TEST
ABBREVIATIO
N
UNITS
mg/dL
NORMAL RANGES
GLUCOSE
GLU
NEGATIVE
Bilirubin
BIL
Ketone
KET
Specific Gravity
SG
1.016 – 1.022
PH
PH
5.0-8.0
NEGATIVE
mg/dL
NEGATIVE
Protein
PRO
mg/dL
NEGATIVE
Urobilinogen
URO
E.U./dL
0.2 - 1.0
Nitrite
NIT
NEGATIVE
Blood
BLO
NEGATIVE
Leukocytes
LEU
NEGATIVE
Multistix Visual Urinalysis Proc 2-2006
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VANDERBILT UNIVERSITY MEDICAL CENTER
POINT OF CARE TESTING
MULTISTIX 10 SG URINE REAGENT STRIP
VISUAL PROCEDURE
XI.
DOCUMENTATION:
Record the following information on the appropriate Quality Control (QC) Log Sheet:

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

NOTE:
Date and time of control testing.
Reagent strip lot # and expiration date.
Control lot # and expiration date.
Control results.
Any corrective action.
Initials and job title of person performing testing.
If quality control is not performed because patient testing is not
required on a given date or shift, “No Patient Testing” must be indicated
on the log sheet.
Record the following information in the patients’ medical record:




Date and time of patient testing
Test strip results
Initials and job title of person performing testing.
Multistix Lot # & expiration date
Storage refrigeration temperatures must be verified and recorded daily on provided
logs.
XII.
QUALITY ASSESSMENT:
The manager or designee has oversight of the following requirements:

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All POCT performed in patient care areas have been approved by the
Diagnostic Laboratories and the State of Tennessee.
Testing is performed only by staff approved by the Diagnostic Laboratories
and the State of Tennessee.
All staff are trained prior to testing, and assessed for competency annually.
Individuals responsible for staff training and /or compliance review, (quality
control and patient documentation), have attended appropriate training
sessions provided by the POCT Support Center.
Initial training records, current annual competency records and “designated”
trainer records must be accessible.
Notification to the POCT Support Center of any changes or transfer of testing
personnel.
Current testing procedures and accessible to all testing staff.
Multistix Visual Urinalysis Proc 2-2006
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VANDERBILT UNIVERSITY MEDICAL CENTER
POINT OF CARE TESTING
MULTISTIX 10 SG URINE REAGENT STRIP
VISUAL PROCEDURE
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Quality control and maintenance procedures are performed, documented and
reviewed for compliance by the manager or designee at least weekly, and are
accessible for two years following review. Any corrective action is noted, and
filed with records.
Routine review of random patient medical records by manager or designee to
verify compliance with patient test result documentation as described in
testing procedures. Examples must be available for inspections.
All testing supplies are stored and labeled according to instructions found in
individual testing procedures.
CAP proficiency testing, as required, is performed according to accompanying
instructions and results and requested information returned to the POCT
Support Center within specified time frame.
Diagnostic Laboratories POCT Support Center Provides:

