Urinary tract infections (UTIs) are the most common infections found in residents in long-term care (LTC) facilities. However, no universal evaluation or treatment is available for a UTI. Often, it is determined by clinical judgment rather than diagnosing via evidence-based practice (EBP).1 It is common in healthcare to "check a urine" when a patient's health declines or an unexplainable event occurs. This strategy can lead to inappropriate evaluation and treatment of UTIs.
Data demonstrated that the percentage of residents in a rural, Midwestern LTC facility who had a UTI was 11.1%, which was 3.3 times greater than the state average of 3.3 % and 4.1 times greater than the national average of 2.7%.2 However, the UTI rate was exaggerated due to the number of discrepancies between UTIs evaluated by best practice and those identified through clinical judgment.3
This article recounts the implementation of an EBP evaluation and treatment protocol at an LTC facility to reduce the percentage of residents with a UTI.
Quality outcomes
The lack of best practices has facility and patient consequences. Facility consequences may be financially related to quality outcome scores. Nursing Home Compare, now known as Care Compare (CC), was initiated in 1998 by the Centers for Medicare and Medicaid Services (CMS) to educate consumers on LTC quality of care.2 Quality scores are calculated based on individual LTC facility statistics derived from the CMS health inspection database, the national database on resident clinical information, the Minimum Data Set retrieved from individual resident assessments, Medicare claims data, and nursing staff hours. Data on rehospitalizations, ED visits, pain, pressure injuries, and UTIs are included in CC quality outcomes. The UTI quality measure is the percentage of residents with a UTI in the previous 30 days. This is an important quality measure as it reflects the LTC facility's cleanliness, nutrition services, and personal care services.2
All data are combined to give each LTC facility a star rating: a five-star rating is the highest, and a one-star rating is the lowest. Data are publicly reported and compare individual facility star ratings to state and national ratings. Consumers can review star ratings to judge an LTC facility's quality of care. Higher facility star ratings can increase resident referrals and admissions, increasing revenue and facility solvency. Conversely, lower ratings may lead to fewer referrals and admissions, decreasing revenue and facility solvency.2
A lack of best practices in UTI evaluation and treatment may negatively impact residents in LTC facilities. Poor practices may cause unnecessary lab testing procedures, adverse drug events, opportunistic infections, antimicrobial resistance, and additional expenses, such as medications and testing.1,4. Residents in LTC, if misdiagnosed and inappropriately treated with antibiotics, are more likely to develop drug resistance and subsequently require the use of alternative, expensive antibiotics.4
UTI approaches
UTI evaluation and treatment
The McGeer Criteria for Urinary Tract Infection Surveillance was developed in 1991 for infection surveillance and guidance in LTC facilities.5 The Criteria require that all signs and symptoms be new or acutely worse, alternative noninfectious signs and symptom causes be ruled out, and clinical presentation and microbiologic findings be present to diagnose infections.5
As of 2012, The McGeer Criteria may no longer apply to new types of LTC facilities, such as LTC hospitals, acute inpatient rehabilitation facilities, and pediatric LTC centers. These types of LTC facilities may have greater technologic resources, such as on-site lab facilities, and serve more diverse, acutely ill residents than traditional LTC facilities.
Stone's5 Revised McGeer Criteria embraced McGeer's three important criteria but also considered the low probability of UTIs in asymptomatic residents without indwelling urinary catheters. Furthermore, Stone's revised criteria require a microbiologic confirmation for a UTI diagnosis, localizing genitourinary signs and symptoms, and a positive urine culture. The revised definitions noted only a positive blood culture with the same organism as from the urine culture can diagnose a UTI without the presence of symptoms.5
Loeb6 outlined a proactive approach involving UTI evaluation and treatment algorithms for residents living in LTC facilities, Loeb's Minimum Criteria for Initiating Antibiotic Therapy. The three important conditions of the original McGeer criteria were retained; however, the Loeb criteria determine if a urine culture should be performed based on assessment findings such as fever, urinary symptoms, pain, new delirium, and the presence of an indwelling urinary catheter. If a urine culture is obtained, the treatment algorithm assesses if a positive urine culture, indwelling urinary catheter, or other urinary symptoms are present, thus advising if an antibiotic should be prescribed.6
"Watchful waiting" is a skilled cornerstone of nursing care that is recommended if a urine culture is not advised. "Watchful waiting" is not an absence of action but an observation and monitoring protocol that supports frequent resident assessments and communication of change in condition.1
Loeb's6 algorithms reduced antimicrobial prescriptions for suspected UTI events in residents in LTC facilities. Residents in LTC facilities were often diagnosed with UTIs based on a positive urine culture which only implies the presence of bacteriuria, not a symptomatic UTI. The prevalence of asymptomatic bacteriuria (ASB) ranges from 25% to 50% in females and 15% to 40% in males. ASB can also coincide with signs and symptoms unrelated to UTIs. It is not unusual to seek a urine culture for self-limiting, inappropriate symptoms rather than following best practices.7
Antibiotic stewardship
Antibiotic overuse is a national health concern. For residents who live in an LTC facility for at least 6 months, 75% receive an antibiotic, of which over half are unnecessary.8 Nearly 75% of antibiotics prescribed for UTIs in LTC facilities do not meet the minimum UTI criteria.8
There are extra financial and quality-of-life costs related to unnecessary antibiotics, including opportunistic infections and adverse drug reactions.9 Antibiotic-resistant organisms develop with the misuse of antibiotics and require alternative, sometimes more expensive, treatments to eradicate.4 Furthermore, unnecessary lab tests and medications can lead to wasted healthcare dollars and poor-quality patient experiences.
