SASKPIC April 16, 2014

Transcription

1 SASKPIC April 16,

2 Why do we need a Continuing Care guideline? Most current guidelines and tools for UTI prevention focus on acute care Age related changes to the urinary tract predispose older adults to urinary tract colonization and to the development of UTIs Research tells us 22 89% of antibiotic prescriptions in LTC are inappropriate Nicolle, LE et al. Infect Control Hops Epidemiol 1996; Loeb, M et al. Infect Control Hosp Epidemiolo 2001: UTI diagnosis often difficult due to: cognitive changes inability to communicate symptoms non specific symptoms or chronic genitourinary symptom 2

3 Goals of the Guideline & Education Improve resident outcomes through practices that prevent or reduce the incidence of UTIs Increase the accuracy of clinical diagnosis for UTIs in Continuing Care settings Optimize the use of testing and laboratory services Reduce inappropriate prescribing of antibiotics for residents with asymptomatic bacteriuria 3

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6 How do we know when someone really has a UTI? When should it be treated? How do you get a proper specimen? What do we do when families insist on antibiotics because Mum is behaving differently today and she is always like this when she has a UTI? How can we reduce the number of UTIs in our LTC homes? 6

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8 Urine retention or incontinence Intermittent or indwelling catheters Dehydration Immunosuppression Diabetes Age related changes to the body easier access to bacteria and urinary tract colonization Over screening of UTIs without real symptoms 8

9 Urine is sterile, therefore any bacteria in the urine is bad and requires treatment! Cloudy or smelly urine is always a sign of infection! In older residents, non specific symptoms like falls, mental or functional changes are a sign of a urinary tract infection! After treatment we should retest the urine to make sure the antibiotics worked! 9

10 As we age, it is very common for bacteria to colonize our bladder without symptoms means the resident has asymptomatic bacteriuria; which means colonization exists not infection, so treatment is not required. A 10

11 may be caused by asymptomatic bacteriuria. Other causes can include dehydration, certain medications, diet or poor hygiene. is a nonspecific symptom and may be due to dehydration, constipation, pain, pneumonia or other reasons that need to be evaluated and monitored. is not recommended unless symptoms persist or reoccur. A A 11

12 Population Prevalence Long term care facility, age 70 Women 25 50% Men 15 40% Community, age 70 Women 11 16% Men 4 19% Chronic indwelling catheters (anywhere) 100% 12

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14 Acute dysuria alone or pain, swelling or tenderness of the testes, epididymis or prostate Fever or leukocytosis plus one new or increased urinary symptom such as: Urgency Frequency New or increased incontinence Costovertebral angle pain or tenderness Suprapubic pain Gross hematuria At least 2 new or increased urinary symptoms 14

15 Fever or rigors(shaking chills) New onset hypotension with no other known or possible infection site Leukocytosis with no other signs of infection plus either an acute change in mental status or functional decline Suprapubic pain or costoverterbral pain or tenderness Purulent discharge form catheter site Pain, swelling or tenderness of testes, epididymis or prostate 15

16 Ensure good peri care is done before collection Obtain a clean catch or midstream to avoid contamination of specimen OR in and out catheterization freshly applied condom catheter for men Check your regional lab manual for details 16

17 Short term indwelling catheters Collect from specifically designed sampling port and not from drainage bag Indwelling catheters greater than 14 days remove existing catheter collect urine from a freshly placed catheter 17

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19 At room temperature bacteria will start multiplying after 1 hour Refrigerate at 4⁰C if specimen is not sent within 30 minutes of collection Transfer to lab by cooler bag Specimen delivery should occur within 24 hours of collection 19

20 Residents may not be able to verbalize how they are feeling Residents may show a decline in function or mental status making assessment more difficult Non specific symptoms are often misinterpreted as indicating a UTI Typical signs and symptoms are required for a correct diagnosis of UTI 20

21 Push fluids for 24 hours If on fluid restriction, monitor fluid intake Monitor vital signs & symptoms for 72 hours for change or progression of symptoms Review symptoms for alternative diagnosis: Respiratory, GI, skin/soft tissue infection If change in mental status review other causes: Constipation, pain, dehydration, urinary retention Medication or dose change, environmental triggers 21

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23 Promote increased fluid intake and a variety of fluids through fluid rounds, happy hours, tea times and especially in social settings Individually monitor those on fluid restrictions and thickened fluids Assess for cultural preferences, hot or cold fluid preferences 23

24 Encourage regular toileting with privacy if possible Schedule toileting assist or reminders q 2 3 hours when awake Prevent constipation and fecal impaction Maximize function and mobility through ambulation, transfers and therapies 24

25 Ensure the perineal area is clean and dry Wash and wipe from front to back Wash with warm water and a mild or neutral soap. Pat dry Avoid bubble baths scented wipes Change incontinence pads and briefs frequently 25

26 UTIs are the most common bacterial infection in LTC Prevention of UTIs should be our daily work Many LTC residents have bacteria in their urine (asymptomatic bacteria) Diagnosis of UTI depends on clinical signs and symptoms of infection plus C&S not dipsticks and non specific changes Giving antibiotics for the right or wrong reason is not without risk: 26

27 No symptoms of UTI Do not test urine Do not treat even if a routine urine test is positive but no symptoms are present. Weakness, delirium or fever without a focus Individualize care Be mindful of the prevalence of asymptomatic bacteriuria Seek other causes Specific UTI symptoms Test or treat as usual 27