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Technical support
Training
Content of training materials and testing procedures
Validation and implementation of testing methodologies
Assistance with request for testing privileges
The POCT Steering Committee is chartered by the VUMC Medical Board and has the
authority to revoke testing privileges.
XIII.
LIMITATIONS:
1. Drugs that contain azo dyes (e.g. Pyridium) nitrofurantoin ( e. g.
Macrodantin), and riboflavin, cause abnormal urine color and may affect
the color development on the reagent pad resulting in both false positive
and negative results.
2. The pH of the urine can become alkaline on standing due to release of
C02 or production of ammonia by urea splitting bacteria. The pH of highly
alkaline urine can appear lower due to a “run-over” effect where acid
buffer from the protein reagent pad runs over the adjacent pH pad. Highly
pigmented urines may mask the color reaction.
3. False negatives at the trace glucose level can be seen when elevated
levels of ketone or ascorbic acid are present.
4. False positive proteins may be seen with highly buffered, alkaline urines,
exposure to quaternary ammonium compounds, or exposure to skin
cleansers containing chlorhexidine.
5. False positive ketone results can be seen in highly pigmented urine
specimens and in the presence of high levels of levodopa.
Multistix Visual Urinalysis Proc 2-2006
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VANDERBILT UNIVERSITY MEDICAL CENTER
POINT OF CARE TESTING
MULTISTIX 10 SG URINE REAGENT STRIP
VISUAL PROCEDURE
6. False negative bilirubin results may occur with old specimens due to
oxidation of bilirubin, and ascorbic acid levels > 25 mg/dL. Indican and
other pigmented drugs may interfere with test interpretation.
7. False positive urobilinogen results may occur with para-aminosalicylic
acid (a bacterial drug) and sulfonamides. False negatives results may
occur when formaldehyde is present. Highly pigmented urines may mask
the color reaction.
8. Strong oxidizing agents can cause false positive leukocyte results.
Falsely lowered reading may be caused by elevated: 1) glucose ( 3000
mg/dL); 2) specific gravity; 3) protein; 4) various drugs including,
tetracycline, cephalothin, cephalexin and ascorbic acid. Highly pigmented
urines, especially those containing azo dyes, may mask this reaction.
9. False negative nitrites may occur with: 1) ascorbic acid levels > 25 mg/dL
at low nitrite levels; 2) improper bladder incubation time (< 4 hours); 3)
lack of dietary nitrate; 4) high urine specific gravity.
10. Highly buffered alkaline urines may cause low specific gravity readings
relative to other methods. Elevated specific gravity readings may be
obtained in the presence of moderate quantities (100 - 750 mg/dL) of
protein.
11. False positive blood may occur with certain oxidizing contaminants such
as hypochlorite and microbial peroxidase. Elevated specific gravity may
reduce the reactivity of the test.
Sensitivity:
Glucose
Bilirubin
Ketone
Blood
Protein
Nitrite
Leukocytes
75 -125 mg/dL
0.4 – 0.8 mg/dL
5 – 10 mg/dL
0.015 – 0.062 mg/dL
15 – 30 md/dL
0.06 – 0.1 mg/dL
5 –15 cells/ hpf in clinical urine
Linearity:
Glucose
Bilirubin
Ketone
Specific Gravity
pH
Protein
Urobilinogen
Nitrite
Blood
Leukocyte
Multistix Visual Urinalysis Proc 2-2006
2000
Large
160
1.030
8.5
2000
8.0
Positive
Large
Large
Page 10 of 11
VANDERBILT UNIVERSITY MEDICAL CENTER
POINT OF CARE TESTING
MULTISTIX 10 SG URINE REAGENT STRIP
VISUAL PROCEDURE
XIV.
PROCEDURAL NOTES:
1. Urine must be collected in a clean dry container free from any detergents,
or disinfectant residue since the oxidants contain in such cleaning agents
may cause the test areas on the urine test strips for blood and glucose to
indicate false positive results.
2. Do not touch the testing area with anything except urine or control
solution.
3. Do not use test strip if the testing areas are discolored.
4. Do not cut or manipulate test strips.
5. Because this test is visually read and requires color differentiation,
individuals with color blindness should not interpret results.
6. If urine test strip screening is unavailable due to QC, supply or staffing
issues, patient specimens must be sent to the hospital Laboratory for
testing.
XV.
SAFETY:
 Observe Standard Precautions
1. Staff using the Siemens Multistix 10 SG should use personal protective
equipment (PPE) when performing urine reagent strip testing.
2. OSHA and institution protocols for handling bio-hazardous materials
should be observed at all times.
XVI.
REFERENCES:
1. Siemens: MULTISTIX10SG Product Insert # AN30516F, Siemens
Healthcare Diagnostics Inc., Tarrytown, NY 10591-5097 USA. Rev.
08/08.
2. BIO-RAD: Control System product insert #02A-975. BIO-RAD
Laboratories, Clinical Diagnostics Group, 9500 Jeronimo Road, Irvine,
California 92618. Rev 8-2008.
3. VUMC Hematology- Urine Reagent strip Testing Procedure, 2002
4. VUMC POCT Support Center
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