How to Use the Toolkit:
Successful Strategies for the
Prevention of Urinary Tract
Infections in Long-Term Care
Virginia Department of Health
March 21, 2012
1
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
2
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
3
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
4
The Toolkit
5
Recognition of Collaborative Partners
• Autumn Care of Portsmouth
• Beth Sholom Village
• The Gardens at Warwick
Forest
• Heritage Hall of Virginia
Beach
• James River Convalescent
and Rehabilitation Center
• Lake Prince Woods
• Lake Taylor Transitional Care
Hospital
• Maryview Nursing Care
Center
• Oakwood Nursing and
Rehabilitation Center
• Riverside Convalescent
Center- Smithfield
• Sentara Nursing Center Windermere
• Virginia Beach Healthcare
and Rehabilitation Center
6
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
7
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
8
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.
9
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 UTIs
10
Definitions Tab
• Glossary of Terms
– Five pages of UTI-related terms
– Alphabetical
– May be helpful when giving in-services
11
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
12
Tools: McGeer and F-Tag 315
13
Tools: UTI Event Form
14
Tools: Resident Illness Log
• Patient info
– Name, age, sex, location
• Illness information
– Onset date, temperature, type of illness,
symptoms, lab information, outcomes
15
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
16
Tools: SBAR
Before calling a clinician for treatment, evaluate
the resident, check vital signs, review chart, and
have the relevant information available when
reporting
Situation
Background
Assessment / Appearance
Request
17
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
18
Tools: Urinary Catheter
Checklist and Reminder
19
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 (CatheterAssociated Urinary Tract Infections)
20
Tools: Policy Templates
21
Education Tab
•
•
•
•
•
•
Prevention Priorities: HICPAC and CDC
UTI Surveillance FAQs
UTI FAQs
CAUTI FAQs
UTI Prevention Strategies: Ideas
Hand Hygiene FAQs
22
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
23
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?
24
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?
25
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
26
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)
27
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 Tab
UTIs: 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
29
Presentation Questions
Urinary 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
30
References Tab
• Resources and References
– Surveillance definitions and clinical guidelines
– Other guidelines and position papers
– Prevention resources
– Antibiotic stewardship resources
31
Thank you!
www.vdh.virginia.gov/epidemiology
/surveillance/hai/uti.htm#Toolkit
To contact the VDH HAI Team:
[email protected]
[email protected]
[email protected]
804-864-8141
32
Our Experience with the UTI
Toolkit
Adriana Agnew RN, BSN, BC, MSNEd, AIT
Director of Quality Management and Infection Preventionist
Fairfax Nursing Center
[email protected]
33
Fairfax Nursing Center’s Use of the
Toolkit
• Assisted with protocol
revisions
• Developed new protocols
• Documented using SBAR
• Reinforced the nurse
driven protocol
34
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
35
Closed
System
In and Out
36
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
37
Policy and Procedures
•
•
•
•
Research completed
Follows the F-tags
Appropriate for long-term care setting
Best practice
38
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
39
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
40
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
41
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
42
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
43
Benefits
• The nurse now has a guide
– Documentation
– Assessment of system
44
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
45
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
47
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
48
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
49
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
50
Thank you for
participating in the
webinar!
51