IMPLEMENTING A NURSE-LED URINARY TRACT INFECTION …

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

NURSE-LED UTI ALGORITHM IN LONG-TERM CARE

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Acknowledgments

I would like to thank my committee for their support throughout the process of planning,

implementing, and completing this project. Thank you for teaching me and allowing me to learn

from your expertise and expansive knowledge of this amazing field.

I would like to thank Palolo Chinese Home and all its staff for allowing me to complete

my project at their facility. It was a new and exciting experience to step into the role of an

educator even for a few hours each week to help improve resident care.

To my loving support system—my fiancé, parents, and sister—we made it through! The

last four years of your endless support and encouragement were exactly what I needed during

this program. Your constant reminders that there is purpose through the struggles and triumphs

were all worth it for the glory of our amazing God!


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Abstract

Background: Long-term care facilities are high-risk settings for the passage of antibiotic-

resistant infections between residents living in a shared space. It is especially important to assess

for infections accurately and prescribe antibiotics only when indicated in order to combat the

growing problem of antibiotic resistance in the United States.

Purpose and Objectives: This evidence-based quality improvement project implemented a two-

fold intervention in a long-term care setting in Honolulu, Hawaii. Providing education and an

algorithm were used to streamline and focus nursing assessments according to published

guidelines. The goal was to improve nursing assessment of suspected urinary tract infections

(UTI) and decrease orders for urinalysis, a common diagnostic tool to test for bacteria in urine.

Methods: A total of 20 registered nurses (RNs) and 10 certified nursing assistants participated in

the educational training sessions. Likert-scale surveys were administered to RNs after each

educational training session and at midpoint of the implementation period in order to assess

effectiveness of the training. Urinalysis orders were monitored as a measure of assessing

effectiveness and use of the algorithm by nurses.

Results: It was found that there was a 31.5% decrease in orders for urinalysis between the pre-

and post-implementation periods. While the UTI algorithm was not used by RNs, the education

provided by the DNP student may have contributed to the positive change.

Conclusion: Sustainability of the UTI algorithm was poor due to the difficulty in incorporating

more tasks and assessments for an already-busy nursing routine. However, the Likert-scale

surveys showed positive results regarding benefits of the educational training sessions. This

project shows promise for relying on the large nursing workforce in order to influence the type

and course of treatment for suspected infections.


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Table of Contents

ACKNOWLEDGMENTS .......................................................................................................... II

ABSTRACT ............................................................................................................................. III

LIST OF TABLES .................................................................................................................. VII

LIST OF FIGURES ............................................................................................................... VIII

LIST OF ABBREVIATIONS .................................................................................................. IX

IMPLEMENTING A NURSE-LED URINARY TRACT INFECTION ALGORITHM IN

LONG-TERM CARE.................................................................................................................. 1

INTRODUCTION ...................................................................................................................... 1

DESCRIPTION OF THE PROBLEM ......................................................................................... 1

REVIEW OF LITERATURE ...................................................................................................... 2

LITERATURE SEARCH STRATEGY AND CRITIQUE ....................................................................... 2

GRADING OF EVIDENCE ............................................................................................................ 3

LITERATURE SYNTHESIS ........................................................................................................... 3

Inappropriate antibiotic use for UTIs .................................................................................. 3

Assessing urinary tract infection (UTI) versus asymptomatic bacteriuria (ASB) .................. 4

Antibiotic stewardship programs (ASPs) ............................................................................. 4

QUALITY, QUANTITY, AND CONSISTENCY OF EVIDENCE ............................................................ 4

LIMITATIONS DISCUSSED IN LITERATURE.................................................................................. 5

INTERVENTION ....................................................................................................................... 6

CONCEPTUAL FRAMEWORK ................................................................................................ 6

PICO QUESTION/STATEMENT OF PROBLEM...................................................................... 7

PURPOSE, PROJECT GOALS, AND AIMS .............................................................................. 8


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METHODS AND PROCEDURES.............................................................................................. 8

PROJECT DESIGN ...................................................................................................................... 8

Setting ................................................................................................................................. 8

Sample ................................................................................................................................ 8

HUMAN SUBJECTS CONSIDERATION .......................................................................................... 9

PROCEDURES ........................................................................................................................... 9

Measurements ..................................................................................................................... 9

Data collection .................................................................................................................. 10

Data analysis .................................................................................................................... 11

RESULTS AND EVALUATION ............................................................................................. 11

PHASE I–EDUCATIONAL TRAINING ......................................................................................... 11

PHASE II–UTI ALGORITHM .................................................................................................... 12

DISCUSSION ........................................................................................................................... 15

FACILITATORS OF PROJECT IMPLEMENTATION ........................................................................ 16

BARRIERS AND LIMITATIONS .................................................................................................. 17

IMPLICATIONS FOR SUSTAINABILITY AND FUTURE PRACTICE................................................... 18

CONCLUSION ......................................................................................................................... 19

REFERENCES ......................................................................................................................... 20

APPENDIX A ........................................................................................................................... 24

APPENDIX B ........................................................................................................................... 25

APPENDIX C ........................................................................................................................... 29

APPENDIX D ........................................................................................................................... 38

APPENDIX E ........................................................................................................................... 39


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APPENDIX F ........................................................................................................................... 40

APPENDIX G ........................................................................................................................... 41

APPENDIX H ........................................................................................................................... 42

APPENDIX I ............................................................................................................................ 43

APPENDIX J ............................................................................................................................ 44

APPENDIX K ........................................................................................................................... 46

APPENDIX L ........................................................................................................................... 48


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List of Tables

Table 1. “Educational Training Feedback” Survey Results ....................................................... 12

Table 2. “Algorithm Feedback” Survey Results......................................................................... 15

