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EBP/INFORMATION LITERACY ASSIGNMENT 1

Evidence Based Practice/Information Literacy Assignment

Marla K. Michaels

University of Mary


Evidence Based Practice/Information Literacy Assignment

Evidence based practice (EBP) is a learning approach to clinical practice that incorporates

a systematic search, critical appraisal and synthesis of the most relevant and best research

evidence to answer burning questions (Melnyk & Fineout-Overholt, 2011). The ever-evolving

health care environment experiences more chaos and instability than most other industries and

predicates the need for EBP to have a more significant role in the nursing discipline. One of the

many duties of a nurse administrator is to manage the organizational environment in effort to

provide a climate of optimal nursing care nursing care by clinical nurses and ancillary staff

(Roussel, 2013). This is only achieved by adhering to a set of standards that includes the ability

to enhance collaborative relationships, advocate for patients and partners in the community,

embrace change and innovation, manage resources effectively, negotiate and resolve conflict,

and communicate effectively using information technology (Roussel, 2013). EBP is instrumental

in providing safe, effective, and efficient quality patient care, and nurse managers should be

proficient in their abilities to search for, appraise, and apply empirical evidence from the

expansive body of research on health care management and possess and exude the experience,

education, and qualifications necessary to uphold these standards (Roussel, 2013).

Clinical Inquiry Scenario

Urinary tract infection (UTI) is one the most frequently diagnosed bacterial infections in

children (Vaillancourt, McGillivray, Zhang & Kramer, 2007). In the ambulatory pediatric

nephrology clinical practice setting I work, a urine specimen is collected from every patient to

for urinalysis. We currently provide patients and caregivers with two or three non-sterile gauze

pads and verbal instructions to moisten the pads with tap water and clean the perineal/genital

area before collecting a mid-stream urine specimen. Nurses and care assistants spend a


significant amount of time providing instructions for collecting the urine specimens and even ask

for patients and caregivers to repeat the instructions back to ensure understanding; however, the

majority of patients and parents do not comply with the instructions. We find evidence of this in

the number of dry gauze pads left in the bathroom, wrapped around the specimen cups, or when

patients or caregivers come out of the bathroom with the dry pads in their hand and ask where

they should put them. The “clean catch” urine collection technique, including our modified

version stated here, used to obtain a urine specimen in the pediatric population is time-

consuming to explain, uncomfortable for patients and caregivers, usually performed incorrectly,

and directly linked to increased costs (Leisure, Dudley, and Donowitz, 1993; Vaillancourt et al.,

2007). In an article by Leisure, Dudley and Donowitz (1993), it was noted that a reliable

midstream urine sample for culture could be used in female adults without perineal washing. Is

there an implication here for urinalysis and urine culture testing in children? Furthermore,

cleansing agents used during the clean catch technique have been associated with false negative

urinalysis results and it has been agreed upon that a urinalysis can be performed on virtually any

specimen (Bitsori and Galanakis, 2012). With the time, cost, and accurate clean catch technique

issues, along with the false negatives associated with using cleansing agents during clean catch

urine collections in ambulatory potty-trained pediatric patients, could cleaning the perineum with

tap water and non-sterile gauze pads yield a reduced rate of mid-stream urine specimen

collection contamination than no cleaning before a mid-stream urine collection?

PICO question: In the toilet-trained ambulatory pediatric patient population, does using

tap water and non-sterile gauze pads to clean the perineum compared with no cleaning before

mid-stream urine collection decrease the rate of bacterial contamination in samples submitted for

urinalysis?


Population: Ambulatory pediatric patients

Intervention: No cleansing before mid-stream urine collection

Comparison: Clean with gauze and tap water before mid-stream collection

Outcome: Increase clinic efficiency, patient compliance and satisfaction, decrease costs

Literature Search and Data Abstraction

The organization I work for provides a fully staffed Health Sciences Library that is

accessible via the intranet or on site. The intranet site allows employees access to many

individual research databases. I perused MEDLINE, CINAHL, and Cochrane using the key

words urine collection, cleansing, contamination, and urinalysis individually and in several

different combinations, which resulted in a wide range of over 111,000 articles to just one (see

Appendix A). After my own search and collection of several articles, I also employed assistance

from the Health Sciences Librarian by filling out the electronic Literature Request Form, for

which I provided my PICO question, and within two days I was provided six articles.

Interestingly, the three articles I determined to be the best for the assignment, I found on my own

first and they were also three of the six best articles provided by the librarian’s literature search.

