IMPLEMENTING A NURSE-LED URINARY TRACT INFECTION ALGORITHM IN LONG-TERM CARE A DOCTOR OF NURSING PRACTICE PROJECT SUBMITTED TO THE GRADUATE DIVISION OF THE UNIVERSITY OF HAWAI’I AT MANOA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF NURSING PRACTICE MARCH 2020 BY Kristia Leanne P. Dizon Committee: Clementina Ceria-Ulep, Chairperson Darlene Nakayama Karen Tessier Keywords: Urinary tract infections, long-term care, elderly, antibiotic stewardship
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IMPLEMENTING A NURSE-LED URINARY TRACT INFECTION ALGORITHM IN
LONG-TERM CARE
A DOCTOR OF NURSING PRACTICE PROJECT SUBMITTED TO THE GRADUATE
DIVISION OF THE UNIVERSITY OF HAWAI’I AT MANOA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF NURSING PRACTICE
Table 3 Definitions of ASB versus UTI ASB UTI Greater than or equal to 105 colony-forming units per milliliter (CFU/mL) in TWO consecutive urine specimens in women or ONE urine specimen in men in the absence of clinical signs and symptoms of UTI.
• Fever greater than 38 degrees Celsius • Chills • Dysuria • Frequency • Urgency • Gross hematuria • Suprapubic or flank pain OR testicular
pain or tenderness Note: It is important to consider other diagnoses for symptoms of lethargy, confusion, or change
in level of consciousness (Detweiler, Mayers, & Fletcher, 2015) as these are nonspecific for UTI
especially in the elderly.
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Appendix B
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NURSE-LED UTI ALGORITHM IN LONG-TERM CARE
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Figure 3. UTI Algorithm
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Appendix C
Table 4 Literature Matrix Table
Author & Title with APA Citation
Purpose Findings/Themes/ Interventions
Conclusion Level of Evidence
Buul, L. W., Veenhuizen, R. B., Achterberg, W. P., Schellevis, F. G., Essink, R. T., Greeff, S. C., . . . Hertogh, C. M. (2015). Antibiotic Prescribing In Dutch Nursing Homes: How Appropriate Is It? Journal of the American Medical Directors Association,16(3), 229-237. doi:10.1016/j.jamda.2014.10.003
To investigate the appropriateness of decisions to prescribe or withhold antibiotics for nursing home (NH) residents with infections of the urinary tract (UTI), respiratory tract (RTI), and skin (SI).
In 598 cases, appropriateness of treatment decisions was assessed; 76% were appropriate, with cases that were prescribed antibiotics judged less frequently “appropriate” (74%) compared with cases in which antibiotics were withheld (90%) (P 1⁄4 .003). Decisions around UTI were least often appropriate (68%, compared with 87% for respiratory tract infections (RTI) and 94% for skin infections [P < .001]). The most common situations of inappropriate antibiotic prescription were those indicative of asymptomatic bacteriuria or viral RTI.
Although the rate of appropriate antibiotic prescribing in Dutch NHs is relatively high compared with previous studies in other countries, the results suggest that antibiotic consumption can be reduced by improving appropriateness of treatment decisions, especially for UTI. Given the current antibiotic resistance developments in long-term care facilities, interventions reducing antibiotic use for asymptomatic bacteriuria and viral RTI are warranted.
Level III: Non-experimental study Prospective cohort study
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Cooper, D., Mcfarland, M., Petrilli, F., & Shells, C. (2018). Reducing Inappropriate Antibiotics for Urinary Tract Infections in Long-Term Care. Journal of Nursing Care Quality,00(0),1-6. doi:10.1097/ncq.0000000000000343
The purpose of this project was to replicate the Cooper Urinary Tract Infection Program (utilizing an algorithm, didactic education, and change champions) in another facility and measure its effectiveness.
For residents who received a UTI diagnosis in both periods, 80.0% occurred in the pre-period while 29.4% occurred in the post-period. There were 18 inappropriate antibiotic treatments in the pre-period and only 1 in the post-period.
In this and the original study, CUTIP led to better UTI diagnostic accuracy and a significant reduction in inappropriate antibiotic treatments. The results of this replication project improve the generalizability and extrapolation of findings to other LTCFs and support dissemination.
