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Pfe-Vota - Metrologie de Jaugeage Appliquee Aux Reservoirs de Ty
Urine dipstick precision with standard visual and automated methods within a small animal teaching
hospital
Authors
Adam George Gow, BVM&S PhD DSAM DipECVIM-CA (Internal Medicine) FHEA MRCVS
Roslin
Midlothian
EH25 9RG
United Kingdom
marisa.ferreira@ed.ac.uk
Abstract
Urine dipstick results may vary between operators/methods. The magnitude of variation across the
veterinary field is currently unknown. The aim of this study was to compare the precision of urine
dipstick results between standard direct visual and automated reading methods, when performed by
several operators. Urine samples were pooled and divided into three aliquots: one plain, one with
glucose, and one with serum. Final year students, veterinary surgeons and veterinary nurses, blinded
to each sample, were then asked to perform dipstick analysis with direct visualization and an
automated analyser, and their technique was observed. A subsequent session was undertaken with
samples which had pH titrated to achieve an acidic, neutral or alkaline value. Sixty-four veterinary
students, 20 veterinary surgeons and seven veterinary nurses, performed the first (n=61) or second
(n=30) part of the study. Precision was greater using the automated reader. The most common
observed technique errors were; lack of sample mixing, for both visual and automated methods, and
not timing readings as per manufacturer instructions, when performing visual analysis. This study
suggests that in an environment with multiple operators, as is the case in veterinary teaching or
large private hospitals, automated urine dipstick reading improves precision of results.
Introduction
Urine dipstick analysis is one of the most frequently performed point-of-care (POC) tests, both for
diagnostic and monitoring purposes. It is considered part of a minimum database when assessing
not only urinary tract disorders, but also diseases in other body systems, for example, endocrine and
degradation over time.1 Urine reagent strips developed for human medicine are often used in
veterinary medicine, given the lack of species specific products. Although the reagent strips are
designed to be a simple test, there is still the possibility of result variation between operators and/or
methods.2-4 The standard direct visual dipstick reading method involves comparing the colour of a
specific reagent impregnated pad against a reference chart provided by the manufacturer to obtain
the result. Therefore, this interpretation is subjective as colour perception varies between
individuals. There is also the possibility that individuals with colour vision deficiencies (CVD, (colour
blindness)) may record different results and that individuals may be unaware that they have CVD. 5 In
addition, visual analysis is liable to human error, specifically reading the wrong result by skipping a
pad in the chart, and not timing each reading as specified by the manufacturer, who generally
provides this information printed on the dipstick container.6 At present, the expected magnitude of
practice in the authors’ institution that visual dipstick reading is performed without reference to a
standard operating procedure (SOP) and the authors would assert that this would be standard
practice in private veterinary surgeries. In the authors’ institution the technique is taught to
Automated urine dipstick analysis has been developed in an effort to improve accuracy, precision
and efficiency; aiming to overall enhance patient care.8-10 The results obtained are either available in
a printed form or directly updated into the patient’s medical record, likely reducing the risk of post-
analytical faults; namely manual transcription errors and loss of information. Additional advantages
might include an in-built memory for results and automatic error messages if the strip has been
exposed to humidity.11
The use of automated POC dipstick analysers has been validated in both dogs and cats and
documented through a few studies.12-1711 However, the visual readings undertaken in these
publications were performed by one or two experienced subjects. In human clinical practice, it has
been shown that when compared to visual reading, automated POC analysis of urine dipsticks may
be associated with higher sensitivity, higher reproducibility and higher agreement with a laboratory
reference method, being also user-friendly.18-20 Consequently, the automated method is currently
recommended21 and several human medical institutions routinely employ it.22; 23 However, these
human medical studies were limited in scope (one parameter investigated)18, number and
experience of subjects19; 20, as well as utilising different strips for visual and automated methods20. At
present, no studies have examined the potential for variation, and potential clinical impact of this
variation, in a large cohort who commonly perform this POC test, particularly in the veterinary field.