I narrowed the results by choosing the most current (published in 2000 or later) pediatric

and adolescent journal articles first and then allowed articles with study populations that

included young women up to the age of 23, which is within one year of the top end of the age

range (22 years old) of what our institution considers a pediatric patient. Female urine specimens

generally tend to have higher contamination rates due to the anatomy of the genitalia and

therefore are of higher interest for my inquiry. After these factors were considered, I read

through the abstracts and discussions to find quality similar comparison studies and further

narrowed the literature to select the three references that would best inform my PICO question.


Vaillancourt, S., McGillivray, D., Zhang, X. & Kramer, M.S. (2007). To clean or not to clean:

Effect on contamination rates in midstream urine collections in toilet-trained children.

Pediatrics, 119(6). 1288-1293. doi:10.1542/peds.2006-2393

Methodology

The quantitative research study by Vaillancourt et al. (2007) was conducted using a

randomized trial method. According to the Pyramid of Evidence (see Appendix B) provided in

the syllabus on the University of Mary (2012) website, the study is placed in the middle area of

the pyramid and at a level 2 on the Level of Evidence Table (see Appendix C) that is also

provided in the syllabus, indicating a strong evidence.

Sample and Research Design

In this randomized trial by Vaillancourt et al. (2007), perineal/genital cleansing was

compared with no cleansing before midstream urine specimens were collected from toilet-trained

children in effort to assess bacterial culture contamination rates in the two collection techniques.

Patients (subjects) between the ages of 2-18 years old who presented to a pediatric tertiary care

center and had a midstream urine sample requested by a practitioner for any medical reason were

cluster-randomized by week according to the “technique of the week” that was chosen for a

particular week (Vaillancourt et al., 2007). A total of 350 subjects were divided by drawing a

card out of a hat at the beginning of each week over an eleven-month time period that indicated

either a cleaning week or non-cleaning week (Vaillancourt et al., 2007).

Validity and Reliability

Subjects instructed not to clean the perineum/genitals were instructed to perform a “clean

catch” technique that involved the child or the parent spreading the labia (girls) or retracting

foreskin (boys) to clean the urethral meatus and perineum with soap and water on gauze pads


twice before collecting a mid stream urine. Participants in the groups were surveyed after the

collection to determine adherence to the instructions, of which 15 participants in the cleaning

group reported that they did not adhere to the cleansing instructions, and 10 participants in the

non-cleaning group reported that they cleaned the perineum/genitals before collecting the urine

specimen (Vaillancourt et al., 2007).

The study sample is homogenous to the research question with the investigation of toilet-

trained children and could be extended and applied to other ambulatory pediatric outpatient

settings. The subjects enrolled in each arm of the study were similar in age, gender, collection

time (day or night), presence of renal problems and circumcision (Vaillancourt et al., 2007). The

randomized assignment of 350 participants constitutes a large adequate subject size. Variability

of the subjects is appropriate, and the statistical analysis for estimation and prediction are also

suitable. The urinalysis and culture instruments, as well as the parameters used to measure

outcomes are well established and the eleven-month time frame allowed for the collection of data

was sufficient.

CRAAP Method

Research article quality assessment based on the CRAAP test (Evaluating Information –

Applying the CRAAP Test., 2010):

Currency. The article was published in 2007 with no more current articles specific to

both genders and collection methods in pediatric populations found.

Relevance. The information partially answers my research question. The cleaning

technique is different, but similar. The information is still valid and useful.


Authority. The authors are all pediatricians specializing in emergency medicine,

epidemiology, and/or university and research institutions. The article has been cited in

other published literature.

Accuracy. I did not find any errors in spelling, punctuation, or grammar, nor did I find

any statements in the article that I believe to be false. The article was supported by over

20 other references, but it is unclear whether it was reviewed buy other experts before it

was published.

Purpose. There is no obvious bias or strong, emotional language that may indicate

prejudice toward one conclusion or another. The authors’ purpose of presenting the

information is to inform and educate users for the benefit of the pediatric patient

populations and the providers who care for them.

Limitations

The literature did not provide reasons why subjects did not complete the study; however,

questionnaires completed after the specimens were collected revealed that 15 of the 179 cleaning

group’s participants reported they did not clean, and 10 participants of the 171 enrolled in the

non-cleaning group reported that they did clean (Vaillancourt et al., 2007). All of the subjects,

including these self-reportedly, non-compliant participants remained in the study and were

analyzed in the groups for which they were initially assigned (Vaillancourt et al., 2007). Follow-

up assessments to study the effect of the interventions were not applicable for the design of this

study.

