10 ways to reduce UTIs

Urinary tract infections (UTIs) are widely acknowledged as the No. 1 infection in long-term care. Therefore, it’s not surprising that multiple initiatives across the Centers for Medicare & Medicaid Services (CMS) and other federal agencies are converging to make UTI prevention a high priority for nursing homes nationwide.

However, the adoption of UTI prevention policies varies widely, according to a recent national survey of 955 nursing homes with 88,135 residents that sought to identify policies and practices associated with lower UTI prevalence. The research was led by Columbia University School of Nursing Centennial Professor of Health Policy Patricia Stone, PhD, as part of the Prevention of Nosocomial Infections and Cost-Effectiveness in Nursing Homes (PNICE-NH) study, and funded under a National Institute of Nursing research grant.

“Most facilities do have policies in place for adequate hydration and perineal care,” says study author Carolyn Herzig, PhD, senior project director at Columbia University School of Nursing's Center for Health Policy. “Otherwise, there is a huge amount of variation in the adoption of other policies.”

Directors of nursing services (DNSs) can have a more consistent, effective UTI prevention program while simultaneously developing synergies with broader directives in the works at CMS. “For example, antibiotic stewardship is very closely aligned with UTI reduction and any infection that can be caused by a multidrug-resistant organism,” says Kristi Felix, BA, RN, CRRN, CIC, FAPIC, infection prevention coordinator for Madonna Rehabilitation Hospital in Lincoln, Neb. Felix serves as a Core National Faculty Member on behalf of the Association for Professionals in Infection Control and Epidemiology (APIC) for the long-term care and ICU-focused catheter-associated urinary tract infection (CAUTI) and healthcare-associated infection prevention projects that APIC is partnering on with the Health Research & Educational Trust and that are funded by the Agency for Healthcare Research and Quality (AHRQ).

Here are critical steps DNSs should consider when updating their UTI prevention program:

1. Review current clinical practice guidelines and revise facility P&Ps

“At the very least, providers should be familiar with current clinical practice guidelines and have policies that are in alignment with those guidelines,” says Herzig. “Understanding what is recommended and then implementing those policies is an important first step.”

In facilities where catheter use is limited or nonexistent, sometimes providers don’t put as much emphasis on their policies and procedures for recognizing and dealing with symptoms of UTI, points out Felix. “In my work with the AHRQ Safety Program for Long-term Care, Preventing CAUTIs and Other HAIs, I’ve found that when first meeting with providers, they sometimes say, ‘We don’t use catheters at all. CAUTIs aren’t a problem here.’ So they’re often not in the mind-set to think about symptoms of UTI.”

Making sure policies and procedures are up-to-date “needs to be done on a regular basis anyway, but DNSs can use this opportunity to provide education on current best practices about prevention of both CAUTIs and non-CAUTI UTIs,” says Felix.

2. Create the right team—and do a risk assessment

Providers should create a UTI prevention committee to drive the project, says Felix. “The most important people who need to be on that committee are the direct-care staff: the nursing assistants and the nurses who work directly with those residents. Basically everyone who has their hands on a piece of resident care needs to be involved in reviewing the processes that are in place in the facility and identifying problems that may lead to infection.”

Once that risk assessment is completed, providers should make process changes that decrease the risk for infection and that work for the staff members who will be doing the job, says Felix. “So DNSs should bring together engaged nursing staff who want to do a good job and empower them to review processes, make decisions on whether there are risks involved, and then determine how to solve those risks using those evidence-based guidelines.”

3. Realize the CAUTI threat is real

Most nursing homes don’t use a lot of catheters, as evidenced by the national average for the publicly reported quality measure, Percentage of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder, currently standing at 3 percent. “Catheter use is heavily regulated to ensure residents have them for the right reasons, so it’s not as much of an issue in long-term care as it is in acute care,” says Felix. F-tag 315 (urinary incontinence) in Appendix PP of the State Operations Manual offers extensive guidance on catheter use, including the investigative protocol used by surveyors. On Nov. 9, 2016, CMS issued an advance copy of a revised Appendix PP, but made no changes to the interpretive guidance to surveyors.

However, even though catheter use is relatively rare in long-term care, the Columbia study found that residents with catheters were about four times more likely to have a UTI compared to catheter-free residents, reports Herzig.

