Caroline Helwick

June 12, 2015

NEW ORLEANS — In long-term care facilities, rates of urinary tract infection and the overtreatment of asymptomatic infection can be reduced, according to a nurse practitioner who led the charge at her institution.

A nurse-driven protocol was implemented by Janice Hoff, MSN, GNP-C, at a facility on the Gulf Coast with a urinary tract infection rate of a whopping 78th percentile of a national group comparison.

"On top of this, there were 12 patients with chronic Foley catheters in a 120-bed facility," she reported. "Plus, every time a patient sneezed, the nurses got a urinalysis."

Approximately 50% of elderly females will develop a urinary tract infection in the long-term care setting, and these often recur. Although infections are a leading cause of poor quality of life, they are often overtreated. The inappropriate use of antibiotics for asymptomatic infection leads to adverse drug reactions, drug resistance, and, of great concern in nursing homes, Clostridium difficile infection, Hoff pointed out.

She described her approach to several common problems — overuse of urinary catheters, overtesting for infection, and overprescribing of antibiotics — here at the American Association of Nurse Practitioners 2015 National Conference.

For the quality-improvement project, Hoff convened a task force to create a plan and its goals. A pivotal part was the education of all nursing staff, including certified nursing assistants, who manage toileting and surveillance, she explained.

The first thing Hoff did was mandate that the nurse practitioner (in this case, her) be called before any urinalysis was ordered. "I got lots of phone calls, but I persevered," she reported.

The nursing staff believed that any sign of "agitation" was reason enough to test. "We started gradually trying to change that mindset," she said.

She also tackled inappropriate specimen collection, which can produce false-positives. For high-risk patients and those suspected of having an infection, she prescribed cranberry tablets 450 mg twice daily and ordered regular hydration and surveillance.

"Hydration and surveillance — those are the biggest things we can do," she explained.

She credits "giving the staff something to do" with the success of the protocol. When nurses reported that their patients were agitated or "not themselves," or when urine looked or smelled "bad," Hoff issued a series of orders.

Orders to Be Followed on Signs of Urinary Tract Infection
Increase fluid intake: offer 120 mL of juice or water every 2 hours for 72 hours
Increase hygiene measures: cleanse anogenital area with soap and water after each incontinence episode or toileting
Schedule toileting, diaper check, or diaper change every 2 to 4 hours
Monitor temperature every shift for 72 hours
Monitor complaints of dysuria, urinary frequency, or flank pain and report to charge nurse
Assess for bladder pain and retention
Perform dipstick urine if three symptoms are present


Hoff explained that in a patient with symptoms, a dipstick test positive for nitrites and leukocytes has about an 80% likelihood of being a bona fide infection.

Now urine is sent out only after a positive dipstick and symptoms. "Doing dipsticks allowed me to reduce the number of urines being drawn," she said.

Hoff monitors patients suspected of having an infection for 72 hours, unless symptoms arise sooner. "You don't want to delay treating a patient who is truly sick," she acknowledged. "The ones who are sick are the easy ones. It's the ones slowly cooking along with asymptomatic bacteria that are more difficult to make a judgment call on."

Antibiotics are warranted for patients with at least 105,000 CFU/mL of a single bacterial species, plus clinical symptoms of urethritis, cystitis, suprapubic pain, pyelonephritis, or fever, she explained.

Hoff also addressed the high rate of chronic catheter use. "This was a bigger challenge than I thought it would be," she said.

It's easy to keep Foleys in because they keep patients dry and nursing staff don't have to fool with toileting, but catheters put patients at risk.

A chart review revealed "neurogenic bladder" as a reason for all patients to be on catheters, but she found this to be the case in only two patients. The rest of the patients were "just bed-bound."

After discussions with urologists, she discontinued catheters for most patients and explained to families that this action "would improve their loved ones' lives," she said.

"Now, nurses will come to me and say, 'You want that catheter out, don't you?'" she said. Cases, of course, must be individualized, she added.

The goals of the project were to achieve a 25% reduction in infection and a 50% reduction in urinary catheter use in the first 3 months. In fact, the intervention resulted in a 38% reduction in infection occurrences and a 50% reduction in catheters, Hoff reported.

"Hydration, increased surveillance, and getting catheters out is what will do this for you," she said.

Hoff's protocol impressed Heidi Maloni, PhD, NP, from the VA Medical Center in Washington, DC.

"She did a great job," Dr Maloni told Medscape Medical News. "She had the courage to create a path where people really don't want to go. It's easy to keep Foleys in because they keep patients dry and nursing staff don't have to fool with toileting, but catheters put patients at risk. Getting catheters out is great."

She emphasized the importance of addressing the high rate of infection in long-term care patients and in those with neurologic disease, such as the patients she sees. "The only people who can tackle this are nurse practitioners, who are at the bedside, in the field, in the weeds, so to speak," she said. "In this case, Hoff changed the behavior of the certified nursing assistants; that's the key. She got them doing things they were not doing before."

Ms Hoff and Dr Maloni have disclosed no relevant financial relationships.

American Association of Nurse Practitioners (AANP) 2015 National Conference. Presented June 11, 2015.


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