In the US, family preferences profoundly influence prescriber antibiotic decision-making, as do off-site prescription processes.1 Families often pressure LTC staff and providers to "do something" even if best practice does not support the "something."1
If a urine culture is completed, an antibiotic will likely be prescribed, with or without an EBP UTI diagnosis.1 According to a narrative review, providers spent less than 2 hours per week in LTC facilities and relied on individual nurses to recognize and communicate changes. A standardized assessment and communication intervention leads to lower antibiotic prescription rates.9
Interventions, education
A national quality improvement assessment found that only 36.1% of licensed personnel recognized that pyuria does not equal a UTI.10 The Agency for Healthcare Research and Quality (AHRQ) provided multiple tools for LTC facilities, such as assessments to determine if the LTC facility has the right staff and resources and areas for quality improvement related antimicrobial stewardship.11 The toolkit assists LTC facilities in the team creation, readiness assessments, implantation plans, and the introduction of new policies and procedures for an antimicrobial stewardship plan.11
The Cooper Urinary Surveillance Tool was developed using consensus evaluation and treatment criteria from McGeer, Stone, and Loeb.5,6 Nurses were educated on best-practice identification of UTI signs and symptoms and appropriate versus inappropriate UTI diagnosis via the tool. After 3 months, the number of UTIs decreased significantly, and there was a 97% reduction in urinalysis (UA) testing.4
In a pilot program, the use of the AHRQ antimicrobial stewardship toolkit resulted in a reduction of unnecessary antibiotic use by 30%.11 In another study, an evidence-based education program and a knowledge evaluation instrument were presented to 42 healthcare personnel at an LTC, and the participants' knowledge was measured both before and following the presentation. Results showed that knowledge of UTI diagnosis significantly improved.12
EBP intervention
In September 2019, an EBP project was developed at a facility in a rural, Midwestern state the US, starting with an organizational and problem assessment. In March 2020, a protocol was created based on the stakeholder assessment, best-practice evidence, the Loeb's Minimum Criteria for Initiating Antibiotic Therapy,6 and the AHRQ antimicrobial toolkit11 (see UTI Evaluation/Treatment Worksheet). The protocol was printed, and an educational intervention was planned for March 18, 2020.
First, a pretest was to be completed by participants and an informational packet and copy of the UTI Evaluation/Treatment Worksheet were to be provided. Then, a 30-minute formal educational program was to be provided to all nursing staff at a scheduled staff meeting. Next, participants would engage in a hands-on activity involving simulated urine and resident signs and symptoms to practice using the worksheet. Education reinforcement was to occur weekly through posters, data displays, and improvement huddles. However, plans changed with the COVID-19 pandemic.
On March 13, 2020, the target facility closed to visitors due to the COVID-19 pandemic. The pretests were eliminated due to the transmission concerns of paper copies. Email was not an option as the facility only had dedicated email accounts for administrative nurses. The project was modified with social distancing regulations, a virtual presentation instead of a staff meeting, and virtual education.
Any staff absent from the virtual education meeting viewed the recorded presentation later. After the educational intervention, the worksheet was placed in the Nurse Communication Books. In the initial stages of the pandemic, follow-up was conducted via email and text messaging. Facility access increased as the COVID-19 tests and vaccinations were released, permitting informal follow-up and education on the EBP process, at most, every 2 weeks.
Evaluation
UTI rates
Data were studied from the CC dataset, UTI Evaluation and Treatment Worksheets, and facility infection control logs. The project participants included facility residents and LTC nurses. Fifteen facility residents required UTI evaluation and treatment. Eighteen LTC facility nurses participated in the UTI evaluation and treatment process and viewed the virtual presentation. Additionally, 24 certified nurse aides viewed the virtual presentation but did not complete the evaluation and treatment process.