Level I: Experimental study Replication study
Crnich, C. J., Jump, R., Trautner, B., Sloane, P. D., & Mody, L. (2015). Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement. Drugs & Aging,32(9), 699-716. doi:10.1007/s40266-015-0292-7
To promote evidence on recommendations for antibiotic stewardship programs in nursing home settings.
Multiple modalities are useful in successfully implementing ASPs in the LTCF when interdisciplinary tools are utilized.
Educational and algorithm interventions may be useful for improving antibiotic prescription for nursing home residents.
Level IV: Clinical practice guideline
Detweiler, K., Mayers, D., & Fletcher, S. G. (2015). Bacteruria and Urinary Tract Infections in the Elderly. Urologic Clinics of North America, 42(4), 561-568. doi:10.1016/j.ucl.2015.07.002
“…review proposed definitions of ASB and UTI, highlight emerging research in causes and prevention of bacteriuria and UTI in the elderly, and examine improvements in patient outcomes over the past 20 years with improved practice guidelines” (p. 561).
Differentiating between UTI and ASB using appropriate criteria for those with and without catheters and those living in facilities or in community will promote better diagnosis of true UTI.
While both UTI and ASB are common problems in elderly adults and represent a significant health burden, differentiating between the two remains controversial among clinicians.
Level IV: Clinical practice guideline
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Feldstein, D., Sloane, P. D., & Feltner, C. (2018). Antibiotic Stewardship Programs in Nursing Homes: A Systematic Review. Journal of the American Medical Directors Association, 19(2), 110–116. https://doi-org.eres.library.manoa.hawaii.edu/10.1016/j.jamda.2017.06.019
To evaluate the current evidence regarding outcomes of antibiotic stewardship programs (ASPs) in NHs. Intermediate health outcomes evaluated included changes in rates of antibiotic prescriptions and the proportion of antibiotic prescriptions that were concordant with guidelines.
The studies reviewed indicated NH ASPs can change intermediate health outcomes by reducing the number of antibiotic prescriptions and by improving adherence to recommended treatment guidelines. It was stated that this document did not support or refute the concern that NH ASPs may increase the number of NH residents who die or experience morbidity from untreated infections.
In conclusion, the evidence on the effectiveness of ASPs in NHs is encouraging but limited. These programs can reduce antibiotic prescriptions. This can, theoretically, improve health outcomes for NH residents, but results to date have not shown reductions in hospitalizations, emergency department visits, or C.Diff Infection (CDI) rates. ASPs are now mandated in the NH and more research is needed to determine whether and to what extent these complex programs will improve NH resident health and, if so, which program components are most effective.
Level II: Systematic review without meta-analysis
Fleet, E., Rao, G. G., Patel, B., Cookson, B., Charlett, A., Bowman, C., & Davey, P. (2014). Impact of implementation of a novel antimicrobial stewardship tool on antibiotic use in nursing homes: A prospective cluster randomized control pilot study. Journal of Antimicrobial Chemotherapy,69(8), 2265-2273. doi:10.1093/jac/dku115
“To evaluate the impact of ‘Resident Antimicrobial Management Plan’ (RAMP), a novel antimicrobial stewardship tool on systemic antibiotic use for treatment of infection in nursing homes (NHs).”
The RAMP intervention promoted accurate and appropriate assessment and documentation by nurses and successively led to improvement in treatment.
The “…pilot study demonstrated that use of RAMP was associated with a statistically significant decrease in total antibiotic consumption and has the potential to be an important antimicrobial stewardship tool for NHs.”
Level I: Cluster randomized controlled trial
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Fleming, A., Browne, J., & Byrne, S. (2013). The effect of interventions to reduce potentially inappropriate antibiotic prescribing in long-term care facilities: a systematic review of randomised controlled trials. Drugs & Aging, 30(6), 401-408. https://doi-org.eres.library.manoa.hawaii.edu/10.1007/s40266-013-0066-z
To evaluate the results of the evidence at the time in regards to appropriate antibiotic prescription in the LTCF setting.
Due to the varying results of the included studies and different interventions and outcome measures employed, it is not possible to attribute the success of an intervention to any one type of intervention strategy.
Interventions in the long-term care setting involving local consensus procedures, educational strategies, and locally developed guidelines may improve the quality of antibiotic prescribing, but the quality of the evidence is low.
