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A long-term care facility attacks UTI prevalence: 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 particular 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 report (2) 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)

The planning at BONRC began January 29, 2003, with a team approach named "The Bugbusters." The team included the administrator, director of nursing (DON), assistant director of nursing (ADON), MDS coordinator, and clinical staff responsible for monitoring quality indicators. The Bugbusters' aim/purpose was to:

* Keep prevalence of UTIs, as reported in the facility Quality Indicator Profile, below 7%. Monthly tracking was reported at the Quality Assurance (QA) meeting.

* Keep the incidence of UTIs below 2% (which would keep the prevalence well below 7%). The facility infection control nurse monitored incidence and reported it at the QA meeting.

* Increase staff knowledge of and compliance with infection control best practices and other care practices related to the prevention of UTIs. This included developing increased knowledge related to hydration, better hygiene practices, and resident education when appropriate. Best practices activities were encouraged by in-services, completion of competencies, and routine monitoring of perineal and catheter care.

A pilot unit was chosen and a retrospective review from April 2002 provided baseline data. The pilot population would include all residents with a diagnosis of chronic bacteriuria and recurrent UTI and all residents with a current diagnosis of UTI. The Medicare prevalence (percentage) of UTIs in long-term care for that year was found to range from 0 to 31%, and the Maryland state average was 16.81%, with BONRC reporting 12.70% during that year. Beginning in January 2003, all data would be broken down by each of the facility's three units to assist with tracking.

The next step was to develop an internal process for education of all those involved. The model adapted from the 1999 guidelines from the Institute for Healthcare Improvement and developed for the facility by The Bugbusters involved six cycles:

Cycle 1. Objective: Ensure that all attending physicians are using AMDA guidelines for diagnosis and treatment of all UTIs (table 1). A letter written by the administrator, DON, medical director, and QA nurse and a copy of the AMDA guidelines were sent to all attending physicians. Data collection started.

Cycle 2. Objective: Ensure that all nurses are competent interpreting urinalysis (U/A) and culture and sensitivity (C & S) laboratory results, and understand AMDA guidelines for the diagnosis and treatment of UTIs. An in-service with case studies and a quiz was prepared for all licensed nurses. A summary of the quiz results demonstrated that 95% of nurses were competent in knowledge of the AMDA guidelines. The data obtained led to an action plan for unit nurses to review all residents treated for UTIs to ensure they met AMDA guidelines. All information was communicated to the DON and QA nurse.

Cycle 3. Objective: Decrease the incidence of UTIs in a trial population by the administration of cranberry capsules twice a day (bid). Research suggests that the cranberry may prevent bacteria from adhering to host cells. (3) A randomized placebo-controlled trial on the effectiveness of cranberry products in preventing UTIs offers further encouragement to continue the objective. (4)

Next, staff identified all residents with a diagnosis of chronic bacteriuria and recurrent UTI and obtained physician's orders for use of one cranberry 425 mg capsule bid. Analysis of data collection for the 23 residents meeting the criteria would be related to the number of UTIs that had been accurately diagnosed and treated in the past six months. This information would be compared with the number of UTIs diagnosed and treated over the following six months.

Cycle 4. Objective: Gain information on "silver-covered catheters" for possible trial use on residents using Foley catheters who have a diagnosis of chronic bacteriuria with recurrent urinary tract infections. Use of Foley catheters in residents as a causative factor in UTIs is well known among healthcare providers. (5,6) Physician's orders were obtained for use of silver-covered catheters in the six residents identified for trial. The catheters were initiated and data collected to identify the number of actual UTIs identified and treated in the past six months, and that was compared with the number treated over the next six months.

Cycle 5. Objective: Ensure all attending physicians are using AMDA guidelines for diagnosis and treatment of all UTIs. In review, six attending physicians continued to treat bacteriuria without symptoms of UTI. A letter reviewed by the medical director was sent from the infection control nurse to these physicians.

Cycle 6. Objective: Ensure that AMDA guidelines are met for diagnosis and treatment of UTIs and are properly reflected in the MDS. The new MDS coordinator at BONRC began work in June 2003, and she was in-serviced on the AMDA guidelines. On review, five residents triggering a UTI on the facility quality indicator profile by the MDS coordinator were coded incorrectly. The MDS coordinator received a second in-service, and no further incidence of coding errors was found.