National, State, and Facility UTI rate means were analyzed from 2018 to 2020 (see 2018-2020 Yearly UTI Rates). The National and State means remained steady from 2.6% to 2.7% and 3.2% to 4.1%, respectively. The Facility means varied widely. The 2018 Facility UTI rate mean was 8.4%, 2019 was 11.1%, and 2020 was 3.1%. Thus, the goal of Facility UTI rate at or below National and State averages by May 2021 was partially met. During the project period (September 2019-December 2020), the Facility was at or below the National and State averages for 10 of 16 months.
Facility documentation audits noted that most UTIs during June-September 2020 did not meet EBP criteria. UAs were obtained due to residents' failure to thrive, and antibiotics were prescribed. Most failure-to-thrive residents died.
Outcomes evaluation indicated the use of an EBP protocol was associated with a decreased incidence of inappropriate UTI evaluation and treatment compared with the nonuse of an EBP protocol over 12 months.
Potential quality and financial benefits
If a urine culture is obtained, an antibiotic will likely be prescribed, with or without a UTI diagnosis (see UTIs appropriately treated with antibiotics).1 This suggests that using the EBP protocol could deter unnecessary urine testing and unnecessary antibiotic treatment. The reduction of antibiotic-related consequences for the facility residents was not monitored and is an area for future consideration.
The treatment of inappropriately diagnosed UTIs unnecessarily increased costs. The exact medication costs are unknown as the medications were directly billed to the residents. The cost of each UTI treatment course was estimated for the three most commonly prescribed antibiotics in the facility. An informal facility assessment revealed the three most frequently prescribed UTI antibiotics were ciprofloxacin, cephalexin, and nitrofurantoin. The average cost of each medication treatment course was calculated using estimated medication costs from three local pharmacies. This average cost, multiplied by the number of inappropriately diagnosed UTIs equaled a potential antibiotic cost savings (see Estimated cost savings if inappropriately diagnosed UTIs were not prescribed antibiotics).
If urinary signs and symptoms do not meet the EBP criteria and a UA is obtained, there is potential for unnecessary expense. The cost per UA in the facility was reported as $49 (see Estimated UA cost savings if inappropriately diagnosed UTIs had no UA order). Facility average daily census (ADC) is included as the declining census may partially affect the data. There also is a potential quality outcome cost. The process of collecting a UA is stressful and unpleasant for older adults, especially those that are cognitively impaired. By not collecting unnecessary specimens, anxiety and loss of dignity can be avoided.
Limitations
The COVID-19 pandemic affected the project. LTC facility priorities turned to resident and staff safety. The educational intervention was delayed and continued only through facility support. One limitation was the lack of data on preintervention versus postintervention knowledge. The pretests were not conducted as the educational intervention was done virtually due to social distancing requirements and transmission concerns with the planned paper tests. Email could not be used due to lack of facility access.
Early in the pandemic, March-December 2020, all outside materials were isolated for 72 hours before being brought into the LTC facility. Therefore, a decision was made not to use posters and data displays in the facility. For an already stressed and exhausted staff, the added burden of retrieving outside materials for distribution was replaced with text messaging and electronic mail contact to relay updates to administrative nurses for distribution.
Another limitation was the small size of the facility and the decreased ADC over the evaluation period. It is unknown if the decline in UTI rates would have naturally occurred with the decline in the census. The project could be repeated with greater population sizes in other LTC facilities.
Recommendations
The findings suggest that an EBP protocol is useful in diagnosing, evaluating, and treating UTIs in residents in LTC facilities. Additional projects to support the EBP on evaluating and treating UTIs in residents in LTC facilities are needed to expand the body of knowledge. Greater focus on patient and prescriber preferences is necessary as these stakeholders affect the UTI evaluation and treatment process. As previously described, family preferences profoundly influence prescriber antibiotic decision-making, as do off-site prescription processes.1 Families often pressure LTC staff and providers to "do something" even if best practice does not support the "something,"1 and this deserves further consideration.
The COVID-19 pandemic altered aspects of LTC facilities, including the care and communication of the EBP project. Visual management such as posters and data displays should be used in future studies. Improvement huddles should also be implemented to share successes and improvement strategies.
Nursing implications
UTIs are the most common infections found in residents in LTC facilities, and EBP nursing interventions can improve quality outcomes. Careful analysis and application of assessment findings empower nurses to make EBP evaluation and treatment clinical decisions at the bedside. The nurse is responsible for educating other nurses and ancillary staff on best practices, and sensitive and measured communication is required during treatment decisions with residents and families. Nurses are ethically responsible for addressing antibiotic stewardship and healthcare costs at every opportunity.
Conclusion
UTI evaluation and treatment rooted in EBP can improve outcomes in LTC facilities. Additional projects to support EBP in evaluating and treating UTIs in residents in LTC facilities are needed to expand the body of knowledge. Further focus on patient and prescriber preferences is necessary as these stakeholders affect the UTI evaluation and treatment process.
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