Level II: Systematic review without meta-analysis
Gee, M. E., Ford, J., Conway, E. L., Ott, M. C., Sellick, J. A., & Mergenhagen, K. A. (2018). Proper Antibiotic Use in a Home-Based Primary Care Population Treated for Urinary Tract Infections. The Consultant Pharmacist,33(2), 105-113. doi:10.4140/tcp.n.2018.105
To evaluate the trends associated with diagnosis and treatment of urinary tract infections (UTI) in a home-based primary care population of Veterans Health System patients from 2006 to 2015.
Out of 366 patients, 68 (18.6%) were tested for possible UTI and appropriate therapy occurred in 26% of cases. Allergy to any antibiotic increased the odds of appropriate treatment (odds ratio [OR] = 5.6, 95% confidence interval [CI] 1.5-23.2). Flank pain and increased urinary frequency also increased the likelihood of being treated appropriately (OR = 25.9, 95% CI 2.9-584.0 and OR = 4.49, 95% CI 0.99-21.2, respectively).
Antibiotics were overused for treating UTIs in the homebound population. Patients with flank pain, increased urinary frequency, and antibiotic allergy were more likely to receive appropriate treatment. Pharmacists, therefore, have a viable opportunity to increase appropriate antibiotic prescribing in the home-based primary care population.
Level III: Non-experimental study Prospective cohort study
Genao, L., & Buhr, G. T. (2012). Urinary Tract Infections in Older Adults Residing in Long-Term Care Facilities. The Annals of Long-Term Care : The Official Journal of the American Medical
To provide a comprehensive overview of UTI in the LTC setting, outlining the epidemiology, risk factors and pathophysiology, microbiology, diagnosis, laboratory
Loeb and colleagues (2001) developed an algorithm which separates the symptoms into major and minor based on the likelihood of their association with UTI. It provided interventions for
UTI is the most common cause of bacteremia and hospitalization in LTC residents, but its mortality rate is much lower than that for pneumonia. UTI is also the condition for which antibiotics are most frequently prescribed;
Level IV: Clinical practice guideline
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Directors Association, 20(4), 33–38.
assessment, and management of symptomatic UTI within the context of UTIs being common suspected diagnoses in the LTC setting.
other common conditions that mimic UTI in LTC residents. Using the algorithm, the rate of suspected UTI decreased by 30% and the rate of antibiotic use for UTI decreased by 20% at 3 months, with the changes persisting after 12 months.
however, many patients are inappropriately treated. Individuals with asymptomatic bacteriuria should not be prescribed antibiotics, as this practice increases the risk of antimicrobial resistance and does not change chronic genitourinary symptoms or improve survival. Treatment of UTI in LTC residents is similar to that in ambulatory patients, with an emphasis on individualized and tailored antimicrobial therapy.
Lemoine, L., Dupont, C., Capron, A., Cerf, E., Yilmaz, M., Verloop, D., . . . Alfandari, S. (2018). Prospective evaluation of the management of urinary tract infections in 134 French nursing homes. Médecine Et Maladies Infectieuses,48(5), 359-364. doi:10.1016/j.medmal.2018.04.387
Prospective assessment of the management of urinary tract infections (UTI) in the nursing homes of the Hauts-de-France region.
There were 134 facilities in participation (out of 397) and 444 UTI episodes. Reported diagnostic criteria were burning urination (32%), malodorous urine (29%), confusion (28%), and turbid urine (19%). 21% of diagnoses were based on erroneous criteria. Less than 50% of residents had a urine dipstick test performed and 94% had a urine culture. The main pathogen was Escherichia coli. Reported indications were uncomplicated cystitis (32%), unspecified UTI (26%), complicated cystitis (9%), while no reason was given in 25% of cases. Only 10% of diagnoses were consistent with guidelines:
Priorities for improving antibiotic use should focus on optimizing diagnostic and follow-up strategies. The high frequency of inadequate prescriptions for asymptomatic bacteriuria should lead to reminding healthcare professionals working in nursing homes of the high frequency of colonization in the elderly and of the need to perform urine diagnostic tests only when UTI symptoms are observed.
Level III: Non-experimental study Prospective cohort study
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complicated cystitis (49%), asymptomatic bacteriuria (21%), acute pyelonephritis (21%), male UTI (9%). Nearly 85% of prescriptions were active on the isolated bacteria. The empirical antibiotic therapy was consistent with the diagnosis in 16% of cases (30% for reclassified diagnoses).
