SCREENING TOOL FOR UTI’s Attempting to reduce the unnecessary use of antibiotics

1. SCREENING TOOL FOR UTI’sAttempting to reduce the unnecessary use of antibiotics Tina Gebarowski, GNP, ANP Countryside Health Care of Milford

2. 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

3. 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

4. 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

5. SCREENING TOOL

6. 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

7. 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

8. 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 co-morbidities or those with significant cognitive impairment

9. 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

10. 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

11. 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

12. 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.

13. CASE STUDIES • Trial use of screening tool • Should patient be started on antibiotics? • Should patient have UA C&S sent?

14. 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

15. 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

16. CASE STUDIES • Trial use of screening tool • Should patient be started on antibiotics?

17. 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 geri-psych care • She remained in-patient for 1 week with treatment only for mental status, no infectious etiology was noted

18. QUESTIONS/CONCERNS