Urinary Tract Infections in Long Term Care: Improving Quality Jeremiah Lopez, MD Michigan State University East Lansing, Michigan

Speaker Disclosures Dr. Lopez gratefully acknowledges the AMDA Foundation for an unrestricted QI Award which provided grant support for this project.

Learning Objectives By the end of the session, participants will be able to: Understand the differences between Asymptomatic Bacteriuria and an Urinary Tract Infection Be familiar with the FADE model of Quality Improvement

Urinary Tract Infections in Long Term Care: Improving Quality While rounding at your Long Term Care Facility, nursing staff asks you to review a urine culture.  It was obtained over the weekend by a covering physician.  The urine studies were on an 83 year old female with history of severe dementia (Functional Assessment Stage of Dementia (FAST) 7B) with behaviors (verbal aggression, combativeness with care and refusal of medications). Staff noticed an increase of difficult behaviors such as refusing to get out of bed and reported that her urine had “a strong odor and was darker than usual”. Vital signs have been stable and there are no localizing signs or symptoms of a UTI.  

Urinary Tract Infections in Long Term Care: Improving Quality Results show >100k E coli, with pansensitivity to commonly used antibiotics. Do you start antibiotics? Does this resident have a UTI?

Urinary Tract Infections in Long Term Care: Improving Quality You decide not to treat and monitor for S/Sx of UTI and investigate alternative causes of increased behaviors.

Urinary Tract Infections in Long Term Care: Improving Quality The daughter, who is the DPOA, visits. She is concerned that antibiotics have not begun. Her concern is “when I used to take my mom to the ER when she had bad behaviors and she always was diagnosed with a UTI...” What do we do now? Although this was a hypothetical scenario, you may have been in a very similar situation. It is important to differentiate between asymptomatic bacteriuria and UTIs

Urinary Tract Infections in Long Term Care: Improving Quality Background Asymptomatic Bacteriuria Presence of bacteria without symptoms 40% of women in Nursing Homes have asymptomatic bacteriuria No treatment is recommended for asymptomatic bacteriuria

Urinary Tract Infections in Long Term Care: Improving Quality Background UTI – Symptomatic Classified anatomically (bladder Vs kidney) or syndromic (uncomplicated Vs complicated) Lower Urinary Tract Symptoms (LUTS) Dysuria, frequency, urgency Upper Urinary Tract Symptoms (pyelonephritis) Fever, chills, nausea, flank pain

Urinary Tract Infections in Long Term Care: Improving Quality Background Long Term Care Residents with dementia have subtle and often atypical presentations of disease Change in functional status may prompt urine studies and culture

Urinary Tract Infections in Long Term Care: Improving Quality Background Quality Improvement initiative based on Quality Measure and CASPER* results Facility located in Ingham County 236 certified beds Long and short term stay residents *CASPER - Certification and Survey Provider Enhanced Reporting

Urinary Tract Infections in Long Term Care: Improving Quality Background Based on Quality Measures and CASPER reporting between 10/1/2014 - 6/30/2015 Facility % National % State % Quality Measures 9.2 5.3 5 CASPER 9.9 4.3 3.8 CASPER Reporting: Facility 9.9 State 3.8 National 4.3

Urinary Tract Infections in Long Term Care: Improving Quality Methods Identify facility cases of UTI Determine diagnosis accuracy and treatment appropriateness Based on McGeer’s Criteria Determine Influential factors for obtaining urine studies Signs and Symptoms were tabulated Examine the role of functional status with diagnosis and treatment ADL Score Develop strategies to decrease incidences of UTI

Urinary Tract Infections in Long Term Care: Improving Quality Methods Study Design Cross Sectional Study Retrospective chart review using MDS Reporting, Electronic Record, Infection Control Nurse Data, Provider documentation Inclusion Criteria Long Term Care Residents Urinary Tract Infection Diagnosis from 10/1/2014 - 6/30/2015 Exclusion Criteria Diagnosis made outside of studied date range

Urinary Tract Infections in Long Term Care: Improving Quality 19 charts were reviewed Diagnosis Accuracy 53% 10/19 residents were diagnosed based on McGeer’s Criteria

Urinary Tract Infections in Long Term Care: Improving Quality Most common symptoms that triggered Urine studies that did not meet criteria Somnolence Lethargy Decreased Oral intake No significant change in ADL score after treatment

Urinary Tract Infections in Long Term Care: Improving Quality Non-Localizing Signs and Symptoms are likely due to other causes and NOT an Urinary Tract Infection Avoid ordering Urine Studies/cultures unless Localizing Signs and Symptoms develop

Urinary Tract Infections in Long Term Care: Improving Quality Intervention UTI and Functional Status Surveillance Forms Based on Localizing Signs and Symptoms to maintain UTI diagnosis accuracy Incorporates “Medical Rule-Out” form for interpretation of acute change in condition Similar to Clinical Practice Guidelines by AMDA

Urinary Tract Infections in Long Term Care: Improving Quality Team approach to limit the ordering of urine studies, including culture, unless a resident meets specific criteria on forms In addition, the use of the Assessment or Diagnosis of Urinary Tract Infection (ICD 10 code – N39.0) should not be used unless: Localizing signs are present that warrant culture AND Positive urine culture If above criteria are not fulfilled, alternative billable diagnosis codes should be used by providers

Urinary Tract Infections in Long Term Care: Improving Quality Results Based on CASPER data: Date range 5/1/16-12/31/16 Facility Observed State Comparison National Comparison 3.9 % 4.3 % 4.6 %

Urinary Tract Infections in Long Term Care: Improving Quality Summary Asymptomatic Bacteriuria has a high prevalence and should not be routinely treated Asymptomatic Bacteriuria and Urinary Tract Infections should not be used interchangeably In the absence of localizing signs or symptoms of urinary tract infections, alternative causes for changes in condition should be investigated FADE model of QI is based on the following broad steps: Focus, Analyze, Develop and Execute

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