McElligott, M., Welham, G., Pop-Vicas, A., Taylor, L., & Crnich, C. J. (2017). Antibiotic Stewardship in Nursing Facilities. Infectious Disease Clinics of North America,31(4), 619-638. doi:10.1016/j.idc.2017.07.008
A review of ASPs in nursing homes from a nursing perspective and recommendations on improving usage of ASPs.
Of 4 categories of possible ASPs (antibiotic prescribing policies/guidelines, broad interventions; pharmacy-driven interventions, and syndrome-specific interventions), LTCFs should not attempt to implement all at once but start with a single intervention and later add to this based on feasibility.
Of four different strategies to implement ASPs, nursing facilities should implement one intervention that is most fitting for the particular facility.
Level IV: Clinical practice guideline
McMaughan, D. K., Nwaiwu, O., Zhao, H., Frentzel, E., Mehr, D., Imanpour, S., . . . Phillips, C. D. (2016). Impact of a decision-making aid for suspected urinary tract infections on antibiotic overuse in nursing homes. BMC Geriatrics,16(1). doi:10.1186/s12877-016-0255-9
To examine the effect of a decision-making aid n antibiotic stewardship programs in NHs.
Most prescriptions for antibiotics to treat UTIs were written without documented symptoms, which was considered ASB upon chart review (71 % during the pre-period). “Exposure to the decision-making aid decreased the number of prescriptions written for ASB (from 78 % to 65 % in the low-intensity homes and from 65 % to 57 % in the high-intensity homes), and decreased odds of a prescription being written for ASB (OR = 0.63, 95 % CI =
The decision-making aid (when used) reduced unnecessary antibiotic use during the study but it was not embedded in the everyday operations of the nursing homes included in the study. The day-to-day operations competing for priority pose a challenge to the longevity in use of an aid.
Level I: Experimental study Retrospective chart review including pre- and post-test with comparison
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0.25 – 1.60 for low-intensity homes; OR = 0.79, 95 % CI = 0.33 – 1.88 for high-intensity homes). The odds of a prescription being written for ASB decreased significantly in homes that succeeded in implementing the decision-making aid (OR = 0.35, 95 % CI = 0.16–0.76), compared to homes with no fidelity” (McMaughan et al., 2016, p. 1)
Nace, D. A., Drinka, P. J., & Crnich, C. J. (2014). Clinical Uncertainties in the Approach to Long Term Care Residents With Possible Urinary Tract Infection. Journal of the American Medical Directors Association, 15(2), 133-139. doi:10.1016/j.jamda.2013.11.009
To provide best practice evidence on treatment of possible UTI in long-term care residents.
Review of a case study revealed inappropriate treatment of confusion, dark colored urine, and a urine culture showing pyuria, 1+ nitrates, and 105 CFU with stable vital signs. Encouraging “watchful waiting” is an appropriate action to take for such a case despite clinicians widely-held but false belief that this is not considered “taking action.”
Practitioners muse rely on consensus based criteria to accurately diagnose UTI.
Level IV: Clinical practice guideline
Olsho, L. E., Bertrand, R. M., Edwards, A. S., Hadden, L. S., Morefield, G. B., Hurd, D., . . . Zimmerman, S. (2013). Does Adherence to the Loeb Minimum Criteria Reduce Antibiotic Prescribing Rates in Nursing Homes? Journal of the American Medical Directors Association,14(4). doi:10.1016/j.jamda.2013.01.002
To examine the relationship between nursing home prescriber adherence to the Loeb minimum criteria (LMC) and antibiotic prescribing rates overall and for each of three types of infections (urinary tract infections, respiratory infections, and skin and soft tissue infections).
This study found no evidence that adhering to LMC was associated with lower prescribing rates. In general, overall staff adherence to LMC was low as well suggesting prescribers relied on other signs, symptoms, or other considerations before prescribing antibiotics.
It was found that prescribers did not usually consider the LMC when making decisions and greater adherence to the LMC did not result in decreased antibiotic prescription. However, the low adoption of LMC before prescribing must be widely used before any substantial gains are to be recognized.
Level III: Non-experimental study Prospective cohort study
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Pettersson, E., Vernby, A., Molstad, S., & Lundborg, C. S. (2011). Can a multifaceted educational intervention targeting both nurses and physicians change the prescribing of antibiotics to nursing home residents? A cluster randomized controlled trial. Journal of Antimicrobial Chemotherapy,66(11), 2659-2666. doi:10.1093/jac/dkr312
To assess a multifaceted educational intervention regarding treatment of infections in the nursing home setting.
