Prof. Frank Chinegwundoh MBE
Consultant urological surgeon, Barts Health NHS Trust
Urine is the diagnostic key to myriad conditions across urology, antenatal health, STIs, diabetes and increasingly certain cancers.
“Urine is so critical to basic medicine, it is hard to understand why there is no standard for its collection.
This range of unreliability and lack of standard procedure, would not be tolerated in most areas of medicine.
“The absence of a urine collection standard has led to a huge variety of collection methods in use across the NHS, which in turn leads to a significant disparity in the quality of specimen results; national contamination rates range from under 5% to over 70%. This range of unreliability would not be tolerated in most areas of medicine, not least because it leads to diagnostic difficulty and delays for patients and clinicians. When you learn that over 65m specimens are delivered to the NHS annually, you begin to appreciate the scale of a problem that potentially leaves over 14m patients undiagnosed every year, with significant time, resources and money wasted.
Infections could be avoided
“Modern medicine is grappling with an increase in Healthcare Acquired Infections (HCAIs), antimicrobial resistance (AMR), urinary tract infections (UTIs), blood infections, sepsis and other life-threatening medical conditions all of which could be ameliorated by the creation of a national standard around accurate urine collection and reliable analysis.
“Urine collection methods have not changed in decades and improvement is long overdue. With NHS resources being squeezed at every level, we must not ignore the need to bring basic urological diagnostic practice into line with other areas of medicine.
Untreated UTIs are masking infections like e-coli.
“The report, “Preventing healthcare associated gram-negative bacterial blood infections” was issued by Public Health England and NHS Improvement in May this year and cites untreated UTI as responsible for 47% of gram-negative blood infections of e-coli, which can lead to sepsis – and even death.
“Treating a UTI relies on accurate urine specimen collection as outlined by PHE UK Standards for Microbiology Investigation of Urine 2017; data from one of the UK’s leading out of hours GP services suggests that untreated UTI is also responsible for the second highest rate of emergency patient visits – at huge cost to the NHS.
Innovation exists that can save lives and money
“Most importantly however, the continuing emergence and spread of AMR is a real threat to public health; high levels of broad spectrum antibiotic prescribing and use, both in hospitals and primary care, is the main driver and every opportunity to educate the public, reduce and manage overuse should be seized. This applies not only to clinicians like myself, but to GPs, frontline nursing staff, health visitors and all of my colleagues who deal directly with patients.
Patients complained to him about the messy collection process.
“A few years ago I came across an innovative and novel urine collection device. Peezy Midstream was conceived and designed by NHS GP Dr Vincent Forte in response to repeat visits from patients who he thought he had treated, but whose conditions returned after a course of broad spectrum antibiotics had been completed. They also complained to him about the messy collection process of start-stop-start into a small Universal Container.
“I decided to trial Peezy Midstream at Barts Health NHS Trust Royal London Hospital to see if we could improve how urine samples being checked for infection were collected. We looked for three things:
- would we get a proper midstream specimen (MSU)?
- would it be easier to collect the sample, especially for women?
- would it be cleaner – and drier?
“Up until this point, our contamination rates were running at 17.4% – below average but still in my opinion too high. The microbiology report would come back saying “scanty growth” or “mixed growth” and so on; growth indicates contamination. You really want the report to say either “no growth” or that there is growth of a particular organism, which is often E. coli.
“We looked to see if by using this device we could reduce contamination, get a better representation of what was happening within the bladder and whether an infection was present The trial is ongoing but so far we’ve found contamination significantly reduced to 1.5% – that’s a massive difference to the historic 17.4%.
“Most patients like it and find it easy to use, appreciating the hygiene, dry hands and dry container. Our experience has been borne out by a more recent usability study by the NHS National Institute for Health Research through the West Midlands Academic Health Science Network (AHSN).
“The ability to use devices such as the Peezy Midstream would make a positive difference and take us some way towards a national reliable and accurate standard. My colleagues and I would be able to provide right-first-time diagnosis and treatment and patients would receive the quality of service that they should expect from the NHS with time and money being saved.
“Adoption of new processes in the NHS can be complex and, of course, there are upfront cost implications which challenge the silo budget systems endemic across both public and private healthcare systems and which can prevent innovation being adopted. I believe though that in cases such as this, the argument for better and more accurate diagnosis and treatment is worth the initial investment, and in due course will be cost-effective.
There are projected direct national savings of over £55m and efficiency savings of £1.5bn.
“The economic model for Peezy Midstream points to direct national savings of over £55m and efficiency savings of £1.5bn; in the interests of clinical and financial excellence I would welcome the opportunity for this model to be examined, and the benefits of accurate urine diagnostics properly assessed by our policy makers who are striving for radical improvement and right-first-time patient care.
“At a recent conference, one of the speakers said it takes on average around 17 years for an innovation to progress from conception to adoption. In this case, I hope we will move faster. A better process enabling right-first-time diagnosis and treatment plus financial savings can only be to the benefit of all.”