The objective of this study was therefore to compare the precision of canine urine dipstick chemical
analysis results between standard direct visual and automated reading methods, when performed
by a large cohort of operators in veterinary clinical practice. It was hypothesised that inter-operator
reproducibility would be higher with automated analysis compared with visual reading, due to
decreased operator subjectivity/error (e.g. an automated analyser would reduce the potential for
operator related error by standardising reading timings, avoiding reading the incorrect pad against
A prospective design was followed for this study and approval was obtained from both the
Urine samples were obtained during routine clinical management of hospitalised canine patients in a
small animal referral teaching hospital. All the samples were frozen and prior to the study day,
thawed at 4oC, mixed and divided into three aliquots (850mL each): one plain, one mixed with 4.7mL
of a 50% glucose solution, and one mixed with 25mL of bovine serum containing 52g/L of total
solids. A fourth aliquot mixed with blood was initially planned, though not carried out, given the
presence of moderate to large amounts of blood already measurable by dipstick analysis in the
original pooled sample. Samples were kept refrigerated throughout the whole study period of 8
hours.
Subjects (n=61) were recruited throughout the study day and included final year veterinary students
on clinical rotations, as well as veterinary nurses and veterinary surgeons who were on clinical duties
during that day. A recruitment sheet was handed at the time containing details on the study’s
purpose, authors, participants’ rights and benefits, as well as confidentiality. Final year students had
had practical classes on urine analysis including the correct use of dipsticks, namely the importance
of read timings and mixing the sample prior analysis, and routinely performed this test in final year
rotations within the small animal teaching hospital and during extramural studies. Blinded to the
type of sample, provided in three numbered aliquots, each subject was requested to perform
dipstick analysis on every aliquot, first by direct visual reading, and then by using a POC automated
Diagnostics Inc.), which was previously validated for analysis of canine urine.13
The same type of commercial reagent strips was used for both visual and automated analysis
(Multistix® 10 SG Reagent Strips, Siemens Healthcare Diagnostics Inc.). Calibration of the automated
analyser was automatically performed each time a test would be undertaken, through an in-built
A self-confidence assessment was given and requested to be filled prior the analysis, with the
question “How confident are you in performing urine dipstick chemical analysis?”. The answer was
marked in a grade of 1 to 5, with 1 being “not confident at all” and 5 being “totally confident”. An
instruction and recording sheet was also provided to each subject (Supplementary File 1a). Subjects
were not provided with other (e.g. verbal) instructions .The written instruction and recording sheet
was designed to focus on the number of samples and task required, rather than describing the
technique of how to correctly perform urine dipstick analysis, as all subjects were all at the stage of
their career where they would be expected to perform full urine analysis competently.. However, it
was stated in the instruction and recording sheet that subjects should use the materials available to
perform the analysis. These included a clock with a second hand for timing readings, as well as
gloves, paper towel, a pen, hand sanitiser and a clinical waste bin. In addition, clear bullet point
operating procedure instructions were available next to the automated analyser, as this was
assumed to be an unfamiliar piece of equipment to all subjects (Supplementary File 1b). The
subjects’ technique was observed during the study period and recorded by three of the authors, who
pooled sample was divided into three aliquots, each titrated with hydrochloric acid and sodium
hydroxide to achieve a visual urine dipstick pH reading of 6 (sample 1), 7 (sample 2) and 7.5 (sample
3) agreed between two of the authors. A calibrated reference benchtop pH meter (MP 225©,
Mettler Toledo, Leicester) was used to verify these results, and measurements of 5.44, 6.55 and 7.66
were respectively obtained. Subject recruitment (n=30) and analysis request was then undertaken in
Although all urine dipstick results were recorded, only the parameters considered to be useful and
reliable in small animal medicine were assessed, namely: bilirubin, blood, glucose, ketones, pH and
protein.24-27
Descriptive statistics were used for analysis of precision and for the self-confidence assessment.
Precision was evaluated by visual analysis of distribution of results obtained for each dipstick
parameter, plotting both methods in perpendicular axes of the same graph. In addition,
nonparametric inferential statistics were employed to analyse the results of the subsequent
session’s pH values accuracy, using the Wilcoxon matched-pairs signed-ranks test. Statistical
significance level was set at P < 0.05. Data introduction, analysis and graphs were undertaken with
commercial software packages (Microsoft® Excel®, version 2016 MSO, ©Microsoft Corporation;
GraphPad InStat, version 3.10, GraphPad Software Inc.; and R, version 3.0.1, ©The R Foundation for
Statistical Computing).