Of 58 LTCFs recruited, 46 completed the study. The educational intervention showed the changes in percentage of infections treated with antibiotics and those handled by physicians as ‘wait and see’ was significant in comparison with controls: 20.124 (95% CI 20.228, 20.019) and 0.143 (95% CI 0.047, 0.240).
The educational intervention did not affect the primary outcome of assessing the proportion of quionolones prescribed for lower UTIs in women. However, results showed a decrease in the overall prescription of antibiotics, the secondary outcome.
Level I: Cluster randomized controlled trial
Pulia, M., Kern, M., Schwei, R. J., Shah, M. N., Sampene, E., & Crnich, C. J. (2018). Comparing appropriateness of antibiotics for nursing home residents by setting of prescription initiation: A cross-sectional analysis. Antimicrobial Resistance & Infection Control,7(1). doi:10.1186/s13756-018-0364-7
The objective of this study was to characterize antibiotic therapy for NH residents and compare appropriateness based on setting of prescription initiation.
Of 735 antibiotic starts, 640 (87.1%) were initiated in the NH as opposed to 61 (8.3%) in the outpatient clinic and 34 (4.6%) in the Emergency Department. Inappropriate antibiotic prescribing for UTIs differed significantly by setting: NHs (55.9%), ED (73.3%), and outpatient clinic (80.8%), P = .023. Regardless of infection type, patients who received antibiotic treatment in an outpatient clinic had 2.98 (95% CI: 1.64–5.44, P < .001) times increased odds of inappropriate use.
Antibiotics initiated out-of-facility for NH residents constitute a small but not trivial percent of all prescriptions and inappropriate use was high in these settings
Level III: Non-experimental study Prospective cross-sectional multi-center study
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Rowe, T. A., & Juthani-Mehta, M. (2014). Diagnosis and Management of Urinary Tract Infection in Older Adults. Infectious Disease Clinics of North America,28(1), 75-89. doi:10.1016/j.idc.2013.10.004
Although several consensus guidelines have developed UTI definitions for surveillance purposes, a universally accepted definition of symptomatic UTI in older adults does not exist. This guideline assesses use of current published guidelines in long-term care facilities.
It was found that a significant challenge faced by clinicians when diagnosing symptomatic UTI in residents in LTCFs is the low incidence of localized genitourinary symptoms, many of which are necessary components of the original Loeb criteria of 2001 and McGeer criteria of 1991 to accurately diagnose UTI.
The diagnosis of symptomatic UTI in older adults continues to be a significant challenge for providers caring for this population. Although guidelines are available to assist providers in diagnosing UTI, they are often not adhered to, and overtreatment with antibiotics remains an important issue.
Level IV: Clinical practice guideline
Stone, N. D., Ashraf, M. S., Calder, J., Crnich, C. J., Crossley, K., Drinka, P. J., … Stevenson, K. B. (2012). Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infection Control & Hospital Epidemiology, 33(10), 965–977. https://doi-org.eres.library.manoa.hawaii.edu/10.1086/667743
To provide an update on UTI assessment criteria for infection surveillance definitions in long-term care as the McGeer criteria had not been updated since 1991.
The revised definitions included in this review take into account the low probability of UTI in residents without indwelling catheters if localizing symptoms are not present. Revisions also take into consideration the need for microbiologic confirmation for diagnosis.
Majority of definitions and criteria were retained with minor revisions of more specific criteria to diagnose UTI.
Level IV: Clinical practice guideline
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Appendix D
Table 5 Evidence Grading Tool
LEVELS OF EVIDENCE
JOHNS HOPKINS LEVELS OF EVIDENCE DEFINITIONS
NUMBER OF ARTICLES REVIEWED
I
Experimental study, randomized controlled trial (RCT) Systematic review of RCTs, with or without meta-analysis 4
II
Quasi-experimental Study Systematic review of a combination of RCTs and quasi-experimental, or quasi-experimental studies only, with or without meta-analysis. 2
III
Non-experimental study Systematic review of a combination of RCTs, quasi-experimental and non-experimental, or non-experimental studies only, with or without meta-analysis. Qualitative study or systematic review, with or without meta-analysis. 5
IV
Opinion of respected authorities and/or nationally recognized expert committees/consensus panels based on scientific evidence. Includes: – Clinical practice guidelines – Consensus panels 7
V
Based on experiential and non-research evidence. Includes: – Literature reviews – Quality improvement, program or financial evaluation – Case reports – Opinion of nationally recognized expert(s) based on experiential evidence 0
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Appendix E
Figure 4. Permission from Denise Cooper, DNP, RN, ANP-BC
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Appendix F
Figure 5. Conceptual Framework: Iowa Model. Used with permission from the University of Iowa Hospitals and Clinics, copyright 2015.
