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A long-term care facility attacks UTI prevalence

May 1, 2007
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Implementing a team approach to increase staff knowledge of and compliance with good infection control practices

Infection control is one of four quality measures that state regulators assess on annual review surveys in long-term care (LTC) facilities in Maryland; the others are post-acute pain, delirium, and pressure ulcers. Delmarva Foundation, Maryland's Quality Improvement Organization, selected a group of LTC facilities in which participants would work on improving at least two quality measures over two years and demonstrate their leadership and commitment to quality care by establishing procedures that could be measured to improve outcomes for residents. These Nursing Home Quality Initiative (NHQI) Select Groups' staff met with representatives of Delmarva to collaborate on their processes and outcomes. Bradford Oaks Nursing and Rehabilitation Center (BONRC), a 180-bed facility in Clinton, Maryland, and part of Adventist HealthCare Senior Living Services, was one of the facilities selected.

Although below the state average in all of the quality measures, BONRC felt that infection control was the area with the most room for improvement. The facility wanted to reduce the prevalence and incidence of urinary tract infections (UTIs) in residents using the state parameters and meeting state assessments, which could improve patient outcomes, decrease cost of treatment, and decrease risk of recurrence.1 Prevalence was defined as the number of residents with a defined clinical condition within a particu-lar time frame, and incidence was defined as a measurement of a clinical condition found in residents over a defined period.1

The American Medical Directors Association (AMDA) and the Centers for Disease Control and Prevention (CDC) have provided guidelines for diagnosis and treatment of UTIs in the LTC setting. In particular, an AMDA report2 reviewed UTI risk factors and found that they are not clearly defined in the elderly. Neurogenic bladder was found to be one proven factor, but hygiene, age, menopause, instrumentation (such as catheterization) and history of UTIs—all thought to contribute to UTIs—were not. Included in the AMDA report but often not considered among risk factors was the effect of hydration. The onset of confusion, agitation, and loss of appetite—symptoms of dehydration—may in fact indicate a UTI and would require further clinical examination.

UTIs versus the presence of bacteria in the urine was also discussed in the guidelines. Positive urine cultures use the standard confirmation of >100,000 colony-forming units (CFU)/ml. Without concurrent symptoms such as frequency of urination, flank pain, fever, or new incontinence onset, the diagnosis could be a UTI or bacteriuria (asymptomatic bacteriuria not being a proven diagnosed UTI). Table 1 outlines those guidelines for use by medical directors and those caring for LTC residents.2

Table 1. Criteria for a suspected UTI2

In a patient without an indwelling catheter, three of the following must be met:

In a patient with an indwelling catheter, two of the following must be met:

Fever (>38°C) or chills

Fever (>38°C) or chills

New or increased burning pain on urination (pain can be diffi cult to assess in patients with dementia)

New fl ank or suprapubic pain or tenderness

New fl ank or suprapubic pain or tenderness

Changes in character of urine

Changes in character of urine and worsening mental function

Worsening mental function