Wisconsi n Healthca r e ‐ Associ at e d In f ection s in L T C Coalition

1. WisconsinHealthcare‐AssociatedInfectionsinLTCCoalition WhentoTestUrine NursingTool: Application to Case Studies and Development of Provider Communication Scripts

2. The Nursing Process – 5 Steps Assessment -a systematic, dynamic way to collect and analyze data Diagnosis -the nurse’s clinical judgment about the patient’s response to actual or potential health conditions or needs Outcomes / Planning -based on the assessment and diagnosis, the nurse sets goals for the patient Implementation -nursing care is implemented according to the care plan Evaluation -both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed. American Nurses Association

3. WhentoTestUrine–NursingTool WisconsinHealthcare-Associated Infections in LTC Coalition Resident Changein Condition Complete Nursing Assessment (BoxA) Consult Provider SeeScript 1 Warning SignsPresent (BoxD) LocalizingUrinary S/S (BoxB) Yes Yes Consult Provider SeeScript 2 No Warning SignsPresent (Box D) Non‐localizingS/S– NonspecificGeriatricS/S Consult Provider SeeScript 3 Yes (BoxC) No Consult Provider Consult Provider SeeScript 4Observe/ Monitor 24‐48 hours Worse SeeScript 5 Improved Consult Provider SeeScript 6Monitorper Medical Director Protocol NoChange No UrineTesting Necessary SeeScript 7

4. When to Test Urine – Nursing Tool First Step: - Assess resident change of condition

5. WisconsinHealthcare‐AssociatedInfectionsinLTCCoalition Case 1:Acuteonsetofdysuria & Fever • Vitals • Temperature:102.3(oral), Pulse:104apical irregular,Respirations:30 andshallow,B/P:150/80, • onroomairis86%. • stickBloodSugar: • Background • Diagnoses:Dementia,COPD, TypeIIDM,CHF,HxCVA withlefthemiplegia,MRSA carrier • Recentantibiotics:10days • Situation:Jimmy hassuddenonsetofacutedysuriaandfrequency.Grosshematuriais presentwithsmallclots.Thereisnosuprapubicorcostovertebraltenderness. • Residentevaluation:Hehasmildlyincreasedconfusionsincemid-afternoontoday.Hehashadafunctionaldeclinerequiringanincreaseinstaffassistwithbedmobility,transfers,andotherADLs.Hisappetiteisdiminishedandoralfluidintakeinthelast16hris600CCs. Lungsareclear.Bowelsoundsarepresentinall4quadrants.Abdomenisnon-tenderwithnovomitingordiarrhea.Hisurineisdarkcoloredandhasmucousshreds. • Appearance:Thisresidentisexhibitinglocalizingurinarytractsignsandsymptomswithhypoxiaandwarningsignsoffeverandtachycardia. • O2Sat • Finger 166 • foruncomplicatedUTI9/12- 9/22 • Allergies:Ciprofloxin • • Anticoagulants, • Hypoglycemic,Digoxin:None • CodeStatus:DNR

6. WhentoTestUrine–NursingTool WisconsinHealthcare-Associated Infections in LTC Coalition Resident Changein Condition Complete Nursing Assessment (BoxA) Consult Provider SeeScript 1 Warning SignsPresent (BoxD) LocalizingUrinary S/S (BoxB) Yes Yes Consult Provider SeeScript 2 No Warning SignsPresent (Box D) Non‐localizingS/S– NonspecificGeriatricS/S Consult Provider SeeScript 3 Yes (BoxC) No Consult Provider Consult Provider SeeScript 4Observe/ Monitor 24‐48 hours Worse SeeScript 5 Improved Consult Provider SeeScript 6Monitorper Medical Director Protocol NoChange No UrineTesting Necessary SeeScript 7

7. WhentoTestUrine–NursingTool WisconsinHealthcare-Associated Infections in LTC Coalition Resident Changein Condition Complete Nursing Assessment (BoxA) Consult Provider SeeScript 1 Warning SignsPresent (BoxD) LocalizingUrinary S/S (BoxB) Yes Yes Consult Provider SeeScript 2 No Non‐localizingS/S– NonspecificGeriatricS/S Warning SignsPresent (Box D) Consult Provider SeeScript 3 Yes (BoxC) No Consult Provider Consult Provider SeeScript 4Observe/ Monitor 24‐48 hours Worse SeeScript 5 Improved Consult Provider SeeScript 6Monitorper Medical Director Protocol NoChange No UrineTesting Necessary SeeScript 7

