How to Use the Toolkit: Successful Strategies for the Prevention of Urinary Tract

Infections in Long-Term Care

Virginia Department of HealthMarch 21, 2012

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Urinary Tract Infections

• Most common healthcare-associated infection in long-term care

• Increase healthcare costs• Can lead to antibiotic resistance and possibly

Clostridium difficile infection when improperly treated

• Infections tracked differently between facilities• Catheter-associated UTIs can be prevented by

limiting use and duration of indwelling catheters

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The Collaborative• Joint project with VDH and Virginia Health Care

Association (VHCA)– Carol Jamerson, RN, BSN, CIC: VDH Nurse

Epidemiologist (co-lead)– Judy Brown, RN, LNHA: VHCA Health Education

Specialist (co-lead)• Conference calls, sharing of best practices and

resources• Development and implementation of

standardized UTI surveillance tools• Educational opportunities: panel presentation,

November 10th VDH/APIC-VA conference• Production and dissemination of a toolkit

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Today’s Agenda

• Introduction– Andrea Alvarez, HAI Program Coordinator, Virginia

Department of Health• Description of toolkit components

– Carol Jamerson• The toolkit in action

– Adriana Agnew, Director of Quality Management and Infection Preventionist, Fairfax Nursing Center

• Q & A– Judy Brown

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The Toolkit

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Recognition of Collaborative Partners

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Recognition of Collaborative Partners

Eastern Virginia Medical School: • Robert M. Palmer, MD, MPH• Edward C. Oldfield, III, MD

Other acknowledgments:• Dana Burshell, HAI Epidemiologist, Virginia

Department of Health• F-Tag 315 information from Agency for Health Care

Administration (AHCA)• Policy/procedure templates originally developed by

Riverside Health System, Riverside Lifelong Health and Aging Related Services

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Table of Contents• Introduction• CMS regulatory guidance• Definitions • UTI tools• UTI prevention policy templates• Educational resources• Resources addressing antibiotic use in long-term

care settings• UTI panel of experts: presentations• UTI prevention resources and references

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Introduction Tab: Introduction to the Toolkit

• Contains infection prevention presentations, resources, and tools that have been adapted for long-term care facilities (LTCFs).

• Documents have been developed from published literature reviews, evidence-based research, standards of practice, or recommendations.

• Introduces and summarizes guidelines and best practices. Does not replace published standards and regulations.

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F-tag 315 Tab: Centers for Medicare & Medicaid

Services (CMS) Regulatory Guidance

Summarized Intent of F-tag315 (§483.25d)• Ensure urinary incontinence is identified and

addressed• An indwelling catheter not used unless there is

valid medical justification• If indwelling catheter used, it is discontinued as

soon as clinically warranted• All residents receive appropriate urinary care to

prevent UTIs10

Definitions Tab

• Glossary of Terms – Five pages of UTI-related terms– Alphabetical– May be helpful when giving in-services

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Tools Tab• McGeer and F315 UTI Surveillance Definitions • UTI Event Form• UTI Denominator Collection Form• Resident Illness Log• Hand Hygiene Monitoring Tool• SBAR• Transfer Form• Urinary Catheter Checklist• Urinary Catheter Reminder

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Tools: McGeer and F-Tag 315

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Tools: UTI Event Form

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Tools: Resident Illness Log

• Patient info – Name, age, sex, location

• Illness information – Onset date, temperature, type of illness,

symptoms, lab information, outcomes

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Tools: Hand Hygiene Monitoring Tool

• Information– Location, room, precaution type, role of observed

• Monitoring staff hand hygiene (HH) and personal protective equipment (PPE) use– HH before, HH after– PPE before, PPE after

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Tools: SBAR

Before calling a clinician for treatment, evaluate the resident, check vital signs, review chart, and have the relevant information available when reporting

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SituationBackgroundAssessment / AppearanceRequest

Tools: Transfer Form

• Inter-facility communication is a top challenge– Needs assessment, trainings, stakeholder meeting

• Developed by a multidisciplinary group in 2009

• Importance of timely transfer of pertinent information

• Get to know the infection preventionist(s) at facilities that commonly transfer residents to/from your facility

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Tools: Urinary Catheter Checklist and Reminder

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Policies Tab

UTI prevention template policies:• Assessment of Urinary Incontinence• Perineal Care for Incontinent Resident• Urinary Catheterization Assessment and Care

Practices• Prevention of UTIs and CAUTIs (Catheter-

Associated Urinary Tract Infections)

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Tools: Policy Templates

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Education Tab• Prevention Priorities: HICPAC and CDC • UTI Surveillance FAQs• UTI FAQs• CAUTI FAQs• UTI Prevention Strategies: Ideas • Hand Hygiene FAQs

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Education: HICPAC and CDC Prevention Priorities for Catheter-

Associated UTIs• HICPAC (Healthcare Infection Control

Practices Advisory Committee)– Prioritization of recommendations– Examples of appropriate indwelling catheter use

• CDC based on HICPAC– Core strategies– Supplemental strategies– Strategies that are NOT recommended

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Education: Surveillance FAQs

• What is surveillance?• How do I conduct surveillance?• What is a log and why use it?• Why use a rate and how do I calculate it?• What is a urinary catheter day and when do I

collect the data?