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Appendix G
Figure 6. Educational Training Feedback
Educational Training Feedback
Thank you for completing the educational session on implementing the UTI algorithm. Your feedback would be greatly appreciated!
1. How satisfied were you with the number of educational sessions available?
1 Very Dissatisfied
2 Dissatisfied
3 Neutral
4 Satisfied
5 Very Satisfied
2. How satisfied were you with the following method of receiving alerts about educational sessions: EMAIL?
1 Very Dissatisfied
2 Dissatisfied
3 Neutral
4 Satisfied
5 Very Satisfied
3. How satisfied were you with the following method of receiving alerts about educational sessions: FLYER?
1 Very Dissatisfied
2 Dissatisfied
3 Neutral
4 Satisfied
5 Very Satisfied
4. How satisfied were you with the following method of receiving alerts about educational sessions: WORD-OF-MOUTH?
1 Very Dissatisfied
2 Dissatisfied
3 Neutral
4 Satisfied
5 Very Satisfied
5. The case study was a helpful tool to teach me how to use the algorithm.
1 Strongly Disagree
2 Disagree
3 Neutral
4 Agree
5 Strongly Agree
6. The educational session was engaging and informative.
1 Strongly Disagree
2 Disagree
3 Neutral
4 Agree
5 Strongly Agree
7. If I have questions about the algorithm, I know who to ask to receive clarification.
1 Strongly Disagree
2 Disagree
3 Neutral
4 Agree
5 Strongly Agree
8. Please comment on any areas of improvement or concern (optional).
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Appendix H
Figure 7. Algorithm Feedback
Algorithm Feedback
Thank you for participating in this project to implement a UTI algorithm. As you have had the opportunity to use the algorithm, please rate the following:
1. How likely were you to use the algorithm when you suspected UTI?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Always
2. The algorithm was easy to find on the unit and implement without disrupting my routine.
1 Strongly Disagree
2 Disagree
3 Neutral
4 Agree
5 Strongly Agree
3. How satisfied were you with the communication system between RNs (inputting trigger in MAR)?
1 Very Dissatisfied
2 Dissatisfied
3 Neutral
4 Satisfied
5 Very Satisfied
4. How satisfied were you with the communication system between RNs and providers (writing in their book)?
1 Very Dissatisfied
2 Dissatisfied
3 Neutral
4 Satisfied
5 Very Satisfied
5. As I have been in practice, I felt comfortable using the algorithm without assistance.
1 Strongly Disagree
2 Disagree
3 Neutral
4 Agree
5 Strongly Agree
6. If I have questions about the algorithm, I know who to ask to receive clarification.
1 Strongly Disagree
2 Disagree
3 Neutral
4 Agree
5 Strongly Agree
7. Please comment on any areas of improvement or concern (optional).
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Appendix I
Table 6 UTI Algorithm Communication Log Between RNs and Health Care Providers
Resident Name (Last, First) Room Start Date End Date Result □ Abx □ Resolved
Symptoms (please check all that apply): □ fever: single oral temperature >100◦F OR repeated oral temperature >99◦F OR repeated rectal temperature >99.5◦F OR single temperature >2◦F from any site above baseline temperature recorded above □ dysuria □ urgency □ frequency □ gross hematuria □ new flank or suprapubic or testicular pain or tenderness
1.1 By the end of the educational period (November 2019), >90% of RNs will receive educational training and know how to use the UTI algorithm. >60% of CNAs will attend the introductory part of educational training sessions in order to promote team work and gain an understanding of the direction of this intervention.
