North East Valley Division of General Practice
Aged Care GP Panels Initiative
October 2006
Aged Care GP Panels Initiative
Case Study
Urine Testing Protocol
Division: North East Valley Division of General Practice (NEVDGP), Victoria
Program team: Dr Mary Belfrage, Dr Alison Sands, Ms Clare Chiminello
1. Context
NEVDGP is located in the North Eastern suburbs of Melbourne. The Division’s aged care
funding covers 40 aged care homes. Our Aged Care Program team is unusual in that two
GPs have a major role in project management, development of resources, & liaison with aged
care homes & GPs. One of our key platforms has been a focus on developing relationships
with our aged care homes. The positive communication & promotion of a team approach
offered by our two GPs has broken down many barriers that previously existed between aged
care home staff & GPs.
2. Background
Early in the Initiative, the NEVDGP Project Team interviewed GPs who worked in aged care.
Many of them reported high levels of frustration with the handling of urine in ACHs. That is,
there was wide-spread screening of urine in the absence of clinical indications for testing.
This generated calls to GPs reporting dipstick urinalysis results and presumptive diagnoses of
urinary tract infections, and requests for urgent GP attendances at the ACH and often
pressure to prescribe (unnecessary) antibiotics. It raised the question about (i) whether or not
screening urine in this population in this setting is appropriate and (ii) if so, whether or not
there is a screening tool that meets the necessary requirements in terms of sensitivity and
specificity.
3. Aims
 Improve management of urine testing & diagnosis of urinary tract infection in aged
care home residents
 Provide evidence-based guidelines for urine testing for aged care home staff
 Provide evidence-based guidelines for urine testing in residential aged care for GPs
 Reduce rates of incorrect diagnosis of UTI & unnecessary use of antibiotics
 Reduce unnecessary and time consuming telephone calls to GPs
 Reduce unnecessary requests for urgent GP attendance
 Provide education for both GPs and aged care home staff
 Promote the uptake of these guidelines in our local aged care facilities
 Share the resources we develop Australia-wide
4. Process
We undertook an informal review of usual practices of urine testing in our local ACHs,
which confirmed a high rate of testing of urine, both by dipstick urinalysis and by MSU and
formal pathology. This was both screening (the well resident) and investigating (the unwell
resident). We postulated this amount of testing lead to
 over-diagnosis of UTI
 large numbers of calls to GPs requesting attendance at the ACH
 frequent prescribing of antibiotics with
o no positive benefit
o the potential for medication-related complications
o a contribution to the development of resistant organisms
 excessive cost associated with current practice including
o tests
o ACH staff and GP time
o pathology services and medications
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North East Valley Division of General Practice
Aged Care GP Panels Initiative
October 2006
4. Process
We also undertook a review of medical literature which supported that, within the
residential aged care setting,
 UTI is over diagnosed and over treated
 elderly people have such high rates of bacteruria and pyuria there is no role for screening
of urine
 dipstick urinalysis is neither sensitive nor specific enough to be used as a screening tool
in this population
 clinical assessment should provide the basis for suspicion of urinary tract infection
 MSU and formal pathology is the investigation of choice and should be done when there
is a clinical suspicion of UTI
 even formal pathology testing of urine has reduced specificity (high false positive rate) in
this population and results should be interpreted in the clinical context
This led to a decision that the NEVDGP Aged Care project team would develop guidelines for
urine testing in the residential aged care setting.
Development of Urine Testing Protocol
As well as being informed by medical literature, the protocol was developed in consultation
with:
 Geriatricians
 NEVDGP Aged Care Project Advisory Group
 Directors-of-nursing of ACHs
 GPs
A Urine Testing Kit was developed comprising:
 Guide for GPs
 Guide for ACHs
 references to support the protocol
We recognized that, as this protocol reflected significant changes to traditional practice,
implementation would require extensive education and promotion to GPs and to ACH
staff. This was done by:
 launching the protocol at a workshop of DONs from ACHs in our region. The
launch included a presentation by a geriatrician
 sending a letter and copy of the protocol to all GPs in our Division
 presenting at meetings between GPs and ACH staff and/or management
 developing an Educators Guide for teaching ACH staff
 providing education to ACH staff provided by Project Team GPs in individual
ACHs
 website posting
 distribution to several other Divisions and key hospitals
 inclusion in the NEVDGP Aged Care Newsletter
Aged Care Program team GPs offered visits to aged care homes to provide 45 minute
education sessions for staff (RN Div 1 & 2 & PCAs). The GPs adapted the presentation to suit
the knowledge level of attendees & were able to use their own clinical knowledge &
experience to discuss questions raised by attendees
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North East Valley Division of General Practice
Aged Care GP Panels Initiative
October 2006
5. Achievement / Outcomes
Given the limitations of our resources we have not formally evaluated the protocol. Anecdotal
feedback indicates that it has been well received by ACHs and GPs:
 numerous ACHs have ceased routine testing without observing adverse
effects
 ACHs report a perceived reduction in costs in terms of staff time and testing
equipment
 post education questionnaires completed by ACH staff indicate the education
sessions are highly valued
 GPs report fewer phone calls, fewer requests to attend the ACH that are
prompted by urine testing results and fewer requests for antibiotic
prescriptions
The Urine Testing Protocol is based on current evidence and expert opinion. Formal
evaluation would establish whether or not implementation of the protocol can be endorsed as
best practice in residential aged care.
Appendices
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Urine Testing Protocol: GP Guide
Urine Testing Protocol: Aged Care Home Guide
Urine Testing Protocol References
Urine Testing Protocol: Guide for the Educator
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