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Education: UTI Frequently Asked Questions (FAQs)

• What are UTIs, CAUTIs, and what are their symptoms?

• Why are LTC residents at risk?• How can you get a UTI/CAUTI?• How can you help prevent a UTI/CAUTI?

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Education: Prevention Ideas

• Promote – Healthy hydration practices– Healthy behaviors– Appropriate practices to avoid UTIs

• Customize these ideas to your facility!• Energize your staff with new practices• Share your ideas and strategies that have

worked with others

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Antibiotic Use Tab• Antibiotic Use in Long-Term Care Facilities

(CDC Get Smart Program)• 12 Steps to Prevent Antimicrobial Resistance

Among Long-term Care Residents (CDC)

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Antibiotic Use

Antibiotic Use in LTCFs• Scope of the problem• Why we need to act• Why focus on LTC• What LTC facilities and providers can do

12 Steps to Prevent Antimicrobial Resistance – LTC• Prevent infection• Diagnose and treat infection effectively• Use antimicrobials wisely• Prevent transmission 28

Presentations TabUTIs: Working Together to Ensure Appropriate Management and Treatment

•Urinary Tract Infections: LTC Facilities– Robert M. Palmer, MD, MPH

•UTIs in LTC: A Diagnostic and Therapeutic Dilemma– Edward C. Oldfield, III, MD

•Urinary Health in Long-Term Care Settings – Edna D. Garcia, BSN, RN-BC

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Presentation QuestionsUrinary Tract Infections: LTC Facilities• What is the CMS/F315 guidance?• How common is bacteriuria?• How to manage recurrent UTIs?• Prevention strategies

UTIs in LTC: A Diagnostic and Therapeutic Dilemma• How to determine who needs treatment• Benefits/harm to treating asymptomatic bacteriuria?• When should you replace a Foley catheter?• Treatment options and antibiotic selection• Should test for cure be done?

Urinary Health in Long-Term Care Settings • Success implementing evidence-based practices• Which tools are useful for promoting urinary health?• Importance of nurse-driven protocols

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References Tab• Resources and References

– Surveillance definitions and clinical guidelines– Other guidelines and position papers– Prevention resources– Antibiotic stewardship resources

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Thank you!

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www.vdh.virginia.gov/epidemiology/surveillance/hai/uti.htm#Toolkit

To contact the VDH HAI Team:Carol.Jamerson@vdh.virginia.govAndrea.Alvarez@vdh.virginia.govDana.Burshell@vdh.virginia.gov

804-864-8141

Our Experience with the UTI Toolkit

Adriana Agnew RN, BSN, BC, MSNEd, AITDirector of Quality Management and Infection Preventionist

Fairfax Nursing Center

qm@fairfaxnursingcenter.com

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Fairfax Nursing Center’s Use of the Toolkit

• Assisted with protocol revisions

• Developed new protocols• Documented using SBAR• Reinforced the nurse

driven protocol

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The First Steps to Change • Changed Foley catheter supplies

– Closed system with needleless port – Straight catheter system with urine collection bag

attached– Decrease in contamination of urine specimen– Closed system self catheter system to prevent urinary

tract infections • Collection tubes

– Urine C&S with preservative– Urinalysis with preservative

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In and Out

Closed System

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McGeer/APIC and F-Tag • Staff educated

– McGeer definition of urinary tract infection – F-Tag 315 – Staff require further education

• Plan to re-educate the staff using the McGeer/APIC and F-Tag definitions tool – Tool clarifies the misperceptions – Can clearly see the similarities between definitions– Increases understanding

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Policy and Procedures

• Research completed • Follows the F-tags • Appropriate for long-term care setting• Best practice

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SBAR Tool

• Made a few changes to the form • Form will be part of the medical record • Increased documentation compliance• Increased communication nurse-to-nurse • Increased communication nurse-to-MD

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Implementing SBAR: Skilled and LTC Units

• Unit layout – Three units with skilled and long-term residents – Two nurses on each unit –assigned to medication

pass • Approximately 25 residents each

• One nurse – assigned to be in charge – Assists with medication pass – Assists with treatments– Calls MD

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Implementing SBAR: Skilled Unit

• One unit mostly skilled • Three nurses – medication nurse • One charge nurse – calls MD with all concerns • One nurse – assists charge nurse

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Current Procedures• Flow of information

– Medication nurse notes a change in condition – Verbally communicates with charge nurse – Charge nurse calls MD and writes on call log

• The information on the call log may not be entered in the nurses notes; nurses write notes on a piece of paper