“So whether or not you use catheters a lot, it is important to look at your list of indications for a resident to have a catheter and make sure that your list is up-to-date with CMS regulations and CDC guidelines,” says Felix. “You need to make sure staff are assessing catheters regularly and taking them out if they are not indicated. Then if they are medically indicated, the other piece of that is making sure that you are caring for catheters appropriately—that staff know how to insert them using sterile technique and how to maintain them in a way that decreases infection as well.”

The Columbia study found that one rarely implemented policy is associated with lower CAUTI prevalence: Residents in facilities with a policy for cleaning the urine collection bag attached to the resident’s leg were 20 percent less likely to have CAUTIs, but fewer than half of surveyed facilities had this policy.

4. Target non-catheter-associated UTIs

“Many of the clinical practice guidelines as they are now focus on CAUTIs,” points out Herzig. “However, in long-term care, most UTIs seem to be occurring in the absence of an indwelling catheter. There needs to be more research to develop an evidence base outside of the acute-care setting that can be applied to the long-term care setting, and DNSs should focus on reducing non-catheter-associated UTIs, as well as CAUTIs.”

The Columbia study found that one rarely implemented policy is associated with lower UTI prevalence: Residents in facilities with a policy for using portable bladder ultrasound scanners to assess urine voiding were 10 percent less likely to have non-CAUTI UTIs, but fewer than one-quarter of surveyed facilities had this policy.

5. Get input from your medical director and nail down UTI symptoms

DNSs should seek assistance from the medical director, a urologist, or a physician, nurse practitioner, or physician assistant who has a heavy patient caseload in the facility, says Felix. “Long-term care facilities tend to do a lot of urinalyses (UAs)—even when residents aren’t really symptomatic for a UTI. So you need to find a leader who can review your guidelines for when you do a UA to see if they are appropriate and evidence-based.” Many providers choose to follow the McGeer Criteria (link above) to define UTIs and other infections.

Good antibiotic stewardship means only doing UAs when a resident is symptomatic for a UTI, says Felix. “You need to review your processes for when UAs are indicated and then educate direct-care staff so they know what the symptoms of a UTI and CAUTI really are.  One area in which staff need clarification is behavior or mental status change. There are specific criteria that define the change in mental status that must be present to indicate CAUTI.”

6. Tailor your program to your resident population

“UTI prevention policies and procedures should be very specific to the type of residents that you care for in your facility,” advises Felix. “If your resident population tends to be more medically unstable, then you may want to check a UA quickly. However, if it’s not, you may have some time to do what my facility calls watchful waiting and try some other interventions to see if the symptom clears up when the resident doesn’t meet the criteria for a UTI.”

For example, when residents have foul-smelling or cloudy urine but not necessarily symptoms of a UTI, “your policy might be to increase fluids and then monitor the residents—taking vital signs and assessing for dehydration—every shift or every 2 hours or whatever time frame is appropriate based on the risk assessment of your population,” says Felix. “If you educate the nurses really well and they are good at their observation skills, they will let you know or they will call the physician if the resident becomes unstable or has additional symptoms that indicate a UTI. In my facility, we started doing watchful waiting using a decision tree that helps staff think through the symptoms of a UTI.  It was developed with the help of one of the providers who saw many of our residents. We were able to decrease the number of UAs we were doing each month.”

INTERACT v4.0 offers CARE PATH Symptoms of Urinary Tract Infection (in residents without an indwelling catheter), a flow chart-based decision support tool that walks clinicians through signs and symptoms and how to decide when to contact the physician immediately, when to contact the physician for orders for further evaluation and management, and when/how to manage residents with potential UTIs in the facility.

7. Designate an in-house expert—and get them trained

According to the October 2016 final rule on the reform of the requirements for long-term care facilities to participate in the Medicare and Medicaid programs (i.e., the Medicare/Medicaid conditions of participation or CoPs), facilities must have an infection prevention and control program (IPCP) that (1) includes an antibiotic stewardship program and (2) must be run by at least one facility-designated infection preventionist (IP) who would serve on the facility’s quality assessment and assurance (QAA) committee.

