SCREENING TOOL FOR
UTI’s
Attempting to reduce the
unnecessary use of antibiotics
Tina Gebarowski, GNP, ANP
Countryside Health Care of Milford
TRIAL OF SCREENING TOOL AT
COUNTRYSIDE HEALTH CARE OF
MILFORD
• Countryside Health Care of Milford
• 85 bed, skilled nursing facility located in
Milford, MA
• 55 long-term care patients
• 30 skilled-rehab patients
• 5 routine physicians that treat at facility
• 2 nurse practitioners
• On call coverage starting at 5p weeknights-7a
and all hours during weekends
2
CURRENT RATES OF UTI’S
AND C DIFF
• Last quarter (Oct, Nov, Dec 2011)
76 UA C&S performed in facility
– 35 positive for UTI
• 13 specimens sent for C diff
– 5 positive for C diff
• All specimens at facility are followed by
in-house infectious disease nurse
• Goal at facility has been to cut down on
unnecessary use of antibiotics
3
PATIENTS WITH
SUSPECTED UTI
• Tool was trialed at facility starting on April 2nd
• Tool was implemented on both nursing units (short-term
and long-term care)
• Education was provided for nursing staff on how to use
the tool and its importance
• Urine testing was only encouraged for those who showed
specific symptoms of UTI
• Routine screening was discouraged with use of tool
• Nursing staff was very receptive with a great deal of
positive feedback
• Regular staff physicians and nurse practitioners were very
receptive as well
4
SCREENING TOOL
5
ONGOING TRIAL
• Since the start of trial, tool has been utilized
for all patients with suspected UTI
• Protocol was followed for most of the patients
although not for all
• Few had UA C&S ordered for unnecessary
reasons
– These studies did all come back negative for
acute UTI
6
POSITIVES
• Works towards ultimate goal of preventing
unnecessary use of antibiotics
• Tool encourages close monitoring of patients
and follow-up
• Nursing felt tool encouraged a certain amount
of guidance in dealing with sick patients
– Allowed more direct communication with covering
staff
• Expected decrease in unnecessary testing
with use of tool would also cut down on costs
for facility
7
DIFFICULTIES
• Another form to fill out
– Some difficulty in communicating importance of
tool
• Frustration of nursing staff when clinicians did
not follow protocol outlined with tool
• Requires more vigilant nursing assessment
with those frail elders with multiple comorbidities or those with significant cognitive
impairment
8
HELPING TO OVERCOME
DIFFICULTIES
• Ongoing communication with nursing staff
and clinicians on importance of using the tool
and its benefits
• Provide positive feedback to nursing staff and
clinicians
– Illustrate proper use of tool by staff
– Identify cases where tool helped to:
• Diagnose UTI
• Prevent uneccesary use of antibiotics
9
BARRIERS WE FACE
• Family
– Wishing for antibiotics even when not
warranted
• Covering clinicians
– Not willing to follow protocol
• Mental Status Changes
– Seems to be the most frequent blame for
UTI although no evidence that this is true
10
WHAT TO WORK ON FOR
THE FUTURE
• Education!!!
– Nurses, clinicians, families
• Possible implementation of education sheets
for families
• Using the tool as proof
– few examples found that work up was negative
and UA C&S was still ordered
– Negative results in these circumstances can only
reinforce the use of tool
11
CASE STUDIES
• Mr. X: 78 y/o male with history of CVA in
2001, admitted to facility for rehab following
dehydration and failure to Thrive. S/p
placement of PEG tube
– Began with fever, hematuria, mental status
changes. Diagnosed with UTI and treated with 1
week course of antibiotics
– 1 day after completion of treatment patient noted
to have some behavioral changes. No fever, no
change in urine and no other symptoms noted.
Labs stable.
– Family involved and wished for patient to have
repeat urine.
12
CASE STUDIES
• Trial use of screening tool
• Should patient be started on antibiotics?
• Should patient have UA C&S sent?
13
CASE STUDIES
• Family was educated concerning lack of
symptoms suggesting UTI. Encouraged
patient would closely be monitored
– Family still insisted and in after hours, covering
MD was notified.
– UA C&S was ordered. Antibiotics were started.
– Testing did come back negative.
– Family was again educated on symptoms of true
UTI and stressed the dangers of frequent
antibiotics use
14
CASE STUDIES
• Mrs. X: 81 y/o female with history of
moderate-severe Alzheimer’s Dementia.
Admitted for rehab s/p Aortic Valve
Replacement
– Shortly after patient’s admission she exemplified
increase agitation and anxiety
– Psych services were involved
– No other symptoms of UTI were noted. UA C&S
was ordered by patient’s PCP
– Results of UA showed + leukocytes, - nitrites, 13
WBC. C&S 70,000 E Coli
15
CASE STUDIES
• Trial use of screening tool
• Should patient be started on antibiotics?
16
CASE STUDIES
• Patient’s PCP ordered 1 week course of
treatment for questionable UTI
• Despite antibiotic treatment her behavioral
status continued to decline
• She was transferred out of facility for geripsych care
• She remained in-patient for 1 week with
treatment only for mental status, no infectious
etiology was noted
17
QUESTIONS/CONCERNS