1. Do We Always Need A UA?
A cost conscious project on urinalysis In Inpatient Medicine
Alexander Abadir PGY2

2. How Often Are we Getting a Urinalysis?
- Examining the records of 36 recent admissions to UC Irvine Internal Medicine Teams (A + B) revealed that 20 of the 36 patients had a Urinalysis obtained on admission.
- Of these, 35 were admitted from the emergency department and one a direct transfer.
- Principle diagnosis varied greatly from CHF exacerbation and chest pain to lower extremity cellulitis or induction of chemotherapy.

3. So What is Wrong with a UA?
Nothing!
- A UA is a broad, relatively inexpensive test that can shed light on a multitude of disease processes. Diabetes, poisoning, CNS disease and of course genitourinary tract infections are some of the many types of diseases can be hinted at with a UA.
- Provided the patient is urinating, it is an entirely noninvasive study with no significant complications.
- Busy in the ED? A UA without preservative can be held for as much as an hour at room temperature before degradation of particles begins1.
- Turnaround time can be on average 10 minutes in a community hospital, faster in an academic setting. A urine dipstick is almost instantaneous2.
Delanghe J, Speeckaert M. Preanalytical requirements of urinalysis. Biochem Med (Zagreb). 2014;24(1): Published 2014 Feb 15. doi: /BM
Starting with bacteria, then other cells
Hawkins RC. Laboratory turnaround time. Clin Biochem Rev. 2007;28(4):

5. Indications
- While the test is an excellent screening tool, issues arise with indications.
- There are many indications for a UA on admission: dysuria or frequency changes, flank pain, hematuria or color changes, CVA tenderness, sepsis without another source, urinary retention, acute nephrolithiasis, catheter obstruction, AKI, electrolyte abnormalities, poisoning, abnormal serum protein/albumin are the most common experienced inpatient. Others may include AMS, fever, or rigors otherwise unexplained.
- However, it is common for patients to have a UA obtained without any of the above indications.

6. The Study
- 36 admitted patients were selected from 2 internal medicine services having been admitted since the start of February There were no exclusion criteria for this study.
- Of these, patients were broken down into two categories: Those indicating a UA by HPI and initial assessment (including labs, imaging, etc.) and those that did not have an indication.
- 13 patients were identified as having a UA performed on admission as indicated. The vast majority were for AKI, though 3 had symptoms concerning for UTI.
- Of the remaining 23, 7 had UAs on admission (30.4%). Of these 2 were send for culture due to positive findings.

7. Why Does it Matter?
- While UAs are comparatively inexpensive, they still cost money and resources. According to healthcare bluebook in our zip code a UA fair price costs $7, and a urine culture $26. Of course in the inpatient setting with a STAT order from the ED we can expect it to be significantly higher.
- Given that in the study 35% of the UAs obtained were not indicated, over a third of the UAs were medical largess.
- Asymptomatic pyuria and bacteriuria is exceptionally common, occurring in large percentages of the population4.

8. Asymptomatic Bacteriuria
- A positive UA in an asymptomatic patient can confuse the clinical scenario (ex. What if the are immunocompromised? IDSA has no recommendation for this category C-III)
- It may confound the clinical picture and least to increased antibiotic use as well as increased testing, which further drives healthcare cost.
Lindsay E. Nicolle, Suzanne Bradley, Richard Colgan, James C. Rice, Anthony Schaeffer, Thomas M. Hooton; Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults, Clinical Infectious Diseases, Volume 40, Issue 5, 1 March 2005, Pages 643–654, 

9. Conclusion
- In this small sample size, approximately a third of UAs ordered were not indicated.
- Of the 7 not indicated, 2 led to culture, further increasing the cost to ~$30 if this was fair priced, which it was likely not.
- Not only does this drive cost, but this effects further testing and antibiotic use, which can have longer term complications.
References:
1. Delanghe J, Speeckaert M. Preanalytical requirements of urinalysis. Biochem Med (Zagreb). 2014;24(1): Published 2014 Feb 15. doi: /BM
2. Hawkins RC. Laboratory turnaround time. Clin Biochem Rev. 2007;28(4):
3. Pallin DJ, Ronan C, Montazeri K, et al. Urinalysis in acute care of adults: pitfalls in testing and interpreting results. Open Forum Infect Dis. 2014;1(1):ofu019. Published 2014 Jun 23. doi: /ofid/ofu019
4. Lindsay E. Nicolle, Suzanne Bradley, Richard Colgan, James C. Rice, Anthony Schaeffer, Thomas M. Hooton; Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults, Clinical Infectious Diseases, Volume 40, Issue 5, 1 March 2005, Pages 643–654,