• The next shift may not have the full picture of the resident

• Lack of information to MD

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New Procedure

• SBAR note• The medication nurse

– Notes a change in the resident’s condition – The nurse suspects a UTI – The nurse documents her findings – Gives the nurses note to the charge nurse at the

desk

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Benefits

• The nurse now has a guide – Documentation – Assessment of system

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Nursing Note

• The charge nurse – Reads the nursing note to the MD

• Increases in accuracy of communication • Improves resident outcomes

– Documents on the same nursing note – Notifies family and documents on the same

nursing note – The nursing note gives a story – Note is placed in the medical record

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Nursing Note Before Calling MD: Evaluate the resident and complete the form (use “N/A” for not applicable) Check VS: BP, pulse, respiratory rate, temperature, pulse ox, and/or finger stick Glucose if indicated Review chart: History of UTI, diabetes, indwelling urinary catheter Have relevant information available when reporting (i.e. resident chart, vital signs, Advanced directives such as DNR and other care limiting orders, allergies, medication List) SITUATION The symptom/signs of possible UTI I am calling about are: No indwelling catheter. Check all that Apply: Not applicable _____The symptom/signs of possible UTI I am calling about are: •Fever (increase of > 2° F; rectal temp > 100°F) •New or increased burning, pain on urination, frequency urgency •New flank suprapubic pain/tenderness •Change in character of urine new bloody urine, new foul smell Change in amount of sediment • lab report of positive result (nitrite +, pyuria, microhematuria) •Worsening of mental worsening of functional status •confusion, lethargy, unexplained falls, recent onset of Incontinence, decreased activity decreased appetite)If resident has indwelling urinary catheter: Not applicable:_________Fever or chills New flank pain New suprapubic tenderness Change in character of urine Worsening of mental status or function BACKGROUND Primary diagnosis and/or reason resident is at the nursing home: ______________________________________________________________________ Vital Signs: BP___/___ HR____ RR___ Temp____ Pulse Oximetry___% on RA__ on 02 at______ L/min via _________ (NC, mask) Mental status changes (e.g. confusion/agitation/lethargy) explain behaviors: ____________________________________________________________________________________________________________________________________________ GI/GU changes (circle all that apply) (E.g. nausea/vomiting/diarrhea/distension/decreased urinary output/other)_ _____________________________________________________________________ Change in intake/hydration explain: _______________________________________ WBC:______________________________Advance directives (circle) (Full code, DNR, DNT) Allergies:_________________ Any Other Data: ______________________________ Nurse Name: __________________ RN/LPN Date: ___/___/__ Time____/____ am/pm Resident label 46

Nursing Note

ASSESSMENT (RN) OR APPEARANCE (LPN) Resident has 3-5 background symptoms Resident has 1-2 symptoms For Indwelling Catheter Resident has 2-4 background symptoms Resident has 1 background symptom Resident appears to have new symptoms of concern

Nurse Name: __________________ RN/LPN Date: ___/___/__ Time_______ am/pm ----------------------------------------------------------------------------------------------------------------------------------- Call placed to: _________________ MD Date: ____/____/____ Time________ am/pm communicated by: Phone In Person left a message Note: _____________________________________________________________________Nurse Name: __________________ RN/LPN Date: ___/___/__ Time_______ am/pm _______________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------------

Return call/new orders from MD: __________ __Date__/__/__Time_______ am/pm Communicated by: Phone In Person Note: _____________________________________________________________________Nurse Name: ___________________ RN/LPN Date: ___/__/__ Time________ am/pm __________________________________________________________________________________ --------------------------------------------------------------------------------------------------------------------------------------

Call placed to: Family or health care proxy: _______________ Date: __/___/__Time: ______ am/pm communicated by: Phone In Person Notified Left a message Nurse Name:__________________ RN/LPN Date: ____/____/____ Time_____ am/pm Note: _________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------_

Family or health care proxy: __________________ Date: ___/___/__Time: ____am/pm communicated by: Phone In Person Notified Nurse Name: _______________RN/LPN Date: ____/____/____ Time______ am/pm Note:

* Adapted from INTERACT II and VDH Resident Label

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Surveillance

• Review the 24 hour report daily • Complete the event form on a daily basis

– UTI event form separated from other infections • Receive a list of all urinary catheters by 10am

daily• Complete the Virginia UTI Denominator Form

daily• Check labs online • End of the month totals

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Model Transfer Form

• Contacted Inova Health System – Meeting with infection preventionist

• Will discuss the model transfer form • Continuum of care with residents with infections • Improvement in communication • Reporting back to the transferring hospital

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Nurse Driven Protocol

• Development of new protocol– Bladder scanner

• Multiple nurses trained – Indwelling catheter

• Protocols to prevent CAUTI• If infection suspected, change catheter

– Proper collection of urine samples • Sterile specimen container • Clean catch • Collection port for catheter

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