Is It Really a UTI? Do You Know It When You See It?

1. Define Symptomatic UTI versus

Asymptomatic Bacteriuria

2. Review RAI MDS Coding Manual

Definition of UTI

3. Analyze UTI as a Quality Measure

4. Discuss UTI Assessment, Criteria and

Communication with Prescribers

5. Consider UTI Reduction in the Nursing

Home from a QAPI Perspective

Today’s Objectives

• Health Quality Innovators HQI (formerly VHQC) is your

Quality Innovation Network – Quality Improvement

Organization (QIN-QIO) for MD & VA

• QIN-QIO’s bring Nursing Homes, Hospitals, Communities and

Patients together in data-driven initiatives that:

• Increase resident safety

• Make communities healthier

• Better coordinate post-hospital care

• Improve clinical quality

HQI Nursing Home Improvement Network

Why Focus on UTIs

in the Nursing Home?

• UTIs are the most frequently reported infections

in long term care1

• UTIs are a significant cause for hospital

readmissions and Sepsis1

• Monitoring of symptomatic UTIs helps identify

trends in these infections and provide data to

improve antibiotic use in your facility:

• 30-60% of antibiotics in SNFs are for suspected UTIs2

• 40-75% of those antibiotics used may be unnecessary

or inappropriate3

1 Agency for Healthcare Research and Quality (AHRQ) Safety Program for Long-Term Care

2 Benoit SR et al. J Am Geriatric Soc 2008; 56: 2039‐44 PMID 19016937

3 CDC. The Core Elements of Antibiotic Stewardship in Nursing Homes

Risk Factors for Developing a UTI1:

• Age (especially over 85)

• Female

• Neurogenic bladder

• Reduced Mobility

• Urinary Incontinence

• Previous UTI

• Prostate enlargement

• Kidney stones

• Catheters: Foley and condom caths 1 https://www.cdc.gov/longtermcare/staff/index.html

Risk Factors

Is it a UTI ?

Diagnosing UTIs in the Nursing Home

But There’s a Change in Mental Status

Remember when…

A Nursing Home UTI used to be characterized by foul

smelling, cloudy urine or a change in mental status

Comparing today’s UTI definitions:

McGeer et al. AJIC 1991; 19: 1-6, Loeb et al. ICHE 2001; 22:120-124, Stone et al. ICHE. 2012; 33: 965-977

For residents without a urinary

catheter:

At least 3 of the following

signs

(a) Fever (~38o C) or chills,

(a) New or increased burning

pain on urination,

frequency or urgency,

(b) New flank or suprapubic

pain or tenderness,

(d) Change in character of

urine,

(e) Worsening of mental or

functional status (may be new

or increased incontinence).

McGeer Loeb CDC/SHEA (aka “Modified McGeer” or “Stone” )

Important Definitions1

• Bacteriuria:

• Bacteria in the urine

• Urinary pathogen ≥100,000 colony-forming units (CFU)

• Asymptomatic Bacteriuria (ASB):

• Bacteriuria in the absence of genitourinary signs or

symptoms

• Symptomatic UTI:

• Bacteriuria in the presence of genitourinary symptoms

• Symptoms may include fever, dysuria, suprapubic pain

or tenderness, frequency, or urgency

1 Infect Disease Clinics North Am. 2014 Mar; 28(1): 75–89.

When should a U/A C&S be sent?

• Urine testing should be

performed when a resident

has localized urinary tract

signs and/or symptoms

• Odorous or cloudy urine are

NOT indications for urine

culture or analysis.

These changes alone do not

represent a UTI.

Hooten et al. IDSA Guidelines, Clinical Infectious Diseases 2010; 50:625‐663

Funded by the Agency for Healthcare Research and Quality (AHRQ)

Midthun et al. Journal of Gerontological Nursing 2004

In one study, using

urine odor to identify

bacteriuria resulted

in error in 1/3 of

cases

Even if urine odor is

caused by

bacteriuria, this does

not indicate that

infection needs to be

treated unless other

symptoms are

present.

Why Not Treat It Just in Case?

• Multiple randomized clinical trials

treating Asymptomatic Bacteriuria in

LTC residents have shown NO benefit • No difference in the # of symptomatic UTIs

• No improvement in chronic urinary incontinence

• No improvement in survival

• Asymptomatic Bacteriuria

Treatment is known to cause: • Increased Adverse Drug events

• Clostridium difficile (C. diff ) infection

• Increased antibiotic-resistant organisms

IDSA Guidelines for the Diagnosis & Treatment of Asymptomatic Bacteriuria in Adults. Journal of Clinical Infectious Disease 2005; 4-:643-54

Asymptomatic bacteriuria in adults: AAFP 2006; 74:985-90.

When calling the

Prescriber

SBAR Tools for UTI

• Situation

• Background

• Assessment

• Recommendation

http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/qu

ality-patient-safety/patient-safety-resources/resources/nh-

aspguide/module1/toolkit1/utisbar-form.pdf

Go to www.ahrq.gov

Search for “Suspected UTI” &

see excellent tools & resources

Which Criteria do you Follow?

• Meet with your Medical

Director to determine

Criteria/UTI definition that works

best for your prescribers and

your team.

• AHRQ’s toolkit for Suspected

UTIs is easy to use (ahrq.gov)

• INTERACT has a UTI CARE PATH

available for download: https://interact2.net/tools_v4.html

UTIs as a Quality Measure

15

CMS UTI Quality Measure

Description :

The percentage of long-stay

residents who have a urinary tract

infection

Definition of Long-Stay: • Cumulative days in facility is ≥ 101 days • A resident must be in your building for at least

101 days to be included in this measure

If they have a UTI,

I count them on the MDS

16

Not so fast…

The MDS 3.0 RAI Manual has very specific coding

instructions and conditions that must be met to

be considered a Urinary Tract Infection:

1. Diagnosis of UTI in the last 30 days

2. Sign or symptom attributed to UTI

3. “Significant laboratory findings”

4. Current medication or treatment for UTI in the

last 30 days

Counting Residents

with UTI in past 30 Days

17 Tip Sheet available from HQI

List Action Items, then apply select interventions on a

smaller scale

Education

• Educate all staff on their responsibility to prevent UTI

• Re-educate staff on UTI assessment & SBAR communication

• Educate environmental services staff on proper cleaning

techniques

• Conduct competency testing for nurses and CNA’s on proper

urinary catheter care and perineal care

• Conduct competency testing for nurses and CNA’s on proper

hand-washing techniques

• Provide/send MDS nurse to an MDS training course

• Provide education to residents, family members, and/or

significant others about ways to prevent UTI

• Access resources, tip sheets and tools from HQI

After Conducting a PIP,

Develop an Action Plan

18

HSAG QIO for California Infection Control Quality Assurance & Performance Improvement Case Study

HQI Quality Improvement Focus

Sheila McLean MBA, LNHA, CPHQ

Vice

President

Lisa Mark RN, BSN

Improvement

Consultant

Theresa Mandela RN, BSN

Improvement

Consultant

Nursing Home Improvement Network Team

from HQI

Allison Spangler RN, BSN

Improvement

Consultant

Contact Us!

20

Theresa Mandela

Improvement Consultant

tmandela@hqi.solutions

Lisa Mark

Improvement Consultant

lmark@hqi.solutions

Allison Spangler

Improvement Consultant

aspangler@hqi.solutions

This material was prepared by Health Quality Innovators (HQI), the Medicare Quality Innovation Network-

Quality Improvement Organization for Maryland and Virginia, under contract with the Centers for

Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.

The contents presented do not necessarily reflect CMS policy. HQI|11SOW|20170112-200800