W

hat is a urinary tract infection (UTI)? Is it a guess? Is it subjective? Is it a vague set of symptoms or complaints? Is it whatever the resident, family member, or physician says it is? Is everyone using the same definition and/or criteria? Does your facility have multiple definitions?
       These are some of the questions that we encountered at our 120-bed long-term care facility. Like many other facilities, UTIs are one of our most common nosocomial infections. They can cause a multitude of symptoms that affect the quality of life for our residents as well as increases in the antibiotic resistance of some organisms, resulting in the prescription of more expensive and potent antibiotics.
       Among the problems we identified at our facility:
• Residents would go out to be seen for their annual physical examinations and return with orders for a routine urinalysis and urine culture sensitivity (UA/C&S)
• Residents would make vague complaints, and we would call the physician right away
• During in-house physical examination, a physician would order a UA/C&S screen
• Covering physicians would order UA/C&Ss when called by the nurse for anything
• Nurses would call the physician at the first symptom of a UTI
• Family members/residents would insist on antibiotics due to questionable or sketchy past history
• Most resident UA/C&S screens would return positive for organisms, even though the resident was asymptomatic.
       As diligent detectives, we would ask the physician for a UA/C&S after noting subtle changes in resident behaviors, a fall, or a symptom of a UTI. We would treat quickly and efficiently. Antibiotics were our first weapon of choice. Our UTI numbers were increasing, and so were the costs.

Treating or Over-treating?

       We suspected that many residents who were asymptomatic were being treated with expensive and potent antibiotics. These antibiotics had some short-term side effects, and we also questioned some of the long-term side effects of frequent antibiotic usage. How would we even know if the positive UA/C&S treatment was effective if the resident was asymptomatic and we did not do a routine follow-up UA/C&S? A team consisting of the following members gathered to look at the problems noted above:
• Infection control nurse
• Administrator
• Director of Nursing (DON)
• Medical director
• Charge nurses
• Certified Nursing Assistant (CNA)
• Quality improvement (QI) nurse
• Nurse managers
• Family members
• Residents
• Activity staff.
       The first issue team members examined was, “What is a UTI?” The team selected criteria based upon the McGeer et al definition: “With no indwelling catheter, [the] resident must have 3 of the following:
• Fever of > 100.4 F
• New or increased burning with urination, frequency, or urgency
• New flank or suprapubic pain or tenderness
• Change in character of urine
• Worsening of mental or functional status.
       Next, the team designed a UTI protocol, which would allow the nursing staff to try some “good old-fashioned” nursing interventions before any medications or putting in a call to the physician.

The Saint Elizabeth Home UTI Protocol

       The Saint Elizabeth Home UTI Protocol was designed to initiate nursing measures for the initial complaint and subsequent complaints.

Figure 1

This protocol was to be initiated if a resident had a complaint or symptom of a UTI. If a resident were to develop another symptom during the 4-day protocol, then the physician was to be called immediately (see Figure 1).
       It was very important to carefully document and communicate the resident’s initial complaint or symptom. Nurses were sure to document the date, time, and setting of the complaint. It was to be documented in the nurses’ note, and shift to shift reports and the protocol document were to be initiated. (Please note that all nursing interventions were initiated as soon as the resident was put onto the protocol, regardless of the initial complaint.) To follow are recommended interventions for various symptoms/complaints.

1. Worsening of mental status or function:
• Check for recent emotional/family issues
• Check for recent environmental changes (eg, room, roommates, seat in the dining room, etc.)
• Establish a Mini Mental Status Exam (MMSE) baseline and new comparison
• Check for medication side effects
• Assess for other infectious problems (eg, pneumonia, congestive heart failure, upper respiratory infection)
• Check time spent at activities like “happy hour.”

2. Increase in temperature and/or chills:
• Check temperature every shift and document
• Use the most accurate route and equipment
• Medicate for temperature
• Adjust the environment (to avoid extreme temperatures)
• Assess for other infectious problems.

3. Changes in character/appearance of urine:
• Determine whether it has changed; know the baseline
• Check the smell; remember, food and medications can affect smell and appearance of urine
• Be sure urine is observed in clear containers, not in the toilet (eg, is it actually cloudy, or is that the toilet paper?)

4. Increase residents’ fluids intake to 1500 cc daily:
• Be creative—smoothies, tropical drinks, special glasses, drink carts, etc.
• Begin tracking intake
• Do not divide fluids over all 3 shifts equally; most should be given on day shift.

5. Complaints of pain/burning with urination:
• Evaluate peri-care by resident and/or staff to determine if it is consistent with accepted practices
• Determine whether they are wiping front to back
• Educate residents and staff on proper procedures
• Look for areas of redness or open areas and treat appropriately
• Ensure that clothes fit loosely
• Ensure that staff/residents are using appropriate peri-care products.

6. New incontinence or increase in frequency:
• Implement scheduled/prompted voiding
• Document voiding time and amount
• Remember that numbers will increase with increase in fluid intake
• Ask resident to save urine; memory can be exaggerated.

7. Identify pain and treat appropriately (new pain only):
• Start pain assessment; remember, it is “flank or suprapubic pain,” not knees/shoulders/back pain
• Use other (eg, occupational and physical) therapies
• Check seating and bed for proper positioning
• Check most recent bowel movements
• Determine whether clothing and/or incontinence products fit properly
• Employ relaxation techniques.

Day Four

       On day 4, the nurse must make a treatment decision and document it on protocol sheet. Treatment options, based on the following situations, include:
• Symptom still present: call the physician and obtain a UA/C&S and treat appropriately. Some physicians may order an antibiotic without a UA/C&S, but that practice is strongly discouraged.
• Symptom has disappeared: Stop protocol.
• Resident develops another symptom at any time: Call the physician.

The Pilot Study

       Once the protocol was developed, we decided to pilot the program on a 40-bed unit at our facility. The team was then able to monitor and track any problems. The team began with massive amounts of education for one and all. We did learning circles, posters, handouts, and in-service training. Education was geared to all involved with the residents, including families, staff, physicians, and the residents themselves. Educating the physicians was the most difficult for the team, and we often asked for the assistance of our medical director. Problems we identified included:
• Staff not putting appropriate residents on the protocol
• Incomplete data
• Lack of communication (written and/or spoken)
• Lack of follow-through with protocol
• Lack of leadership.
       Problems were identified and addressed with meetings, in-services, and one-on-one teaching opportunities by the team members. The protocol is now being used in the entire facility with great success. Quality improvement studies are done routinely to track problems. (Please note that this protocol is not expected to eliminate UTIs from your facility.) It is necessary to frequently review the policy and procedures of the protocol with the staff as a refresher or to assist new staff with understanding the importance of the program.

Pilot Study Data

       During the pilot study, which lasted a year, 29 residents went on the protocol. Twenty-six of them, or 90%, never developed a second symptom. Only 3 were placed on antibiotics. Under the old way, we are certain that all 29 residents would have been tested and, most likely, prescribed an antibiotic by the physician. The data collected through various methods support the protocol.
This protocol was designed to assess, prevent (to the extent possible), and treat a symptomatic UTI. Potential savings include dollars associated with UA/C&S, antibiotics, Part A managed care, nursing time, and physician visits. That impact is significant.

Conclusion

       Our facility was able to dramatically reduce the number of UTIs as well as the number of unnecessary laboratory tests. We did it through proper assessment and interventions. Our current data continue to support our program. We consider it a leading-edge program that is based on evidence of success that will help us promote the highest quality of care and life for our residents.