Virginia Department of Health March 21, 2012

1. How to Use the Toolkit: Successful Strategies for the Prevention of Urinary Tract Infections in Long-Term Care Virginia Department of Health March 21, 2012

2. Urinary Tract Infections • Most common healthcare-associated infection in long-term care • Increase healthcare costs • Can lead to antibiotic resistance and possibly Clostridium difficile infection when improperly treated • Infections tracked differently between facilities • Catheter-associated UTIs can be prevented by limiting use and duration of indwelling catheters

3. The Collaborative • Joint project with VDH and Virginia Health Care Association (VHCA) • Carol Jamerson, RN, BSN, CIC: VDH Nurse Epidemiologist (co-lead) • Judy Brown, RN, LNHA: VHCA Health Education Specialist (co-lead) • Conference calls, sharing of best practices and resources • Development and implementation of standardized UTI surveillance tools • Educational opportunities: panel presentation, November 10th VDH/APIC-VA conference • Production and dissemination of a toolkit

4. Today’s Agenda • Introduction • Andrea Alvarez, HAI Program Coordinator, Virginia Department of Health • Description of toolkit components • Carol Jamerson • The toolkit in action • Adriana Agnew, Director of Quality Management and Infection Preventionist, Fairfax Nursing Center • Q & A • Judy Brown

5. The Toolkit

6. Recognition of Collaborative Partners • Autumn Care of Portsmouth • Beth Sholom Village • The Gardens at Warwick Forest • Heritage Hall of Virginia Beach • James River Convalescent and Rehabilitation Center • Lake Prince Woods • Lake Taylor Transitional Care Hospital • MaryviewNursing Care Center • Oakwood Nursing and Rehabilitation Center • Riverside Convalescent Center- Smithfield • Sentara Nursing Center - Windermere • Virginia Beach Healthcare and Rehabilitation Center

7. Recognition of Collaborative Partners Eastern Virginia Medical School: • Robert M. Palmer, MD, MPH • Edward C. Oldfield, III, MD Other acknowledgments: • Dana Burshell, HAI Epidemiologist, Virginia Department of Health • F-Tag 315 information from Agency for Health Care Administration (AHCA) • Policy/procedure templates originally developed by Riverside Health System, Riverside Lifelong Health and Aging Related Services

8. Table of Contents • Introduction • CMS regulatory guidance • Definitions • UTI tools • UTI prevention policy templates • Educational resources • Resources addressing antibiotic use in long-term care settings • UTI panel of experts: presentations • UTI prevention resources and references

9. Introduction Tab: Introduction to the Toolkit • Contains infection prevention presentations, resources, and tools that have been adapted for long-term care facilities (LTCFs). • Documents have been developed from published literature reviews, evidence-based research, standards of practice, or recommendations. • Introduces and summarizes guidelines and best practices. Does not replace published standards and regulations.

10. F-tag 315 Tab: Centers for Medicare & Medicaid Services (CMS) Regulatory Guidance Summarized Intent of F-tag315 (§483.25d) • Ensure urinary incontinence is identified and addressed • An indwelling catheter not used unless there is valid medical justification • If indwelling catheter used, it is discontinued as soon as clinically warranted • All residents receive appropriate urinary care to prevent UTIs

11. Definitions Tab • Glossary of Terms • Five pages of UTI-related terms • Alphabetical • May be helpful when giving in-services

12. Tools Tab • McGeerand F315 UTI Surveillance Definitions • UTI Event Form • UTI Denominator Collection Form • Resident Illness Log • Hand Hygiene Monitoring Tool • SBAR • Transfer Form • Urinary Catheter Checklist • Urinary Catheter Reminder

13. Tools: McGeer and F-Tag 315

14. Tools: UTI Event Form

15. Tools: Resident Illness Log • Patient info • Name, age, sex, location • Illness information • Onset date, temperature, type of illness, symptoms, lab information, outcomes

16. Tools: Hand Hygiene Monitoring Tool • Information • Location, room, precaution type, role of observed • Monitoring staff hand hygiene (HH) and personal protective equipment (PPE) use • HH before, HH after • PPE before, PPE after

17. Tools: SBAR Before calling a clinician for treatment, evaluate the resident, check vital signs, review chart, and have the relevant information available when reporting Situation Background Assessment / Appearance Request

18. Tools: Transfer Form • Inter-facility communication is a top challenge • Needs assessment, trainings, stakeholder meeting • Developed by a multidisciplinary group in 2009 • Importance of timely transfer of pertinent information • Get to know the infection preventionist(s) at facilities that commonly transfer residents to/from your facility

19. Tools: Urinary Catheter Checklist and Reminder

20. Policies Tab UTI prevention template policies: • Assessment of Urinary Incontinence • Perineal Care for Incontinent Resident • Urinary Catheterization Assessment and Care Practices • Prevention of UTIs and CAUTIs (Catheter-Associated Urinary Tract Infections)

21. Tools: Policy Templates

22. Education Tab • Prevention Priorities: HICPAC and CDC • UTI Surveillance FAQs • UTI FAQs • CAUTI FAQs • UTI Prevention Strategies: Ideas • Hand Hygiene FAQs

23. Education: HICPAC and CDC Prevention Priorities for Catheter-Associated UTIs • HICPAC (Healthcare Infection Control Practices Advisory Committee) • Prioritization of recommendations • Examples of appropriate indwelling catheter use • CDC based on HICPAC • Core strategies • Supplemental strategies • Strategies that are NOT recommended

24. Education: Surveillance FAQs • What is surveillance? • How do I conduct surveillance? • What is a log and why use it? • Why use a rate and how do I calculate it? • What is a urinary catheter day and when do I collect the data?

