When is it really a UTI? - PDF Free Download

When is it really a UTI? Adrienne Mims, MD, MPH, FAAFP, AGSF VP, Chief Medical Officer Adrienne.Mims@AlliantQuality.org 2/19/2016 1

Disclosure This educational activity does not have commercial support or sponsorship. Planners and presenters have no conflict of interest and or vested interest with this educational activity. This educational activity has no endorsement of any products, or co-providerships.

Objectives Understand the harm of over using antibiotics Learn the diagnostic criteria for a UTI Learn the appropriate reasons for when to order a urine analysis QAPI Using Data to Drive Improvement New Opportunity

A post antibiotic era in which common infections and minor injuries can kill far from being an apocalyptic fantasy, is instead a very real possibility for the twenty-first century, Data from 129 member states show extensive resistance to antimicrobial agents in every region of the world. Keiji Fukuda, WHO Assistant Director-General for Health Security http://www.cdc.gov/media/subtopic/lib rary/diseaseagents/img17.jpg pseudomonas

Tom Frieden, MD / Director - CDC Each year, in the U.S. 2,049,442 illnesses caused by bacteria and fungi that are resistant to at least some class of antibiotics, out of those illnesses 23,000 deaths $20 billion each year in additional healthcare spending An additional $35 billion lost to society in foregone productivity

If we are not careful, we will soon be in a post-antibiotic era, and for some patients and for some microbes, we are already there. ~ Tom Frieden, MD, Director - CDC

How Antibiotics Can Cause Harm Cause nausea and vomiting Cause secondary infections (Candida) Rash or other allergic reactions Harm kidneys or other organs Create bacterial resistance Cause diarrhea (C.difficile)

Risk of getting C. diff

Percentage of Clostridium difficile infection (CDI) cases (N = 10,342), by inpatient or outpatient status at time of stool collection and type/location of exposures http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm * United States, Emerging Infections Program, 2010

Impact of C. diff

Infection vs. Colonization Infection Presence of pathogen on culture Organism growth & invasion of host Presence of clinical signs & symptoms Colonization Presence of microorganism on culture No tissue invasion Absence of clinical signs & symptoms

Surveillance vs. Clinical Criteria Surveillance Criteria Focused on specificity Applied easily retrospectively Not for case finding Not for diagnostic purposes Not for clinical decision making Facility A Clinical Criteria Focused on sensitivity Applied prospectively Can be for case finding Mrs. Jones

http://www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/ patientsafety/2014nhqdr-ptsafety.pdf

Use of Indwelling Catheter Only inserted when there is a physician order and one of the following is present: diagnosis of obstruction diagnosis of neurogenic bladder stage III/IV perineal or sacral ulcer or terminal illness/hospice

Infection should be suspected in LTCF residents with: Localizing symptoms /criteria Acute delirium New 3 point decline in functional status (ADL) Fever, define as: (1) A single oral temperature >100F (>37.8C); or (2) repeated oral temperatures >99F (>37.2C) or rectal temperatures >99.5F (>37.5C); or (3) an increase in temperature of >2F (>1.1C) over the baseline temperature Guidelines for the Evaluation of Fever and Infection CID 2009:48 (15 January)

Confusion Assessment Method (CAM) 1. Acute Onset or Fluctuating Course 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness Diagnosis of delirium requires 1 and 2 and either 3 or 4 https://www.nhqualitycampaign.org/files/cam_confusion_assessment_instrument.pdf

Initial Diagnostic Testing Advance directives for residents should be reviewed prior to any intervention. If not prohibited by such directives, initial diagnostic tests for suspected infection can be performed in the LTCF if resources are available and if studies can be done in a timely manner

The minimum laboratory evaluation for suspected UTI Complete blood count (CBC) with differential cell counts Should be performed within 12-24 hours of symptom onset In absence of fever or leukocytosis and/or left shift, additional tests are not indicated Blood cultures demonstrate low yield and rarely influence therapy; thus are not recommended unless sepsis is suspected Guidelines for the Evaluation of Fever and Infection IDSA 2008 guidelines

Urine Tests Urinalysis and urine cultures should not be performed for asymptomatic residents Urinalysis evaluation for: leukocyte esterase nitrite level Microscopic examination for WBCs: pyuria (>10 WBCs/high-power field) If positive dipstick and microscopic exam, only then should a urine culture (with antimicrobial susceptibility testing) be ordered Guidelines for the Evaluation of Fever and Infection IDSA 2008 guidelines

Minimum Criteria for Initiation of Antibiotics for Suspected UTI Localized Criteria Acute dysuria New or worsening: Urgency Frequency Incontinence Hematuria Suprapubic or flank pain Scrotal/prostate tenderness Purulent urethral discharge Non-Localizing Criteria Fever Rigors in absence of another source Acute delirium Leukocytosis (>14,0000 or left shift (>90% neutrophils or >6% bands) in absence of another source Improving the Management of Urinary Tract Infections in Nursing Homes: It s Time to Stop the Tail From Wagging the Dog. http://www.annalsoflongtermcare.com/print/2519

Unified algorithm for the diagnostic evaluation and treatment for suspected UTI in nursing homes Improving the Management of Urinary Tract Infections in Nursing Homes: It s Time to Stop the Tail From Wagging the Dog. http://www.annalsoflongtermcare.com/print/2519