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33 CA UTIs: Result in increased health care costs Hospital admissions, more medications Contribute to poor resident outcomes illness, death BUT quality improvement strategies such as: Reducing catheter use and duration Using aseptic technique to insert catheters Maintaining a closed drainage system Having policies and procedures in place to promote these practices Can help to prevent CA UTIs in our residents 33

34 Urinary Meatus 34

35 Role of Urinary Catheters in UTI Development 35

36 Start to develop on the surfaces of catheters and catheter bags after a few days Are resistant to antibiotics and the body s defenses Scanning electron micrograph of S. aureus bacteria on the luminal surface of an indwelling catheter with interwoven complex matrix of extracellular polymeric substances known as a biofilm Photograph from CDC Public Health Image Library: 36

37 A collection of practices that can be used to reduce the risk of harm or infection for residents undergoing a particular treatment or have a medical device in place Several interventions bundled or combined together can significantly improve resident care outcomes. SHEA-IDSA: Society for Healthcare Epidemiology of America/Infectious Disease Society of America 37

38 Hand Hygiene Avoid unnecessary urinary catheters Insert urinary catheters using aseptic technique Maintain urinary catheters based on recommended guidelines Policies and procedures in place for catheter care 38

39 1. Catheter Use 4. P & P Hand Hygiene 2. Catheter Insertion 3. Catheter Maintenance 39

40 Studies: 21% of catheters not indicated at insertion 41 58% in place found to be unnecessary Catheters Are uncomfortable for patients Decrease mobility, which may impair recovery and contribute to other complications (e.g. pressure ulcers, Saint S, Lipsky deep BA. Preventing vein catheter-related thrombosis) bacteriuria: Should we? Can we? How? Arch Intern Med Apr 26;159(8): Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995;155:

41 Urinary tract obstruction Neurogenic bladder with retention Open stage 3 or 4 pressure ulcers Prolonged immobilization (e.g. unstable spinal or pelvic fractures) Comfort or Palliative Care (if requested) Resident/caregiver choice (with education) 41

42 Intermittent catheters External condom catheters Bladder scanner or ultrasound (if available) Review the need for chronic indwelling catheter on a regular basis Incontinence management products and reminders 42

43 Meatal cleaning and disinfection Sterile equipment, specifically using: gloves, a drape, and sponges; sterile or antiseptic solution for cleaning the urinary meatus Single use packet of sterile lubricant jelly for insertion Use smallest catheter size possible 43

44 Allow urine to drain before inflating the balloon Attach sterile drainage bag and secure below bladder but not in contact with floor Properly secure the catheter after insertion to prevent movement and injury Document information about catheter insertion in resident record 44

45 Maintain unobstructed flow of urine Tubing and catheter are free of kinks Resident is not lying on catheter or tubing Drainage bag is below level of bladder Drainage bag is not touching the floor 45

46 Maintain a sterile, continuous closed drainage system Catheter and drainage tubes should never be disconnected unless for a good clinical reason Consider systems with pre connected, sealed cathetertubing junctions 46

47 For residents who prefer leg bags A linkage system connecting a larger bag for night use is recommended to maintain a closed system 47

48 Empty drainage bag regularly Use separate clean container for each resident No contact between drain and collection container Good pericare at least once daily plus after bowel contamination. 48

49 Do not perform bladder or catheter irrigation unless medically necessary Do not replace catheters routinely if there is no evidence of obstruction or infection Do not send a urine for C & S unless there are symptoms Repeat urine cultures after antibiotics are not required unless symptoms persist 49

50 Recommended catheter use, discontinuation, insertion and management techniques and alternative to catheters. o Staff should receive education on these Routine assessment and documentation re: need for an indwelling catheter Only HCWs trained in aseptic technique should be allowed to insert urinary catheters. Checklist for routine maintenance of catheters 50

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54 Guidelines for the Prevention and Treatment of Urinary Tract Infections in Continuing Care Saskatchewan Infection Prevention Program March 2014

55 Table of Contents Final Tools and Guideline on Ministry of Health Website ABCs for Diagnosing UTIs in Continuing Care Settings Power Points without Audio Introduction and Review of the Guideline for the Prevention and Treatment of UTIs in Continuing Care Settings Antibiotic Information Brochure for client/residents and their care givers Urinary Health Part 1: The Basics of UTI Identification and Prevention Guidelines for the Prevention and Treatment of UTIs in Continuing Care Settings Treating Asymptomatic Bacteriuria Urinary Health Part 2: Strategies to Reduce Cather Associated Urinary Tract Infections (CA-UTIs) UTIs and Asymptomatic Bacturiuria Power Points with Audio Introduction and Review of the Guideline for the Prevention and Treatment of UTIs in Continuing Care Settings Urinary Health Part 1: The Basics of UTI Identification and Prevention Urinary Health Part 2: Strategies to Reduce Cather Associated Urinary Tract Infections (CA-UTIs) Tools in Progress Basics of Urinary Health (companion guide to Part 1 ppt.) in both PDF and Microsoft Publisher Strategies to Reduce CA-UTI (companion Guide to Part 2 pp.) in both PDF and Microsoft Publisher Sample Urinary Catheter Checklist in both PDF and Microsoft Word

56 Saskatchewan Infection Prevention and Control Program Thank you for your time today If you have questions, concerns or This information based on the Guidelines for the Prevention and Treatment of Urinary Tract Infections in Continuing Care Settings along with the tools present today can be viewed at: 56