1.1.1 Identify RNs and CNAs that will receive education 1.1.2 Provide educational training sessions to all shifts (day, evening, night) throughout the period from October 18 to November 8, 2019 1.1.3 Administer Likert survey #1 to RNs at end of educational training sessions (to assess initial thoughts on implementation process and use of algorithm) 1.1.4 Notify all providers (6) about new algorithm
- Management approval of use of training room - RNs and CNAs employed at Palolo Chinese Home - Educational materials (example case studies; PPT with details, background, and timeline) used to provide training - Produce UTI algorithm in an easy-to-use paper format and display in each unit - Develop Likert scale survey
1.1.1 Number of RNs and CNAs in attendance at educational training sessions 1.1.2 Number of educational training sessions completed to reach at least 90% of RNs and at least 60% of CNAs 1.1.3 Number of Likert surveys administered to RNs
1.1.1 At the end of November 2019, all RNs who received training will complete post-education survey (Likert survey #1) 1.1.2 At the end of November 2019, all CNAs who received training will be aware of overall goals of using UTI algorithm
-Attendance count will show >90% RN and >60% CNA attendance and number of educational training sessions completed - Likert survey #1 results
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1.2 By December 2019, Likert survey #2 results will demonstrate an increased comfort with implementing UTI algorithm and its ease of use.
1.2.1 Administer Likert survey #2 midway through implementation period (to assess ease of use of algorithm) to RNs who attended educational training sessions
- Time to administer survey without interfering with unit routines
1.2.1 Number of surveys administered
1.2.1 At the end of December 2019, 50% of RNs will rate their likelihood of using the UTI algorithm at least ‘often’ (1-never, 2- rarely, 3- sometimes 4- often, or 5-always) 1.2.2 At the end of December 2019, 50% of RNs will at least ‘agree’ they are comfortable using the algorithm independently (1-strongly disagree, 2-disagree 3-neutral 4- agree 5-strongly agree)
- Likert survey #2 results indicating ease of use of UTI algorithm and increased comfort with using algorithm
1.3 By February 2020 (end of implementation period), RNs will implement the algorithm >60% of the time for cases of suspected UTI. Ultimate Outcome Objective: By the end of the evaluation period (February 2020), there will be at least a 50% decrease in UA orders
1.3.1 Establish communication log with providers to determine when algorithm was started 1.3.2 Monitor DLS reports monthly (from November 2019 to February 2020) for UAs ordered for suspected UTI
- Use communication log - Develop standing order to trigger in EMR for RNs to input per algorithm instructions - Gain access from Director of Nursing (DON) to monitor infection control logs monthly
1.3.1 Number of algorithm starts 1.3.2 Number of UA orders
1.3.1 At the end of February 2020, the algorithm will be embedded into practice at Palolo Chinese Home
- Communication log review indicating number of algorithm starts -DLS report review indicating number of UA orders
Assumptions: - Literature supports the use of specific criteria for accurately diagnosing UTI and differentiating between asymptomatic bacteriuria
External Factors: - This setting has 30% turnover rate of RNs which may initially affect the process of educating all nurses within a specified time frame - Ensuring educational reach to all target individuals may be difficult due to scheduling (3 shifts); night shift nurses typically only receive email notifications of changes rather than formal educational training sessions
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Appendix K
Table 8 Gantt Chart
Sub-Tasks Responsible Person
Start Date
Due Date
Comments
Major Task #1: Background Project Planning
Determine major plans for the project
DNP Student, DNP Chair
03/24/19 05/10/19 Meeting to determine overall plan of clinic and what is doable at Palolo Chinese Home so planning process can continue
Finalize the project plan prior to start of summer session
DNP Student, DNP Chair
03/24/19 05/10/19 Make changes to project plan as necessary prior to the final planning process
Meet with project preceptor and discuss project plan
DNP Student, Content Expert
03/01/19 06/01/19 Agreed on project plan and preceptor agreement signed
Objective #1: By the end of the educational period (November 2019), >90% of RNs will receive educational training and know how to use the UTI algorithm. >60% of CNAs will attend the introductory part of educational training sessions in order to promote team work and gain an understanding of the direction of this intervention. Develop and establish algorithm availability (via paper), Likert-scale surveys (2), communication log with providers
DNP Student 06/01/19 07/10/19 Likert survey #1 is regarding education process to be administered October to November 2019. Likert survey #2 is regarding comfort with using algorithm to be administered December 2019.
Develop educational materials: example case study; PPT with details, background, and timeline
DNP Student 07/10/19
Turn in educational materials, attendance sheet, algorithm, and surveys to Chair and Content Expert for review and approval
DNP Student, DNP Chair, Content Expert, Director of Nursing (DON)
06/01/19 07/31/19
Identify RNs and CNAs that work at Palolo Chinese Home and who are able to receive education
DNP Student, Unit clerk for list of staff names and/or DON
07/31/19
Receive approval from facility management for use of training room
DNP Student, DON, Content Expert
Advertise meeting dates via flyers and word-of-mouth
DNP Student, DON, Content Expert
09/15/19 10/18/19
Train/educate staff by providing educational training sessions once per week at change-of-shift over 1 month
DNP Student, DON, Content Expert, staff
10/18/19 11/08/19 DNP Student to provide food/refreshments at meetings.