8. WhentoTestUrine–NursingTool WisconsinHealthcare-Associated Infections in LTC Coalition Resident Changein Condition Complete Nursing Assessment (BoxA) Consult Provider SeeScript 1 Warning SignsPresent (BoxD) LocalizingUrinary S/S (BoxB) Yes Yes Consult Provider SeeScript 2 No Non‐localizingS/S– NonspecificGeriatricS/S Warning SignsPresent (Box D) Consult Provider SeeScript 3 Yes (BoxC) No Consult Provider Consult Provider SeeScript 4Observe/ Monitor 24‐48 hours Worse SeeScript 5 Improved Consult Provider SeeScript 6Monitorper Medical Director Protocol NoChange No UrineTesting Necessary SeeScript 7

9. WhentoTestUrine–NursingTool WisconsinHealthcare-Associated Infections in LTC Coalition Resident Changein Condition Complete Nursing Assessment (BoxA) Consult Provider SeeScript 1 Warning SignsPresent (BoxD) LocalizingUrinary S/S (BoxB) Yes Yes Consult Provider SeeScript 2 No Non‐localizingS/S– NonspecificGeriatricS/S Warning SignsPresent (Box D) Consult Provider SeeScript 3 Yes (BoxC) No Consult Provider Consult Provider SeeScript 4Observe/ Monitor 24‐48 hours Worse SeeScript 5 Improved Consult Provider SeeScript 6Monitorper Medical Director Protocol NoChange No UrineTesting Necessary SeeScript 7

11. Script I Physician Communication Localizing Signs and Symptoms with Warning Signs WisconsinHealthcare-Associated Infections in LTC Coalition PHONE CONTACT NECESSARY Resident:Jimmy Issick Provider: Dr. Wesby Date:11/7/158:00PM Thismessageisto informyouof a changein condition: ChiefComplaint:Acuteonsetof dysuriaand fever over thelasttwohours. Situation:Jimmyhassudden onsetof acutedysuriaandfrequency.Gross hematuria ispresent withsmallclots.Thereisnosuprapubicor costovertebral tenderness. Vitals:Temperature102.3 (oral)Pulse104apicaland irregular,Respirations30 andshallow, B/P 150/80.O2 Sat on roomair is86%. Finger‐stickBlood Sugar:166 Background: Diagnoses:Dementia, COPD, type2 DM,CHF,Hx CVAwithlefthemiplegia, MRSA carrier Recentantibiotics:Had Trimeth/Sulfa10daysfor LowerRespInfx9/12‐9/22 Allergies:Ciprofloxin Anticoagulants,Hypoglycemics,Digoxin:NoneCodeStatus:DNR Residentevaluation: Hehasmildly increasedconfusionsincemid‐afternoontoday.Hehashadafunctionaldeclinerequiring anincreasein staffassistwith bedmobility, transfers, and otherADL's. Hisappetiteisdiminishedandoralfluid intakein thelast16hr is 600 CCs. Lungs are clear. Bowelsoundsarepresent inall4quadrants.Abdomenis non‐tenderwith novomitingor diarrhea.Hehasmucous shreds,urineisdark colored. Appearance: This resident isexhibiting localizing urinarytractsignsand symptomswith hypoxiaandwarning signsoffever, tachycardia. Review/Notify: According to our understanding of best practices and our facility protocols, the information is sufficient to indicate an active urinary tract infection. We request an order to obtain a urinalysis and culture. Please advise regarding further treatment.

12. Role Playing Between Nurse and Provider Using Case Study 1 Script

13. Nursing Tool: Case Study 2

14. Case 2 - Localizing Signs/Symptoms w/o Warning Signs Situation: Tommy has acute onset of dysuria, urgency and frequency with no costo-vertebral or suprapubic tenderness. Urine is clear and amber Resident evaluation: He has no recent med changes or change in mental status. His oral intake is unchanged, weight is stable, follows commands and is oriented in person, place, and time. He has no shortness of breath, chest or abdominal pain and he has not vomited. Bowel sounds are normal Appearance: The resident is exhibiting localizing signs and symptoms of a localized urinary tract infection without warning signs. Vitals Temperature: 98 (Oral) Pulse: 78 (apical) BP: 112/68 O2 Sat: 94% RA Finger stick Blood Sugar: 166 Background Diagnoses: C0PD, mild CHF, HTN Recent antibiotics: None Allergies: Trimeth/sulfa Anticoagulants, Hypoglycemics, Digoxin: none Code Status: Full Code

