UTI Definition Workgroup

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1 UTI Definition Workgroup

2 Purpose To develop standard clinical definitions on select diagnoses & categories to be used consistently across all hospitals in Maryland Definitions will be informed by published criteria, existing hospitaldeveloped definitions and supported by industry consensus and comments from the field Definitions will not conflict with federal inpatient coding guidelines and will be applied to any occurrence of the diagnosis, not only in scenarios that might trigger a PPC Our goal is that these definitions will be considered and adopted by hospitals Medical Executive Committees 2

3 Background Under the state s waiver agreement, hospitals must meet reduction targets for Potentially Preventable Complications (PPCs) Additionally, the Health Services Cost Review Commission (HSCRC) incorporates reduction targets into payment policy Having a uniform set of clinically defining criteria may facilitate care improvement Consistency allows for both a performance comparison amongst hospitals and for a measurement of an individual hospital s performance improvement over time Consistency helps demonstrate that Maryland hospitals have put in time and effort to achieve clinically significant performance improvement in addition to improvement achieved through revised documentation practices 3

4 Participants HOSPITALS Adventist Healthcare Brian Carpenter, MD, Chief Hospitalist, Adventist HealthCare Shady Grove Medical Center Michelle Cousineau, Senior Coding Coordinator, Adventist HealthCare Joy Gill, Clinical Data Manager, Adventist HealthCare Johns Hopkins Julia Gardner, Infection Control Epidemiologist, Johns Hopkins Hospital Kerri Huber, Infection Prevention Manager, Johns Hopkins Bayview Medical Center Heidi Milby, Coding Compliance Auditor, Johns Hopkins Hospital Pat Rodriguez, Coding Quality Manager, Johns Hopkins Health System Julie Trivedi, MD, Clinical Associate In Medicine, JHUSOM And Hospital Epidemiologist, Suburban Hospital, JHHS Lifebridge Health Mary Lou Bond, Data Quality Manager, Lifebridge Health Joelle Glass, Infection Prevention And Control Manager, Lifebridge Health Rose Lim, Clinical Documentation Improvement Specialist, Lifebridge Health Susan Mani, MD, Chair Department Of Medicine, Chief Quality Officer, Northwest Hospital Medstar Health Bernard Ravitz, MD, Physician Advisor PAC-CDI, Medical Director for SSU/Observation Unit, MedStar Good Samaritan University of Maryland Mangla Gulati, MD, Medical Director For Clinical Effectiveness, UMMC Surbhi Leekha, Assistant Professor for Epidemiology and Public Health, UMMC Michael Anne Preas RN, Director Infection Prevention and Control, UMMC STAFF Maryland Hospital Association Nicole Stallings, Vice President Justin Ziombra RN, Analyst Berkeley Research Group Joni Dion, Associate Director Kristen Geissler, Managing Director 4

5 Phase 1 Meeting Calendar UTI PPCs 65, 66 January 28 February 17 Renal PPCs 24, 25 OB PPCs 55, 56, 57, 58 Respiratory PPCs 3, 4, 5, 6 February 2 February 23 January 29 February 18 March 5 February 5 February 19 March 10 All meetings to be held from 8:30 11:30 at MHA 5

6 Meeting Workflow Schedule Meeting 2, January 28: Review feedback from stakeholders and update draft definitions Homework prior to Meeting 3: Draft definitions will be submitted to hospital field for comment Meeting 3, February 17: Review comments Finalize definitions 6

7 Meeting 1 Takeaways

8 Key Takeaways Our workgroup concluded that the most straightforward way to diagnose a UTI would be to craft a scoring system that assigns points for certain indications A UTI will be diagnosed when a particular point threshold has been reached The points will be weighted to assign higher points to more significant potential indicators The need for a scoring system was agreed upon as a better alternative to listing the multiple combinations of signs, symptoms, and lab values that might constitute a positive UTI diagnosis The group concluded that a UTI does not include: Colonization without other signs symptoms Yeast-only infections 8

9 UTI Scoring Tool Indication Points Fever >38 or <36 1 For responsive patients or 2 for obtunded patients Costovertebral angle pain or tenderness 2 Suprapubic tenderness 1 Urinary frequency and/or Urinary urgency and/or Dysuria 1 Negative Urinalysis -1 Positive Urinalysis 2 Negative or absent urine culture 0 Positive urine culture 2 Threshold Required To Diagnose a UTI 4 Scoring tool is only designed for inpatients without a catheter Tool excludes certain patient populations that will likely require a modified scoring methodology, including: 1) the very young (exact ages to be defined) 2) the elderly (exact ages to be defined) 3) patients residing in nursing homes 4) immunocompromised patients 5) patients who have suffered brain or spinal cord injuries or other neurologic disorders 6) pregnant patients 7) patients being treated for severe burns 8) patients who have an ileal conduit 9) patients who have recently been treated with antibiotics 9

10 Chart Reviews The chart reviews did not indicate that our scoring system captured a significant amount of those patients with a documented UTI Of the 72 cases members reviewed, only 41 (56.9%) met the scoring threshold of 4 points 10

11 Positive Urinalysis Please see member submitted material and studies regarding what urinalysis findings are indicative of a UTI 11

12 Workgroup Discussion How should we refine the scoring tool? Might this scoring tool still be acceptable, as currently constructed, if it s presented as definitive but not comprehensive? What criteria should we use to define UTIs in patients with catheters? Note: Please see IDSA criteria in Appendix How should we define UTI for special populations? Special populations enumerated at first meeting: 1) the very young (exact ages to be defined) 2) the elderly (exact ages to be defined) 3) patients residing in nursing homes 4) immunocompromised patients 5) patients who have suffered brain or spinal cord injuries or other neurologic disorders 6) pregnant patients 7) patients being treated for severe burns 8) patients who have an ileal conduit 9) patients who have recently been treated with antibiotics What UA findings are indicative of a UTI? Note: Please see member submissions 12

13 Homework We will disseminate the consensus criteria for UTI that we develop here today to all hospitals We will distribute their comments to you prior to our next meeting Please consider these comments and come prepared to finalize criteria at our next meeting Our next meeting is here, on February 17 th, at 830am Thank You!! 13

14 Appendix IDSA Guidelines for CAUTI

15 IDSA - CAUTI CAUTI in patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization is defined by the presence of symptoms or signs compatible with UTI with no other identified source of infection along with >10 3 colony-forming units (cfu)/ml of >1 bacterial species in a single catheter urine specimen or in a midstream voided urine specimen from a patient whose urethral, suprapubic, or condom catheter has been removed within the previous 48 hrs Signs and symptoms compatible with CAUTI include new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain; costovertebral angle tenderness; acute hematuria; pelvic discomfort; and in those whose catheters have been removed, dysuria, urgent or frequent urination, or suprapubic pain or tenderness In patients with spinal cord injury, increased spasticity, autonomic dysreflexia, or sense of unease are also compatible with CAUTI In the catheterized patient, pyuria is not diagnostic of catheter associated-bacteriuria (CA-ASB) or CAUTI The presence, absence, or degree of pyuria should not be used to differentiate CA-ASB from CAUTI Pyuria accompanying CA-ASB should not be interpreted as an indication for antimicrobial treatment The absence of pyuria in a symptomatic patient suggests a diagnosis other than CAUTI In the catheterized patient, the presence or absence of odorous or cloudy urine alone should not be used to differentiate CA-ASB from CAUTI or as an indication for urine culture or antimicrobial therapy Hooton et al., Diagnosis, Prevention, and Treatment of Catheter- Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America; IDSA Guidelines,

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