25. Education: UTI Frequently Asked Questions (FAQs) • What are UTIs, CAUTIs, and what are their symptoms? • Why are LTC residents at risk? • How can you get a UTI/CAUTI? • How can you help prevent a UTI/CAUTI?

26. Education: Prevention Ideas • Promote • Healthy hydration practices • Healthy behaviors • Appropriate practices to avoid UTIs • Customize these ideas to your facility! • Energize your staff with new practices • Share your ideas and strategies that have worked with others

27. Antibiotic Use Tab • Antibiotic Use in Long-Term Care Facilities (CDC Get Smart Program) • 12 Steps to Prevent Antimicrobial Resistance Among Long-term Care Residents (CDC)

28. Antibiotic Use Antibiotic Use in LTCFs • Scope of the problem • Why we need to act • Why focus on LTC • What LTC facilities and providers can do 12 Steps to Prevent Antimicrobial Resistance – LTC • Prevent infection • Diagnose and treat infection effectively • Use antimicrobials wisely • Prevent transmission

29. Presentations Tab UTIs: Working Together to Ensure Appropriate Management and Treatment • Urinary Tract Infections: LTC Facilities • Robert M. Palmer, MD, MPH • UTIs in LTC: A Diagnostic and Therapeutic Dilemma • Edward C. Oldfield, III, MD • Urinary Health in Long-Term Care Settings • Edna D. Garcia, BSN, RN-BC

30. Presentation Questions Urinary Tract Infections: LTC Facilities • What is the CMS/F315 guidance? • How common is bacteriuria? • How to manage recurrent UTIs? • Prevention strategies UTIs in LTC: A Diagnostic and Therapeutic Dilemma • How to determine who needs treatment • Benefits/harm to treating asymptomatic bacteriuria? • When should you replace a Foley catheter? • Treatment options and antibiotic selection • Should test for cure be done? Urinary Health in Long-Term Care Settings • Success implementing evidence-based practices • Which tools are useful for promoting urinary health? • Importance of nurse-driven protocols

31. References Tab • Resources and References • Surveillance definitions and clinical guidelines • Other guidelines and position papers • Prevention resources • Antibiotic stewardship resources

32. Thank you! www.vdh.virginia.gov/epidemiology/surveillance/hai/uti.htm#Toolkit To contact the VDH HAI Team: Carol.Jamerson@vdh.virginia.gov Andrea.Alvarez@vdh.virginia.gov Dana.Burshell@vdh.virginia.gov 804-864-8141

33. Our Experience with the UTI Toolkit Adriana Agnew RN, BSN, BC, MSNEd, AIT Director of Quality Management and Infection Preventionist Fairfax Nursing Center qm@fairfaxnursingcenter.com

34. Fairfax Nursing Center’s Use of the Toolkit • Assisted with protocol revisions • Developed new protocols • Documented using SBAR • Reinforced the nurse driven protocol

35. The First Steps to Change • Changed Foley catheter supplies • Closed system with needleless port • Straight catheter system with urine collection bag attached • Decrease in contamination of urine specimen • Closed system self catheter system to prevent urinary tract infections • Collection tubes • Urine C&S with preservative • Urinalysis with preservative

36. In and Out Closed System

37. McGeer/APIC and F-Tag • Staff educated • McGeer definition of urinary tract infection • F-Tag 315 • Staff require further education • Plan to re-educate the staff using the McGeer/APIC and F-Tag definitions tool • Tool clarifies the misperceptions • Can clearly see the similarities between definitions • Increases understanding

38. Policy and Procedures • Research completed • Follows the F-tags • Appropriate for long-term care setting • Best practice

39. SBAR Tool • Made a few changes to the form • Form will be part of the medical record • Increased documentation compliance • Increased communication nurse-to-nurse • Increased communication nurse-to-MD

40. Implementing SBAR: Skilled and LTC Units • Unit layout • Three units with skilled and long-term residents • Two nurses on each unit –assigned to medication pass • Approximately 25 residents each • One nurse – assigned to be in charge • Assists with medication pass • Assists with treatments • Calls MD

41. Implementing SBAR: Skilled Unit • One unit mostly skilled • Three nurses – medication nurse • One charge nurse – calls MD with all concerns • One nurse – assists charge nurse