Major Conclusions

Pediatric patients randomly assigned to the cleaning group were less likely to have a

positive urinalysis than those in the non-cleaning group (Vaillancourt et al., 2007). Cleansing the


perineum/genitals of toilet-trained pediatric patients before a mid-stream urine collection may

reduce the risk of positive urinalysis and unnecessary further investigations.


Tostif, S., Baker, A., Oakley, E., Donath, S., & Babl, F. (2012). Contamination rates of different

urine collection methods for the diagnosis of urinary tract infections in young children:

An observational cohort study. Journal of Paediatrics and Child Health 48. 659-664. doi:

10.1111/j.1440-1754.2012.02449.x

Methodology

The quantitative research study by Tostif, Baker, Oakley, Donath, & Babl (2012) is a

retrospective observational cohort study. According to the Pyramid of Evidence (see Appendix

B) provided in the syllabus on the University of Mary (2012) website, the study is placed in the

middle range of the pyramid and at a level 4 on the Level of Evidence Table (see Appendix C)

that is also provided in the syllabus, indicating moderate strength of evidence.


The retrospective cohort study used microbiology data and medical records from children

at a large tertiary children’s hospital in Melbourbne, Australia (Tosif et al., 2011). The

represented sample is well defined by using only the initial specimen collection urine culture

results collected in either the emergency department or inpatient wards between February 1 to

April 31, 2008 from febrile children who were 24 months of age or younger (Tosif et al., 2011).

Urinalysis results were not reported in this study; however, it provides culture contamination

rates by urine collection methods, which is relevant, valuable information for this investigation

since there was only a minute number of current, reliable studies found on the subject in

question, and while there is no standardized method for clean catch urine (CCU) technique, this

was the only study found that specified the most similar CCU specimen technique (cleansing

with water only) that my clinic currently uses.



The study set out to observe and report on the contamination rates for four different

collection methods: clean catch urine (CCU), suprapubic aspiration (SPA), catheter specimen

urine (CSU), and bag specimen urine (BSU) (Tosif et al., 2011). The primary outcome measure

for each of the collection methods was the contamination rate (Tosif et al., 2011). Samples were

considered contaminated if they were reported as “mixed growth”, and not contaminated if a

pure single organism was reported for each of the urine specimen collection methods identified

(Tosif et al., 2011).

It appears the researchers were objective and unbiased in their collection of 818 samples

that were reduced to 599 after 218 were excluded because they were second or subsequent

samples, rather than initial samples or they were collected using a methods specifically not

included in this study (vesicostomy or nephrostomy) (Tosif et al., 2011). Of the 599 samples,

202 (34%) were CCU (comparator), 97 (16%) CSU, 85 (14%) SPA, 13 (2%) BSU, and 203

(34%) were from methods unknown (Tosif et al., 2011). The researchers additionally sought to

adjust for possible confounding factors including the effect of age, gender, location, past history

of UTI and urogenital abnormality, and antibiotic use at the time of specimen collection,

although SSU and specimens with unknown method of collection were excluded from these

additional investigations (Tosif et al., 2011).

The retrospective design of the study did not warrant any interaction between the data

collectors and researchers, and the cohorts, which negated any interference or adverse effects on

the study subjects. Many aspects of this study are generalizable to other contexts of pediatric

patient care settings; however, we would not perform a SPA in the outpatient setting. The study

data is beneficial for the care of patients in the ambulatory pediatric nephrology clinic I work


since we collect a BSU from every clinic patient under the age of two that is not potty trained

after the perineal/genital area is cleaned with water and non-sterile gauze.

CRAAP Method



Currency. This study was published in 2012 and was the most current of the articles

found to be relevant during my search for information. The data on this topic is not

subject to rapid change.

Relevance. The information found in this article provides further insight and support for

learning more about my research question, but does not fully answer it. The data is not

too simplified or technical and is beneficial for researching my question.

Authority. The researchers are physicians associated with a large children’s hospital, a

medical center, a pediatric research institute, and a two major universities. In perusing the

Internet, this study has been cited in several articles and at least one systematic review,

and each of the researchers have participated as investigators in other research studies.

Accuracy. The article is supported by 28 references and there were no false statements or

errors in spelling, punctuation or grammar found, with the exception of the difference in

the spelling of some words from the American version of the English language, since the

researchers are based in Australia.

