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

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

3. 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

4. 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.  

5. 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?

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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

12. Urinary Tract Infections in Long Term Care: Improving Quality
Background
Based on Quality Measures and CASPER reporting between
10/1/ /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

14. 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

15. 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/ /30/2015
Exclusion Criteria
Diagnosis made outside of studied date range

16. 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

17. 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

18. 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

19. 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

23. 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

24. 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 %

25. 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

26. References
CMS Manual System . Department of Health & HumanServices (DHHS). Pub. 100-07 State Operations. Transmittal 8. JUNE 28, 2005.
Durso, Samuel, Sullivan, Gail. Geriatrics Review Syllabus. 8th Edition
Halter, Jeffrey, et.al. Hazzard’s Geriatrics Medicine and Gerontology. 7th Edition
Juthani-Mehta, Manisha, et.al. “Diagnostic Accuracy of Criteria for Urinary Tract Infection in a Cohort of Nursing Home Residents.” J Am Geriatr Soc 55: , 2007.
Nicolle, L.E. “Urinary Tract Infections in the Elderly”. Clin Geriatr Med 25 (2009) 423–436.
Rowe, Theresa; Juthani-Mehta, Manisha. “Diagnosis and Mangement of Urinary Tract Infection in Older Adults”. Infect Dis Clin N Am 28 (2014) 75–89.
Stone, Nimalie, et. Al. “Surveillance Definitions of iNfections in Long-Term Care Facilities: Revisitng the McGeer Criteria.” Infect Control Hosp Epidemiol 2012;33(10):