42. Current Procedures • Flow of information • Medication nurse notes a change in condition • Verbally communicates with charge nurse • Charge nurse calls MD and writes on call log • The information on the call log may not be entered in the nurses notes; nurses write notes on a piece of paper • The next shift may not have the full picture of the resident • Lack of information to MD

43. New Procedure • SBAR note • The medication nurse • Notes a change in the resident’s condition • The nurse suspects a UTI • The nurse documents her findings • Gives the nurses note to the charge nurse at the desk

44. Benefits • The nurse now has a guide • Documentation • Assessment of system

45. Nursing Note • The charge nurse • Reads the nursing note to the MD • Increases in accuracy of communication • Improves resident outcomes • Documents on the same nursing note • Notifies family and documents on the same nursing note • The nursing note gives a story • Note is placed in the medical record

46. Nursing Note • Before Calling MD: • Evaluate the resident and complete the form (use “N/A” for not applicable) • Check VS: BP, pulse, respiratory rate, temperature, pulse ox, and/or finger stick Glucose if indicated • Review chart: History of UTI, diabetes, indwelling urinary catheter • Have relevant information available when reporting (i.e. resident chart, vital signs, • Advanced directives such as DNR and other care limiting orders, allergies, medication List) • SITUATION • The symptom/signs of possible UTI I am calling about are: • No indwelling catheter. Check all that Apply: Not applicable _____ • The symptom/signs of possible UTI I am calling about are: • Fever (increase of > 2° F; rectal temp > 100°F) • New or increased burning,  pain on urination, frequency  urgency • New flank  suprapubic pain/tenderness • Change in character of urine  new bloody urine,  new foul smell  Change in amount of sediment • lab report of positive result (nitrite +, pyuria, microhematuria) • Worsening of mental  worsening of functional status • confusion,  lethargy,  unexplained falls,  recent onset of Incontinence, decreased activity  decreased appetite) • If resident has indwelling urinary catheter: Not applicable:_________ • Fever or chills • New flank pain  New suprapubic tenderness • Change in character of urine • Worsening of mental status or function • BACKGROUND • Primary diagnosis and/or reason resident is at the nursing home: ______________________________________________________________________ • Vital Signs: BP___/___ HR____ RR___ Temp____ Pulse Oximetry___% on RA__ on 02 at______ L/min via _________ (NC, mask) • Mental status changes (e.g. confusion/agitation/lethargy) explain behaviors: ____________________________________________________________________________________________________________________________________________ • GI/GU changes (circle all that apply) • (E.g. nausea/vomiting/diarrhea/distension/decreased urinary output/other)_ _____________________________________________________________________ • Change in intake/hydration explain: _______________________________________ • WBC:______________________________Advance directives (circle) (Full code, DNR, DNT) • Allergies:_________________ Any Other Data: ______________________________ • Nurse Name: __________________ RN/LPN Date: ___/___/__ Time____/____ am/pm • Resident label

47. Nursing Note ASSESSMENT (RN) OR APPEARANCE (LPN) Resident has 3-5 background symptoms Resident has 1-2 symptoms For Indwelling Catheter Resident has 2-4 background symptoms Resident has 1 background symptom Resident appears to have new symptoms of concern Nurse Name: __________________ RN/LPN Date: ___/___/__ Time_______ am/pm ----------------------------------------------------------------------------------------------------------------------------------- Call placed to: _________________ MD Date: ____/____/____ Time________ am/pm communicated by: Phone In Person  left a message Note: _____________________________________________________________________ Nurse Name: __________________ RN/LPN Date: ___/___/__ Time_______ am/pm _______________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------------ Return call/new orders from MD: __________ __Date__/__/__Time_______ am/pm Communicated by: Phone In Person Note: _____________________________________________________________________ Nurse Name: ___________________ RN/LPN Date: ___/__/__ Time________ am/pm __________________________________________________________________________________ -------------------------------------------------------------------------------------------------------------------------------------- Call placed to: Family or health care proxy: _______________ Date: __/___/__Time: ______ am/pm communicated by: Phone In Person  Notified  Left a message Nurse Name:__________________ RN/LPN Date: ____/____/____ Time_____ am/pm Note: _________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------_ Family or health care proxy: __________________ Date: ___/___/__Time: ____am/pm communicated by: Phone In Person  Notified Nurse Name: _______________RN/LPN Date: ____/____/____ Time______ am/pm Note: * Adapted from INTERACT II and VDH Resident Label

48. Surveillance • Review the 24 hour report daily • Complete the event form on a daily basis • UTI event form separated from other infections • Receive a list of all urinary catheters by 10am daily • Complete the Virginia UTI Denominator Form daily • Check labs online • End of the month totals

49. Model Transfer Form • Contacted Inova Health System • Meeting with infection preventionist • Will discuss the model transfer form • Continuum of care with residents with infections • Improvement in communication • Reporting back to the transferring hospital

50. Nurse Driven Protocol • Development of new protocol • Bladder scanner • Multiple nurses trained • Indwelling catheter • Protocols to prevent CAUTI • If infection suspected, change catheter • Proper collection of urine samples • Sterile specimen container • Clean catch • Collection port for catheter