Purpose. The purpose of the article is to investigate contamination rates for CCU, SPA,

CSU, and BSU urine specimen collections and to inform and educate users for the benefit

of the pediatric population and the providers who care for them. The article appeared to


be free of prejudice, bias, and emotional language. Alternative points of view were

openly discussed.

Limitations

There were a number of limitations identified in this study including the lack of

information regarding the clinical situations and indications for which the urine was collected

(Tostif et al., 2012). Data was not available for whether a urine dipstick was completed for pre-

screening before the urine was sent for culture, nor were any histories extracted for multiple

urinary tract infections or urogenital abnormalities (Tostif et al., 2012). Also, the retrospective

design of the study did not allow for an assessment of the response by clinicians as a result of the

culture results, nor follow up or consequences for the patients involved (Tostif et al., 2012). Even

with all of these limitations, this data is strong in comparison to many previous smaller studies

performed under regulated research conditions since a large number of subjects were studied in

unrestricted, blind clinical practice, which more likely represents real-life care situations (Tostif

et al., 2012).

Major Conclusions

The study by Tostif et al. (2012) demonstrates a high rate of contamination in BSU,

which are collected for every patient in our clinic under the age of 2 years that is not potty

trained. Preemptive antibiotics are prescribed for many of these patients while awaiting culture

results. CCU specimens are optimal compared to BSU for an initial urine specimen; however, the

age of the subject groups limits the opportunity and another method must be chosen. Performing

the CSU method on every patient is much too invasive, but obtaining a CSU after an initial

positive BSU while the patient is still in clinic would provide a more precise specimen for a

second urinalysis and may help prevent the overuse of preemptive antibiotic therapy.


Blake, D.R. & Doherty, L. F. (2006). Effect of perineal cleansing on contamination rate of mid-

stream urine collection culture. Journal of Pediatric and Adolescent Gynecology, 19(1),

31-34. doi: 10.1016/j.pag.2005.11.00

Methodology

The quantitative research study by Blake and Doherty (2006) is an experimental

randomized control trial (RCT) with two descriptive assessment questions included. According

to the Pyramid of Evidence (see Appendix B) provided in the syllabus on the University of Mary

(2012) website, the study is placed in the mid range of the pyramid, and according to the Level

of Evidence Table also provided in the syllabus, the RCT section of the study is placed at a Level

2 and the descriptive section at a level 6 (see Appendix C).


This study was designed to compare mid-stream urine samples collected from 50 female

participants without symptoms of pyuria between the ages of 14 -23 years old (mean range 18.5

years) at a New England university based adolescent clinic between June 6, 2003 and August 1,

2003 (Blake & Doherty, 2006). Patients were either assigned to the standard group and were

instructed to collect a clean catch urine specimen by using an antiseptic towelette to clean the

perineum before the mid-stream collection, or they were assigned to the non-cleaning collection

group and were instructed not to clean the perineum before collecting a mid-stream specimen.

All specimens were sent for culture to determine contamination rates (Blake & Doherty, 2006).

The purpose of the study is to assess the degree to which bacterial contamination is reduced by

cleansing before urine specimen collection and also measure patient ratings for ease and comfort

of collection (Blake & Doherty, 2006).



The study sample was not entirely homogenous to the research question in that the age

and gender for the study population were more specific than the general potty-trained pediatric

population in question; however, the data is still appropriate; especially since the female patients

in our clinic have been observed to have higher urine collection contamination rates, which is

most likely due to anatomical differences from their male counterparts. While the size of the

sample was small and the amount of time data was collected was only a couple months, the study

could easily be reproduced in a larger study and other contexts and health care settings.

While there is no universal standard for categorization of bacterial measures, the bacterial

colony count measures in this study used to categorize and determine “no growth” (0-9,999

colonies/ml), contamination (10,000-99,000 colonies/ml), and positive UTI (> 100,000

colonies/ml) were appropriate (Blake & Doherty, 2006). The survey opinion result measures for

ease and comfort questions were answered by participants using a scale of 1-5, with 5

representing agreement with the most ease and comfort and 1 representing agreement with the

most difficulty and least comfort were also appropriate (Blake & Doherty, 2006). The Chi-

square, Fisher’s exact test and Spearmen correlation statistical analysis techniques were suitable

for the study design.

It is always difficult to determine whether study participants followed the assigned and

provided urine collection technique instructions since they are not performed or observed by

health care professionals. Comfort and ease of collection is more of a concern for proper

technique in female patients; however, this study could be expanded to include male patients and

could also include younger children, with or without assistance form parents.