Cycles 1 and 2 were developed for background and to gather information needed to begin the process. The first analysis to provide action plans would be Cycle 3, and that analysis of data collected provided the first facility action plan: All residents with a diagnosis of chronic bacteriuria and recurrent UTI would be treated with cranberry capsules bid.

Analysis of data collected from Cycle 4 resulted in the following action plan: The facility would continue to monitor this process for six more months and would continue to use silver-covered catheters for all residents using Foley catheters with a diagnosis of chronic bacteriuria and recurrent UTI. The plan initiated after the review of Cycle 5 reminded the team that continued monitoring and reinforcing of the AMDA guidelines with physicians would be essential to meet the goals of The Bugbusters.

Data monitoring revealed the prevalence (percentage) of UTIs (table 2). The incidence of UTIs (table 3) is demonstrated for April 2002 through April 2003, the time frame of the cycles for action planning. The data have since been updated.


Cycles 5 and 6 emphasize the need for conscientious monitoring of each step of this project and timely intervention for clinical success. Continued education of physicians and all staff involved is the only way this process can be maintained. BONRC has shared its knowledge with others in the NHQI Select Groups and has benefited from information gained from other facilities. The facility continues to adhere to the guidelines, and the prevalence in May 2005 was zero. The prevalence rate of less than 1% continued through 2006. The monthly incidence was zero to one patient. There was an increase in incidence in August and September 2006 of four and three patients, respectively. BONRC conducted staff education, and in October the incidence returned to pre-August rates of less than 1% (zero to one patient). Monitoring and education can be a powerful tool in management.

Adherence to recommended clinical guidelines has benefited residents through consistency in care and reduced medication need. Healthcare providers have received satisfaction with improved outcomes. An old proverb--"knowledge is power"--has proven true in this cycle for change.

Donna McMullen, RN, CWOCN, has been a board-certified Wound Ostomy Continence Nurse (WOCN) Clinician for 20 years. She is one of two founding partners in E T Consultants, Inc., begun in 1997. Janet M. Bartlett, RN, is Director of Nursing, and Jeresel G. Rosario, RN, is Assistant Director of Nursing at Bradford Oaks Nursing and Rehabilitation Center in Clinton, Maryland. For more information, phone (240) 715-4362. To send your comments to the authors and editors, please e-mail


1. Gray M. Clinical epidemiology: Essential concepts and principles. In Prevalence and Incidence: A Toolkit for Clinicians. Journal of Wound, Ostomy, and Continence Nursing 2005;1-5.

2. Vance J. Diagnosing & managing urinary tract infections: Myths, mysteries, & realities. Caring for the Ages 2002;3:18-21.

3. Howell AB, Vorsa N, Der Marderosian A, Foo LY, Inhibition of the adherence of P-fimbriated Escherichia Coli to uroepithelial-cell surfaces by proanthocyanidin extracts from cranberries. New England Journal of Medicine 1998;339:1085-6.

4. Stothers L. A randomized trial to evaluate effectiveness and cost effectiveness of naturopathic cranberry products as prophylaxis against urinary tract infection in women. Canadian Journal of Urology 2002;9:1558-62.

5. Maki DG, Tambyah PA. Engineering out the risk for infection with urinary catheters. Emerging Infectious Diseases 2001;7:342-7.

6. Saint S, Elmore JG, Sullivan SD, et al. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: A meta-analysis. American Journal of Medicine 1998;105:236-41.

Table 1. Criteria for a suspected [UTI.sup.2]

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

Fever (>38[degrees]C) or chills Fever (>38[degrees]C) or chills
New or increased burning pain on New flank or suprapubic pain or
 urination (pain can be difficult tenderness
 to assess in patients with
New flank or suprapubic pain or Changes in character of urine
Changes in character of urine and Worsening mental function
 worsening mental function

Table 2. Prevalence (%) of UTIs per facility quality indicator,

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

9.2 8 6.9 5.9 7.7 7.8 7.1 5.6 6.3 7.5 7.6 6.9
6 5.2 3.1 0.8 0 0.9 3.8 2.2 0 0 0.8 0
0 0 0 1.5 1.6 0 0.7 0 0 0 0 0

Table 3. UTI incidence (%), April 2002-2003

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

--- --- --- 3 0.6 2.25 1.3 0.1 1.75 1.3 1.75 0.6
1.75 2.25 0.6 0 0 0 0 0.55 0 0 0 0.6
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Title Annotation:featurearticle
Author:Rosario, Jeresel G.
Publication:Nursing Homes
Date:May 1, 2007
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