Results
The first part of the study was completed by 61 subjects, comprising 45 veterinary students, 13
veterinary surgeons and three veterinary nurses. The results from the self-confidence assessment
questionnaire showed that 82% (n = 50) of the population were either very confident or totally
Figure 1. When assessing results obtained with the automated reader, glucose was always recorded
for the glycosuric sample, ketones were not detected in any sample, protein was present in all
samples, and pH was precise at 7. Conversely, when assessing results obtained by direct visual
reading, several discrepancies were noted as follows. The glucose containing sample was visually
classified as non-glycosuric by two individuals (one student and one veterinary surgeon). In addition,
ketones were stated to be present in the same sample by three individuals (two students and one
veterinary nurse) and in a non-glucose containing sample by one student. Furthermore, protein was
recorded to be absent in the glucose containing sample by one veterinary surgeon, whereas it was
recorded as present by all other participants. Moreover, two individuals, one student and one
veterinary surgeon, were responsible for variation in two parameters each, with one classifying the
glucose containing sample as non-glycosuric and the plain sample as positive for ketones, and the
other classifying the glucose containing sample as both non-glycosuric and negative for protein.
These individuals recorded that they were either totally or very confident in performing urine
dipstick chemical analysis prior to performing the tests. Finally, notable variation in pH was recorded
visually, with all three initial samples being classified as both acidic and alkaline (Figure 1).
The most common observed technique errors were lack of mixing the urine sample before both
visual and automated analysis (87%, n = 53), not timing readings as per strip manufacturer
instructions when performing visual analysis (52%, n = 32), and not blotting the strip after dipping it
into the urine sample (26%, n = 16). In addition, while undertaking visual analysis and using the
colour chart for guidance depicted in the dipstick strips bottle, five subjects held the strip
horizontally against the chart, instead of vertically, and one subject was noted to be holding the strip
upside down. The same two individuals recording the glucose containing sample as non-glycosuric
also didn’t time their visual readings. Furthermore, one of the subjects recording the glucose
containing sample as positive for ketones also held the strip horizontally against the chart.
For the second part of the study, with varying pH values, 30 subjects participated (19 veterinary
students, seven veterinary surgeons and four veterinary nurses). Precision was better using the
automated analyser compared to visual reading for every sample (Figure 2). Samples 2 and 3 were
visually reported by different individuals as both alkaline and acidic, whereas all results obtained
with the automated reader were recorded as either neutral or alkaline for both these samples.
Finally, considering the benchtop pH meter as gold standard, accuracy was higher for automated
compared to visual analysis for all the samples, with respective automated and visual median values
of; sample 1 with 6 and 6.5 (P < 0.0001), sample 2 with 7 and 7.5 (P = 0.0059), and sample 3 with 7.5
and 8 (P = 0.0003).
Discussion
To the authors’ knowledge, this is the first study to assess the impact of an automated urine dipstick
analyser when used in a small animal hospital with multiple operators. Considerable discordance of
results was seen between visual and automated urine dipstick reading methods in this study, with
Results visually read as non-glycosuric for sample 2, would potentially mean a diagnosis of diabetes
mellitus would be missed, with significant consequences for the patient. Conversely, the visual
ketonuria obtained, may lead to a false diagnosis of ketosis in diabetic patients or to a false suspicion
of proximal renal tubular disease28; 29. In addition, although the measurement of urine protein-to-
creatinine (UPC) ratio is a more objective and reliable assessment for proteinuria30, proteinuria
assessed by urine dipstick might still be used solely in several practices due to practical and financial
constraints. This technique can be of value if results are interpreted in conjunction with specific
gravity, also allowing decision making guidance towards requesting a UPC ratio only in selected
samples.31 Consequently, protein results visually read as negative or trace in this study, could have
led to a decision of not requesting a UPC ratio, when it would be indicated. Lastly, by classifying a
sample as acidic instead of alkaline or vice-versa, the management of urinary tract infections or
All participants would be expected to be competent to perform dipstick urine analysis. However,
despite a reported high level of confidence in performing urine dipstick analysis, several operator
technique errors were noted. Some of these, e.g. not respecting the advised visual reading times,
which was recorded in over half of the subjects, would be prevented using the automated method.