15. WhentoTestUrine–NursingTool WisconsinHealthcare-Associated Infections in LTC Coalition Resident Changein Condition Complete Nursing Assessment (BoxA) Call Providerto request urine testing- SeeScript 1 Warning SignsPresent (BoxD) LocalizingUrinary S/S (BoxB) Yes Yes Call or fax Provider to request urine testing-SeeScript 2 No Call ProviderASAP to request further testing-SeeScript 3 Warning SignsPresent (Box D) Non‐localizingS/S– NonspecificGeriatricS/S Yes (BoxC) No Call Provider to request O2 and /or additional treatment – See Script 5 Call or Fax Provider to Observe/24 hr. Monitor See Script 4 Worse Improved Call or fax Provider- Monitorper Medical Director Protocol -See Script 6 NoChange No UrineTestingIndicated after Observation - SeeScript 7

16. Blank Script - PHYSICIAN COMMUNICATION Localizing Signs and Symptoms with Warning Signs Box A Mode of Communication: PHONE FAX 0 0 Nursing Assessment Complete nursing assessment Resident: Box B Localizing Urinary S/S Provider: Acute dysuria 0 New or worsening frequency 0 Date: New or worsening urgency 0 New or worsening incontinence 0 This message is to inform you of a change in condition: Gross hematuria 0 Suprapubic pain 0 Chief Complaint: Costalvertebral angle pain 0 New scrotal / prostate pain 0 Urethral purulence Situation: 0 Box C Non - localizing / Non - Specific Geriatric S/S Behavior Changes 0 Functional Decline 0 Mental Status Change 0 Vitals: Temperature Pulse Resp B/P O2 Sat Falls 0 0 Restlessness Finger - stick Blood Sugar: 0 Fatigue 0 “Not Being Her or Himself Background - Diagnoses: Box D Warning Signs Recent antibiotics: Fever 0 Clear - cut Delirium 0 Allergies: Altered LOC o Disorganized Thinking o Anticoagulants, Hypoglycemic, Digoxin: Psychomotor Retardation o Rigors (shaking chills) 0 Code Status: Hemodynamic Instability 0 Hypotension o Resident evaluation: Tachycardia o Appearance: Review/Notify: When to Test Urine – Communication Blank Script

17. Case Study 2 – Answer Keys

18. When to Test Urine – Nursing Tool Case Study 2 – Nursing Tool Answer Key WisconsinHealthcare-Associated Infections in LTC Coalition Resident Changein Condition Complete Nursing Assessment (BoxA) Consult Provider SeeScript 1 Warning SignsPresent (BoxD) LocalizingUrinary S/S (BoxB) Yes Yes Consult Provider SeeScript 2 No Warning SignsPresent (Box D) Non‐localizingS/S– NonspecificGeriatricS/S Consult Provider SeeScript 3 Yes (BoxC) No Consult Provider Consult Provider SeeScript 4Observe/ Monitor 24‐48 hours Worse SeeScript 5 Improved Consult Provider SeeScript 6Monitorper Medical Director Protocol NoChange No UrineTesting Necessary SeeScript 7

19. SCRIPT 2 - PHYSICIAN COMMUNICATION Localizing Signs and Symptoms without Warning Signs MAY FAX Resident: Tommy Needalittlehelp Provider: Dr. Wesby Date: 11/7/15 3:00PM This message is to inform you of a change in condition: Chief Complaint: Acute onset of dysuria, urgency and frequency starting after lunch today. Situation: Tommy is complaining of acute dysuria, urgency and frequency. He has been incontinent three times today which is unusual for him. Urine is clear and amber in color. He has no costovertebral angle tenderness or suprapubic tenderness. He is not otherwise in distress. Vitals: Temperature 98 (oral), Pulse 78 apical, Respirations 20 and unlabored, B/P 112/68, O2 Sat 94%. Finger-stick Blood Sugar: 166 Background Diagnoses: COPD, mild CHF, HTN Recent antibiotics: None Allergies: Trimeth / Sulfa Anticoagulants, Hypoglycemic, Digoxin: None Code Status: Full code Resident evaluation: He’s had no recent medication changes. He has no change in mental status and is oriented to person, place and time and follows commands. He is independent with ADLs. He’s eating and drinking and is on a 1400 cc 24 hr. fluid restriction and took in 1400 ccs in the last 24 hours. His weight is stable. There is no shortness of breath, chest or abdominal pain and he is not vomiting. Bowel sounds are active in all quadrants. Appearance: This resident is exhibiting localizing symptoms suggesting the need to obtain a urinalysis. Review/Notify: According to our understanding of best practices and our facility protocols, the information is sufficient to indicate an active urinary tract infection. We request permission to obtain a urinalysis, continue to encourage fluids within resident’s fluid restriction guidelines and continue to observe. This resident does NOT need an immediate prescription for an antibiotic, but may need further evaluation and treatment. We will update MD with lab results.

20. May Role Play Using Case Study 2 Script