While an IP who has completed specialized training in infection prevention and control is not officially required until Phase 3 (Nov. 28, 2019) of the three-phase implementation process for the new CoPs, many activities that would be associated with that position implement in Phase 1 (Nov. 28, 2016) and Phase 2 (Nov. 28, 2017). For example, the requirement for an antibiotic stewardship program that includes antibiotic-use protocols and a system to monitor antibiotic use implements in Phase 2.

See pp. 591 – 593 of survey-and-certification memo S&C:07-17-NH for details about when the different parts of the new infection control (§ 483.80) regulations implement, as well as the “Implementation Timeline” in the final rule. Also, to learn specifics about IPCP requirements in Phase 1, review the CMS surveyor training course, Phase 1 Implementation of New Nursing Home Regulations for Providers.

Providers could face a steep learning curve implementing all of the required components of an IPCP given a widespread lack of infection control training. “In our overall study, we found that fewer than half—40 percent—of facilities reported that the person in charge of their infection control program actually had specific training in infection control,” says Herzig. “Our finding that there is an inadequate level of infection control training is consistent with other studies.”

That training deficit could have a negative impact on UTI prevention, says Herzig. “We saw a lower prevalence of UTI in those facilities in which the person in charge of the infection control program had specific training in infection control through an APIC course.”

For the absolute basics, the Medicare Learning Network offers three free web-based continuing education training courses in infection control: Environmental Safety, Hand Hygiene, and Injection Safety. For more advanced work, APIC offers the online course “Continuing the Care: Infection Prevention in the Long-term Care Setting,” which can serve as the foundation of a comprehensive Infection Control in Long-term Care certificate series.

8. Take a hard look at hydration

Even though many facilities have hydration policies, in practice hydration can be overlooked, says Felix. “This is a problem because dehydration and UTI look a lot alike, so you need to be careful not to treat residents with antibiotics when they may just be dehydrated.”

In some facilities, person-centered care may inadvertently contribute to resident dehydration, she points out. “Providing patient-centered care is extremely important, but a resident saying ‘I don’t want a drink’ doesn’t mean providers should ignore basic issues like hydration. Sometimes you have to encourage residents more and be creative to figure out how to get them to agree to drink more fluids.”

Getting residents to drink can be difficult, acknowledges Felix. “So monitoring fluid intake and knowing what residents are taking in is important. Then you have to come up with some creative ways to keep your residents hydrated on a regular basis. Your dietary department and nutrition therapists often can provide ideas on how to get different kinds of fluids into residents. For example, using food that is high in water content might be one way to increase hydration. Making sure mouth care is being done regularly so residents want to eat and drink is also important.”

The October 2016 final rule revising the CoPs added specific requirements in the food and nutrition services section (§ 483.60) for facilities to provide “drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration.” In the July 2015 proposed rule, CMS specifically cited UTI as one of the conditions that elderly people are susceptible to when they don’t receive adequate hydration.

9. Involve the residents and families

Residents and families should be involved in UTI prevention, says Felix. “You need to educate families about the symptoms of a UTI and the risks of antibiotic use because they tend to want to jump to antibiotic use very quickly. Families can be part of UTI prevention as they usually have good ideas—and those ideas might be something that will work for other residents too. So be sure to ask the families to help with providing hydration when they visit.  They can also let the staff know when something doesn’t seem right with their resident.”

10. Monitor staff compliance with policies and procedures

Having appropriate policies and procedures doesn’t guarantee UTI prevention, says Herzig. “Our study looked at policies and procedures that nursing homes have in place. We did not see an association between, for example, having a policy to ensure adequate hydration and differences in UTI.”

Policies and procedures are just the first piece of the puzzle, she suggests. That point was raised in a recent Office of Inspector General performance audit, which found that the nursing home’s staff failed to follow care plan interventions to detect or prevent UTIs in residents who were subsequently hospitalized with a potentially preventable UTI.

“That audit really demonstrates that it is one thing to have a policy in place (e.g., a care plan that says the resident needs to be assessed for hydration every shift), but ensuring staff adherence to that policy—that compliance is good—is another thing entirely,” says Herzig. “We have actually shown in other studies in acute-care settings looking at the impact of interventions on central line-associated bloodstream infections, that it is necessary to have excellent compliance with those policies for there to be reduced infection rates. So how DNSs monitor staff compliance is a worthwhile issue to address.”