The discrepancy of results recorded by several individuals might have been explained by their
respective observed technique errors. Nonetheless, is not possible to exclude that these subjects
could have CVD. There is no routine testing for CVD and individuals may be unaware that they suffer
from it. Prospective testing could therefore promote self-awareness, aiming to provide appropriate
counselling and reassurance for future practising clinicians, including acknowledging the existence of
supporting equipment, namely automated analysers.32; 33 It is of note that omitting to mix the
sample prior to performing analysis was a common error, yet this would not explain the observed
variation, as lack of sample mixing also occurred for the automated analysis, nonetheless with much
The second part of this study was undertaken to assess if samples with pH other than 7 were still
read more precisely by the automated analyser compared to visual analysis. Although pH meters are
considered more accurate, urine dipstick pH analysis is more commonly used in clinical veterinary
practice due to method availability and expense, despite previously reported suboptimal agreement
results.16; 34; 35 The results obtained in this study served to establish that the precision of the
automated method was superior than visual reading for different pH values. Moreover, when using
the benchtop pH meter as a gold standard, accuracy was higher for automated versus visual
It appeared that variation with the visual results was present in all the groups tested i.e. students,
veterinary surgeons and nurses however, further work could assess if increased experience would
reduce variation. Variation was still present using the automated method, but to a lesser degree.
This variation may still have been due to operator methods e.g. differences in dwell time in the
urine, blotting or not blotting the stick prior to insertion in the analyser tray, or may be that the true
Some limitations have been identified in this study. The presence of observers in the room, albeit
not immediately next to each subject, though recording their technique, could have led to bias by
introduction of an observer effect. Furthermore, there were no mechanisms in place to ensure that
subjects who had completed the study would not communicate with subjects who hadn’t. If
influencing final results, these two limitations would be thought to possibly lead to improvement of
precision in results obtained with the visual reading method. Nonetheless, precision was still inferior
with this method in comparison with the automated reader. An additional limitation is the fact that
the whole spectrum of possible results was not explored for each analyte. As an example, it is
unknown if a similar spread of variation would have occurred visually testing a sample with only a
small or trace amount of blood, as all the samples in this study contained moderate to large amounts
of blood read by the automated analyser. The initial pooled sample was collected from hospitalised
patients, some of which therefore must have had a degree of microscopic haematuria, which
precluded this assessment. . Moreover, no sample containing ketones was tested so it is unknown if
In conclusion, this study suggested that when multiple operators are involved, as is the case in
veterinary teaching or large private hospitals, automated urine dipstick reading improves precision
of results. Further research is warranted to understand how this variation may impact clinical
decision making, as well as to understand the role of implemented quality assurance strategies, e.g.
written SOPs and training briefings, in improving precision for visual reading analysis and how would
Acknowledgements
The authors would like to thank the institution’s hospital staff and students for participating in this
study.
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Figure 1 – Precision of visual (x axis) and automated (y axis) urine dipstick analysis results when
performed within a small animal teaching hospital (n = 61), using three different urine samples (1 –
plain, 2 – added glucose solution, 3 – added bovine serum). The circle diameter in each area
represents the number of results obtained for each. Values lying within the 45-degree dashed line
represent the agreement of results between visual and automated methods. Categories from each
parameter are divided according to the reagent strips manufacturer’s criteria. Units are in mg/dL for
glucose, protein and ketone. Categories for blood correspond to the following approximate
concentrations (erythrocytes/µL): 10 for trace, 25 for small, 80 for moderate and 200 for large. For
bilirubin, correspondent values for each category are not available from the manufacturer (reported
sensitivity is 0.4-0.8mg/dL).
Figure 2 – Precision of visual (x axis) and automated (y axis) urine dipstick pH results when
performed within a small animal teaching hospital (n = 30), using urine samples with three different
pH values (1 – 5.44, 2 – 6.55, 3 – 7.66). The circle diameter in each area represents the number of
results obtained for each. Values lying within the 45-degree dashed line represent the agreement of