CRAAP Method




Currency. The article was published within the last ten years and the topic is not one that

changes rapidly. There are minimal studies available on this topic that are pediatric

specific and current or at least published after 2000.

Relevance. The information found in this article provides further insight and support for

learning more about my research question, but does not fully answer it. The data is not

too simplified or technical and is beneficial for researching my question.

Authority. The lead investigator is a medical doctor and professor affiliated with a large

university-based medical center/school and has been cited as an investigator on 13

research studies. This particular article has been cited by at least 20 other books or

articles.

Accuracy. The article is supported by 16 references and there were no false statements or

errors in spelling, punctuation or grammar found. A physician colleague reviewed this

article before publication.

Purpose. The purpose of this article is to investigate bacterial contamination rates in two

different urine collection techniques and to inform and educate users for the benefit of the

pediatric population and the providers who care for them. The article appeared to be free

of prejudice, bias, and emotional language. Alternative points of view were discussed.

Limitations

The small sample size does not provide sufficient power to reject the null hypothesis of

no difference between the two collection method groups (Blake & Doherty, 2006). Inclusion of

only asymptomatic patients is another limitation, since results may have differed in symptomatic


patients (Blake & Doherty, 2006). Both deficiencies could be rectified in larger, expanded

studies.

Major Conclusions

This small sample study concludes that perineal cleansing in adolescent and young

women free of pyuria symptoms did not significantly reduce the perineal flora contamination

rate in mid-stream urine cultures (Blake & Doherty, 2006). There was only a 12% (28%) higher

rate of contamination for the culture results in the non-cleaning group (40%) over the standard

clean catch group. The mean rating for ease of collection was insignificant between the two

groups with the mean standard collection rating reported at 4.3, and non-cleaning reported to be

4.0 (Blake & Doherty, 2006). The mean rating for comfort with collection was only slightly

more differential at 4.6 for the standard collection technique and 4.1for the non-cleaning

technique. Interestingly, increased comfort was associated with a higher contamination rate in

the standard collection group, but not the non-cleaning group, which leads back to the question

of whether or not CCU collection instructions are actually followed correctly, or at all, during the

privacy provided behind the bathroom door.

Summary of Findings

In reviewing the three articles, the findings indicate that cleansing the perineum/genitals

in toilet trained children may reduce the likelihood of false positive urinalysis results and urine

culture contamination in children when the CCU technique is performed before collecting a mid

stream urine (Tosif et al., 2012; Vaillancourt et al., 2007). However, in asymptomatic young

women, perineal cleansing did not significantly reduce contamination in mid stream cultures

(Blake & Doherty, 2006). There is no standardized method for a CCU, which complicates

comparisons, but also sheds light on the commonality of the definition discrepancy of the


technique. All three of the studies described different instructions for what was considered a

CCU: cleansing with soap and water using gauze pads; cleansing with only water and gauze

pads; and cleansing with an antiseptic towelette before collecting a mid stream urine. The study

that utilized an antiseptic towelette during the CCU technique reported no difference between

CCU and no cleansing.

Application

The conclusion of the study by Vaillancourt et al. (2007) indicated that there was a lower

rate of positive urinalysis and contaminated urine culture results using the CCU technique;

however, the clinic I work in uses only tap water and gauze pads to wipe the perineum/genitals

and patients are not instructed to spread the labia or retract the foreskin before the mid stream

collection. The study by Tostif et al. (2012) was the only study I found that used the same

cleaning technique (water and gauze pads) utilized in our clinic; unfortunately, it did not

compare cleaning and non-cleaning techniques, but rather contamination rates for collection

techniques, which at least provided some support for our current procedure. The age ranges and

the presence or absence of UTI symptoms in the subjects across all studies were appropriate

population comparisons and applicable for our clinic. The study by Blake and Doherty (2006)

supports my inquiry that cleansing may not be necessary for asymptomatic toilet-trained patients

in our clinic. Although the study was limited to females only, they have been observed through

clinical practice to have a higher incidence of contamination, and therefore, the information is

deemed appropriate for application in our clinical setting. Our population is unique in that they

are all nephrology specific patients and likely have nephrology and/or genitourinary etiologies

that may complicate the decision making process, but there are no socioeconomic, cultural, or

regulatory factors that would need to be considered. After reviewing the information provided in


these studies, along with additional studies perused, I would elect to eliminate our current

practice of lengthy, complicated, and embarrassing CCU explanations for every patient in our

clinic. We should obtain simple mid stream urine collections from asymptomatic toilet-trained

patients and CCU from only those patients whose diagnoses indicate a need for the extra

precautions during urine collection. If the initial non-cleaning sample results in a positive

urinalysis, then repeat mid stream CCU should be obtained.