Management of UTI in Nursing Homes Driven by institutional attitudes likely face resistance to change To overcome challenge: Standardize the way health status is evaluated Change antibiotic decision-making process to be both condition-based and criterion Use tools STOP AND WATCH; SBAR

STOP AND WATCH Seems different than usual; Talks or communicates less than usual; Overall needs more help than usual; Participated in activities less than usual; Ate less than usual (not because of dislike of food); N Drink less than usual; Weight change; Agitated or nervous more than usual; Tired, weak, confused, or drowsy; Change in skin color or condition; Help with walking, transferring, or toileting more than usual

Suspected UTI SBAR

Residents and Families who want antibiotics Don t trust the natural healing process Want pain / symptom relief Are confident they know the best treatment Instead Educate on when antibiotics may not be needed Discuss alternative treatments: Increased fluid intake, perineal hygiene, regular toileting / pad change, respiratory therapy Monitor for fever or complications

American Geriatrics Society Don t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present. http://www.choosingwisely.org/cl inician-lists/american-geriatricssociety-antimicrobials-to-treatbacteriuria-in-older-adults/

Checklist Leadership support Accountability Drug expertise Actions to improve use Tracking: monitoring antibiotic prescribing, use, and resistance Reporting information to staff on improving antibiotic use and resistance Education

Antibiotic Stewardship for Nursing Homes Antibiotic prescribing and use policies Documentation of : Dose: including route Duration: start date, end date, and planned days of therapy Indication: which includes both rationale (i.e., prophylaxis vs. therapeutic) and treatment site (i.e., urinary tract, respiratory tract) Culture results Applies to those started in facility or prior to arrival

Antibiotic Stewardship for Nursing Homes Establish best practices for use of microbiology testing no test of cure cultures Use guidelines and local susceptibilities to create facility specific treatment recommendations (pneumonia, UTI, skin) Review the antibiotic agents available in the facility (inventory accessible during off hours)

Antibiotic Stewardship for Nursing Homes Develop and implement algorithms for the assessment of residents by clinical staff Utilize a communication tool for discussing residents with attending clinicians Develop and disseminate a facility-specific report of antibiotic susceptibility to clinical providers antibiogram Reduce prolonged antibiotic treatment courses for common infections short courses

Infection specific interventions to improve antibiotic use Do not treat with antibiotics in asymptomatic bacteriuria Reduce antibiotic prophylaxis for prevention of UTI Clarify when to treat pneumonia in facility vs. transferring Do not use superficial wound cultures

Next Steps

What is QAPI? QAPI is the merger of two complementary approaches to quality: Quality Assurance (QA) & Performance Improvement (PI) Both involve seeking and using information, but they differ in key ways: QA ~ Process of meeting quality standards and assuring that care reaches an acceptable level. PI (aka Quality Improvement - QI) -pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems.

Quality Improvement: Using Data to Drive Using QAPI YOU have an opportunity to build a system that ensures: A systematic, comprehensive and data driven approach to care reporting & reducing C diff Use tools that are free to you Learn from others in the new C diff Cohort (also known as the fun new group for NHSN in NC)

Join in the new work coming soon! Hospitals with Clostridium difficile Infections (CDI) SIR >= 1.175 and Nursing Homes by Star Rating Q4 2013- Q3 2014

Getting Started with Data What are you going to measure? When are you going to measure (frequency)? How are your going to measure (where will you get your data)? Who will be responsible for tracking? What is your performance goal or aim? How will data findings be tracked and displayed? **Measure/Indicator Development Worksheet

Identify a Baseline AE Tracking Tools The ProcessTracking - graphs tracking the average number of days between date of diarrhea onset; date contact precautions are implemented; date a specimen is collected AboutOurCases - displays the distribution of event type (incident/recurrent/duplicate) and the proportion of cases that are nursing home onset NHIncidentCaseLocations - provides distribution of your cases by service type and neighborhood. DataforWebsiteEntry - tab contains your calculated outcome measures for the month: # of CDI nursing home onset incident cases % of residents who are being treated for CDI when they are admitted https://www.nhqualitycampaign.org/goaldetail.aspx?g=inf#tab1

Examine Your Process Assessment of current practices Identify problem areas/concerns Evaluate current process gaps Target Improvement Opportunities Review of current strategy for preventing & identifying infections Environmental Cleaning practices Tracking & Surveillance Activities ** AE tool to assess current practices

Root Cause Analysis Why is our C difficile Infection (CDI) rate high? Which groups are most affected? Is there a process for early diagnosis and isolation of CDI? Do you have preventative hand hygiene processes in place? Are there environmental factors connected with our CDI rates? How do you use antibiotics? How affective are your systems for assessment of infections, communication and tracking?

Create Improvement Establish a C diff PIP Prevention Team! Resident CNA Environmental Service Infection Control DON Admin Pharmacist Attending Physician/Medical Director

Putting It All Together: Next Steps Keep goal and progress in view track your infection data Visit the Advancing Excellence site Join in the upcoming work with C-diff to learn more Communicate status/celebrate successes

This material was prepared by GMCF, for Alliant Quality, the Medicare Quality Innovation Network Quality Improvement Organization for Georgia and North Carolina, 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. Publication No. 11SOW-GMCFQIN-NC-C2-15-14