Administer Likert survey #1 to RNs at end of educational training session
DNP Student, staff
10/18/19 11/08/19 Assessing initial thoughts on implementation and education process
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Notify all providers of new algorithm to be used in facility beginning July 1, 2019
DNP Student, providers
09/01/19 09/30/19 Notification to be completed via email, communication book between RNs and providers, word-of-mouth
Objective #2: By December 2019 (midpoint of implementation period), Likert survey #2 results will demonstrate an increased comfort with implementing UTI algorithm and its ease of use. Administer Likert survey #2 to RNs that attended educational training sessions
DNP Student, staff
12/15/19 12/31/19 Goal to complete without interfering with unit routines.
Converse with staff informally about their thoughts of the algorithm, implementation process, and answer any questions; gather qualitative data
DNP Student, staff
10/18/19 02/29/20 Goal to keep algorithm current in staffs’ minds
Objective #3: By February 2020 (end of implementation period), RNs will implement the algorithm >60% of the time for cases of suspected UTI. Assess number of algorithm starts based on communication logs between October 2019 and February 2020
DNP Student 02/29/20
Evaluation/Objective #4: By the end of the evaluation period (February 2020), there will be at least a 50% decrease in orders for UA. Assess number of UA orders based on DLS reports between October 2019 and February 2020
DNP student, DON
02/29/20
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Appendix L
Table 9 DNP Essentials Criteria DNP Essential DNP Student’s Activities and Products Essential I: Scientific Underpinnings for Practice
• Required DNP program coursework was completed. Topics include evidence-based practice, program evaluation, leadership, translation science, development and implementation of a DNP project, informatics, bioethics, economics, and health policy.
• Literature search, critique and rating of evidence was completed in order to incorporate up-to-date evidence in this DNP project.
• This evidence-based quality improvement project utilized current evidence and scientific rationale to improve outcomes for elderly individuals residing in long-term care facilities.
Essential II: Organizational and Systems Leadership
• Required DNP program coursework as outlined in Essential I was completed and is in alignment with this DNP essential.
• This DNP student led this quality improvement project using effective communication skills with staff, providers, and committee members. These skills also required processes of planning and advertising for educational training sessions to be completed.
• This pilot project aimed to decrease costs to facility associated with UA orders and simultaneously provided improved and culturally-sensitive health care.
Essential III: Clinical Scholarship and Analytical Methods for EBP
• Literature search and critique completed prior to implementation allowed for the promotion of “…safe, timely, effective, efficient, equitable, and patient-centered care” (American Association of Colleges of Nursing, 2006, p. 12).
• UTI guidelines were adapted from most current evidence and adapted to the particular facility of PCH.
• Data collection and analysis of surveys was completed in accordance with objectives outlined in this DNP project.
Essential IV: Information Systems and Technology
• This quality improvement project utilized a combination of paper and electronic charting systems as staff became accustomed to transitioning from paper charting systems to electronic medical records.
Essential V: Health Care Policy for Advocacy in Health Care
• Coursework for health policy, in addition to coursework listed in Essential I, was completed.
• The UTI algorithm was adapted to policies in place for assessment of UTI and made easier for staff to actively use.
Essential VI: Inter-Professional Collaboration
• Collaboration with providers, nurses, and committee members allowed for smooth transitions and the implementation of this DNP project.
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Essential VII: Clinical Prevention and Population
• An aim of this quality improvement project included promoting comfort for residents with incontinence and preventing unnecessary straight catheterizations to collect urine samples. Prevention of unnecessary urine testing and promotion of interventions to prevent UTIs for a vulnerable elderly population residing in the LTCF setting.
Essential VIII: Advanced Nursing Practice
• While no interaction occurred between the DNP student and residents for the purposes of this project, good rapport was built between the DNP student, facility staff, committee members, and administrators at PCH.
• Education provided during this DNP project allowed nurses to improve their skills when assessing for suspected UTI in elderly individuals.
• Completion of at least 500 hours of clinical rotations through the duration of the DNP program.