Conclusion

Evidence based practice (EBP) is an advanced, contemporary approach to clinical

decision making that encourages practitioners to not only use available quality research

resources, but incorporate expanded aspects of health care, such as internal evidence that

includes the clinical status and circumstance of a patient, evidence generated internally from

quality projects and outcome management, as well as health care resources, a patient’s

preferences, and making decisions based on clinical expertise (DiCenso, Ciliska, & Guyatt,

2004; Melnyk and Fineout-Overholt, 2011). In our pediatric nephrology clinic, we collect a urine

specimen from every patient and provide instructions for them to wipe the perineal/genital area

with non-sterile gauze pads dampened with tap water before collecting mid-stream urine. This

process is time-consuming to explain, uncomfortable for patients and caregivers, usually

performed incorrectly, and directly linked to increased costs (Leisure, Dudley, and Donowitz,

1993; Vaillancourt et al., 2007). By integrating EBP principles and using the available research

data, our clinic could save time and resources while increasing patient satisfaction and

compliance, without compromising clinical outcomes by implementing a patient specific process

for urine collection.


References

Bitsori, M. & Galanakis, E. (2012). Pediatric urinary tract infections. Expert Review of Anti-

Infective Therapy, 10(10). 1153-1164.

Blake, D.R. & Doherty, L. F. (2006). Effect of perineal cleansing on contamination rate of mid-

stream urine collection culture. Journal of Pediatric and Adolescent Gynecology, 19(1),

31-34. doi: 10.1016/j.pag.2005.11.00

DiCenso, A., Ciliska, D., & Guyatt, G. (2004). Introduction to evidence based nursing. In A.

DeCenso, D. Ciliska, & G. Guyatt (Eds.), Evidence-based nursing: A guide to clinical

practice (pp 3-19). St. Louis, MO: Elsevier.

Evaluating Information – Applying the CRAAP Test. (2010). California State University, Chico.

Retrieved from http://www.csuchico.edu/lins/handouts/eval_websites.pdf

Leisure, M. K., Dudley, S. M., & Donowitz, L.G. (1993). Does a clean catch urine sample reduce

bacterial contamination? The New England Journal of Medicine 328, (289-290).

doi:10.1056/NEJM199301283280420

Melnyk, B. M. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and health

care: A guide to best practice. Philadelphia, PA: Wolters Kluwer Health/Lippincott

Williams Wilkins.

Roussel, L. (2013). Management and leadership for nurse administrators (6th ed.). Burlington,

MA: Jones & Bartlett Learning.

University of Mary. (2012). NUR 601 Evidence-Based Practice and Strategic Health Care

Decision Making [Class syllabus]. Department of Nursing, University of Mary,

Bismarck, ND. Retrieved February 28, 2015 from

https://canvas.umary.edu/courses

https://canvas.umary.edu/courses%20/8344/assignments/syllabus

http://www.csuchico.edu/lins/handouts/eval_websites.pdf


/8344/assignments/syllabus

Tostif, S., Baker, A., Oakley, E., Donath, S., & Babl, F. (2012). Contamination rates of different

urine collection methods for the diagnosis of urinary tract infections in young children:

An observational cohort study. Journal of Paediatrics and Child Health 48. 659-664. doi:

10.1111/j.1440-1754.2012.02449.x

Vaillancourt, S., McGillivray, D., Zhang, X. & Kramer, M.S. (2007). To clean or not to clean:

Effect on contamination rates in midstream urine collections in toilet-trained children.

Pediatrics, 119(6). 1288-1293. doi:10.1542/peds.2006-2393



Appendix A

Table 1

External Data Key Search Terms and Databases for Urinalysis Cleansing Technique Search

CINAHL MEDLINE Cochrane

Urine collection 215 2,513 205

Cleansing 801 21,373 70

Contamination 9,682 111,225 25

Urinalysis 3,898 9,422 1

1 & 2 3 70 2

2, 3 & 4 2 267 4

1, 2, 3 & 4 2 2,646 3


Appendix B

Table 2

Example of Level of Evidence Table









Appendix C

Figure 1

Pyramid of Evidence








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