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The Florida Nursing Home
Quality Care Connection
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Reduction in Urinary Tract Infections(UTIs) and 
Prescribed Antibiotics
Looking at a nursing home population on a really good day, when the nursing home (NH) residents are all feeling great, having no behavior issues, and no complaints, and having tested the urine of all of the residents, we would find that a significant number have abnormal urine results.  In 1996, Ouslander published a study on the prevalence of pyuria    and bacteriuria in asymptomatic chronically incontinent NH residents (J Am Geriatr Soc 1996; 44:420-423).  Forty-five percent of residents had pyuria, defined as >10 wbc/hpf and 43 percent had bacteriuria, defined as >100K CFU's of a pathogen. These findings were in asymptomatic NH residents!  Lesson learned: When we order urine tests, half the time we may find residents with either pyuria or bacteriuria. These findings are meaningless without other corroborating clinical findings.  Otherwise, the possibility of inappropriately ordering antibiotics can occur, which can then create problems such as Clostridium difficile infections (CDIs).

HAI Prevention:
Roadmap to Elimination
According to the "National Action Plan to Prevent
Healthcare-Associated Infections (HAIs): Road Map to Elimination"
 (April 2013), UTIs are the most commonly reported and treated infection in long-term care residents. However, implementing a comprehensive surveillance and antibiotic stewardship program will reduce the overuse of antibiotics in treating suspected UTIs and reduce the risk of spreading CDIsin nursing homes. Join HSAG and other local and national experts on a new Quality Assurance & Performance Improvement (QAPI) initiative to prevent and reduce CDIs, while improving antibiotic prescribing to enhance the quality of care and life for residents in nursing homes. By joining this project, nursing homes will enroll in the CDC National Healthcare Safety Network (NHSN) databank that allows facilities to track both UTIs and CDIs in a streamlined and systematic way. HSAG is available to assist nursing homes in NHSN enrollment and tracking infections.
Tips for Improving the UTI  Long-Stay Quality Measure
The UTI measure reports the percentage of residents who have had a UTI within the last 30 days.
Minimum Data Set (MDS) Coding Requirements
In the MDS:
1. Include a look-back period of 30 days.
2. Code only if all of the following are met:
  • Physician, certified nurse practitioner, physician assistant, or clinical nurse specialist diagnosed a UTI in the last 30 days.
  • Documented signs and symptoms of a UTI, such as fever, burning, frequent urination, pain, or tenderness in the flank, confusion, mental status change, or pyuria exist.
  • Current medication or treatment of a UTI has occurred in the last 30 days.
  • Significant laboratory findings exist. (Attending physician should determine the level of significant laboratory findings and whether a culture should obtained or not.)
This measure will not be triggered if the target assessment is an admission, a prospective payment system (PPS) 5-day assessment, or a readmission/return assessment.

Ask these questions:
  •  Was the MDS coded as per the Resident Assesment Instrument requirements?
  • Does the facility have established criteria for testing (such as the McGreer Criteria, available on the Centers for Disease Control and Prevention [CDC] website), and are the nurses aware of the criteria?
  • Does the resident need to be placed on a hydration program?
  • Is water accessible at all times and offered to dementia residents?
  • Are chronic conditions treated?
  • Are staff members monitored for proficiency in perineal-/catheter care and handwashing?
  • If a catheter has been inserted, was the diagnosis appropriate?

QAPI Corner
Step 1: Leadership & Accountability 
Facility leadership (e.g., medical director, administrator, director of nursing, and other key managers) is responsible for "setting the tone" to help staff identify how to meet the organization's mission, vision, guiding principles, standards, and expectations. Without strong leadership, change efforts often fail or are not sustainable. As a leadership team, consider these key questions:

- How can we provide needed resources for QAPI? 

- Is our culture open, respecting and "just" (fair)

- What does our culture look like? 

- How can QAPI blend with our existing QA efforts? 


 Not sure where to start? Review pages 9-10 of QAPI at a Glance and page 8 of the QAPI Companion Guide to get started.      

Next Month: Focusing on a deliberate approach to teamwork.  

Upcoming Webinar

  Developing a
Regional Approach to
CDI Prevention

Hear from Erin Epson, MD, from the California Department of Public Health (CDPH), on a unique CDI prevention approach that focuses on bringing together all healthcare facilities to combat CDI on a community level, rather than just within the four walls of a facility.
Thursday, August 25
1 p.m. to 2 p.m. ET
Have you completed your QAPI Self-Assessment? 
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