Implementing the Long-Term Care UTI Toolkit Wisconsin Coalition on HealthCare Association Infection in Long Term Care
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1 Implementing the Long-Term Care UTI Toolkit Wisconsin Coalition on HealthCare Association Infection in Long Term Care MetaStar Health Care Quality Symposium: The Value of Better Health Paula Kock RN Joe Boero MD Learning Objectives Demonstrate how to navigate the Wisconsin Health Care Associated Infection in Long-Term Care(LTC) website pertinent to urinary tract infection management in long term care Recognize opportunities within their own long term care facility to create systems to implement antibiotic stewardship programs utilizing items from the HAI LTC WI website. Recognize that it is alright Not To Think Urine First when a resident in long term care has a change in condition without localizing urinary symptoms 1
2 Bibliography ISDA Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship Delitt, et. al. CID 2007:44 (Jan 15) Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria Stone, et.al. Infect Control Hosp Epidemiol 2012:33(10): Development of Minimum Criteria for the Initiation of Antibiotics in residents of Long-Term-Care Facilities: Results of a Consensus Conference Loeb, et.al. Infect Control Hosp Epidemiol 2001:22(2): Clinical Uncertainties in the Approach to Long Term Care Residents With Possible Urinary Tract Infection Nace, et.al. JAMDA 15 (2014) Treatment of Bacteriuria Without Urinary signs, Symptoms, or Systemic Infectious Illness (S/S/S) Drinka JAMDA 10 (2009) The Core Elements for Antibiotic Stewardship in Nursing Homes CDC Sept 15, 2015 dhttp:// Module I: Improving Communications and Decisions about Antibiotic use in Nursing Homes; AHQR The Role of DONs in Cultivating Nurse Empowerment Annals of Long Term Care Vol 24, April Wisconsin Healthcare-Associated Infections (HAIs) in Long-Term Care Coalition 2
3 HAI-LTC Wisconsin UTI Management Toolkit Domain I: Overview-scope of Problem Domain II: Prevention of UTI Domain III: When to Test Domain IV: When to Treat Domain V: Organizational Improvement Domain VI: How to Treat 3
4 Script for Non Localizing Urinary Symptoms, No Warning Signs Rm 202 Today s date 11:00 AM Situation: She has a complaint of generalized discomfort. She has had a mental status change of mild lethargy and mild confusion tending to wander but is orientable. She didn t go to activities this afternoon. Appetite poor since this morning. She remains alert. She has a recent med change consisting of addition of gabapentin 300 mg bid oral for pain. Vitals: Temperature 97.2(Buccal) Pulse 68 and regular, Respirations 20, B/P 120/62. O2 Sat on room air is 97%. Appearance: This resident is an elderly long term care woman with hours of complaint of poorly localized general discomfort with mild confusion and poor appetite. Resident Evaluation: She has not recently fallen. There is no recent exposure to infectious residents or visitors. Lungs are clear and there is no chest pain. She has had no change in BMs with last one yesterday and there is no vomiting or diarrhea. There are no focal urinary symptoms or signs. There are no skin rashes or sores, and no new joint, chest, or abdominal pains. Review/Notify: According to our understanding of best practices and our facility protocols, the information is insufficient to indicate an active urinary tract infection. The resident does NOT need an immediate prescription for an antibiotic, but may need further evaluation and treatment. We are asking for an order for a hour period of observation and will call physician for change in condition. Script for Localizing Urinary Symptoms, With Warning Signs Rm 202 Today s date 11:00 AM Situation: Jimmy has sudden onset of acute dysuria and frequency. Gross hematuria is present with small clots. There is no suprapubic or costovertebral tenderness. Vitals: : Temperature 102.3(Buccal) Pulse 104 apical and irregular, Respirations 30 and shallow, B/P 150/80. O2 Sat on room air is 86% Appearance: He has mildly increased confusion since mid-afternoon today. He has had a functional decline requiring an increase in staff assist with bed mobility, transfers, and other ADL's. His appetite is diminished and oral fluid intake in the last 16hr is 600 CCs. Lungs are clear. Bowel sounds are present in all 4 quadrants. Abdomen is non-tender with no vomiting or diarrhea. He has mucous shreds, urine is dark colored. Resident Evaluation: This resident is exhibiting localizing urinary tract signs and symptoms with hypoxia and warning signs of fever, tachycardia. Review/Notify: According to our understanding of best practices and our facility protocols, the information is sufficient to indicate an active urinary tract infection. We request an order to obtain a urinalysis and culture. Please advise regarding further treatment. 4
5 Two main core Stewardship strategies 1. Prospective auditing of antibiotic use with direct interaction and feedback to the prescribing physician 2. Formulary restriction and prior authorization requirements. ISDA 2007 (2). Using the right drug for the right diagnosis in the right dose for the right length of time. Crnich 2013 As simply as possibly stated, antibiotic stewardship in LTC is: Creating a system for gathering data Deciding on best practice criteria for antibiotic use in bacterial infection within your institution Determining whether antibiotic use for that infection is within the institutional criteria Ensuring right drug, right indication, right dose, right length of time Providing feed-back to the prescribing providers and staff so they can improve their practice behavior Measuring outcomes 5
6 Antibiotic Stewardship Program 1. Staff and Family Education 2. Nursing Assessment Skills 3. Staff Critical Thinking / Judgment 4. Medical Record Documentation 5. Infection Surveillance-audit and feedback 11 6
7 Outcomes of Antibiotic Stewardship Decrease the overuse, misuse, and abuse of antibiotics De-escalate antibiotics when possible Give the most appropriate antimicrobial with the correct dose and duration. Minimize the development of antibiotic resistance and adverse drug reactions Consider these efforts an organized QAPI project 14 7
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