Table 3. Definitions of ASB versus UTI .................................................................................... 24

Table 4. Literature Matrix Table................................................................................................ 29

Table 5. Evidence Grading Tool ................................................................................................ 38

Table 6. UTI Algorithm Communication Log Between RNs and Health Care Providers ............ 43

Table 7. Logic Model ................................................................................................................ 44

Table 8. Gantt Chart .................................................................................................................. 46

Table 9. DNP Essential Criteria ................................................................................................. 48


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List of Figures

Figure 1. Number of UAs ordered per month in the pre-implementation period, from October

2018 to October 2019. ............................................................................................................... 13

Figure 2. Number of UAs ordered per month during the implementation period, from November

1, 2019 to December 31, 2019. .................................................................................................. 14

Figure 3. UTI Algorithm ........................................................................................................... 28

Figure 4. Permission from Denise Cooper, DNP, RN, ANP-BC ................................................ 39

Figure 5. Conceptual Framework: Iowa Model .......................................................................... 40

Figure 6. Educational Training Feedback .................................................................................. 41

Figure 7. Algorithm Feedback ................................................................................................... 42


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List of Abbreviations

ASB Asymptomatic bacteriuria

ASP Antibiotic stewardship programs

CNA(s) Certified nurse aides

DLS Diagnostic Lab Services

DON Director of Nursing

DNP Doctor of Nursing Practice

ICF Long-term/intermediate level of care

LTCF Long-term care facility

PCH Palolo Chinese Home

RN(s) Registered nurses

SNF Short-term rehabilitation level of care

UA(s) Urinalysis

UTI(s) Urinary tract infection(s)


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Implementing a Nurse-Led Urinary Tract Infection Algorithm in Long-Term Care

Introduction

Antibiotic resistance is a growing public health concern. A Centers for Disease Control

and Prevention (CDC) report entitled Antibiotic Resistance Threats in the United States, 2013

stated that each year in the United States, at least 2 million people contract an antibiotic-resistant

infection and at least 23,000 people die as a result. With increasing antibiotic resistance, “…the

loss of effective antibiotic treatments will not only cripple the ability to fight routine infectious

diseases but will also undermine treatment of infectious complications in patients with other

diseases” (CDC, 2013, p. 24). The long-term care facility (LTCF) setting houses a particularly

vulnerable population of older adults with decreased immunity toward infections. Nurses are

first-line staff interacting with residents and are in a unique position to provide accurate

assessments and recommendations to health care providers for appropriate treatment of

infections. For the purposes of this DNP project, nurses assessed urinary tract infections (UTIs)

in residents without indwelling catheters and without recurrent UTI. This paper outlines the plan

to implement a UTI protocol pilot program that includes an educational intervention and

algorithm in the LTCF setting based on the most recently published evidence.

Description of the Problem

Antibiotics are one of the most commonly prescribed drug classes in the LTCF setting

(Crnich, Jump, Trautner, Sloane, & Mody, 2015), with 47% to 79% of residents receiving at

least one course of antibiotics annually (Buul et al., 2015). Antibiotic-resistant infections have

also been associated with increased morbidity, mortality, and healthcare costs (Buul et al., 2015;

Crnich et al., 2015; Feldstein, Sloane, & Feltner, 2018; McElligott, Welham, Pop-Vicas, Taylor,

& Crnich, 2017; Nace, Drinka, & Crnich, 2014; Pettersson, Vernby, Molstad, & Lundborg,


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2011). The trigger for this project was an evidence-based practice concern regarding assessment

of suspected UTI at Palolo Chinese Home (PCH) in Honolulu, Hawaii. While this LTCF serves

short-term rehabilitation (SNF), long-term/intermediate care (ICF), and hospice level of care

residents, all residents are at increased risk of developing a multi-drug resistant organism

infection (Feldstein et al., 2018) for which appropriate antibiotic treatment may not have always

occurred.

At PCH, urinalysis (UA) testing may be completed for residents with suspected UTI but

must meet minimum criteria prior to requesting the health care provider’s order for UA.

Minimum criteria include at least three new or worsening symptoms of UTI as outlined in

Appendix A or Box 2 of Appendix B. Between October 2018 to October 2019, of 76 total UAs

ordered, about 49% of UAs were negative with an average of three diagnosed UTIs per month,

showing that there is room for improvement in testing urine for UTI only when indicated. It is

important to consider other sources of infection before UTI such as respiratory or skin infections.

It is also imperative to rule out environmental factors that may be contributing to confusion, a

common complaint that is nonspecific for UTI (Detweiler, Mayers, & Fletcher, 2015). In

general, over-testing residents without meeting minimum criteria can result in unnecessary costs

and discomfort especially to those requiring straight catheterization.

Review of Literature

Literature Search Strategy and Critique

A literature search was conducted using PubMed and CINAHL databases. Search terms

included “urinary tract infections,” “adults,” “elderly,” “geriatric,” “nursing homes,” “long-term

care facilities,” “prevention,” “diagnosis,” “management,” “antibiotic stewardship programs,”

and “antibiotic prescription.” Initial searches of various term combinations were used and nested


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together using “AND” and “OR” Boolean phrases yielding as many as 1,500 articles. Results

were filtered based on age 65+ and limited to publication dates between 2010 and 2019, reducing

results to about 30 articles. A review of abstracts and titles reduced the number of relevant

articles to 18 for critique in this literature synthesis (Appendix C).

Grading of Evidence

Articles were graded using the Johns Hopkins Nursing Evidence-Based Practice toolkit

(LibGuides, 2019) provided in Appendix D. This grading tool has a two-part system which

includes Quality Guides and a Levels of Evidence scale. However, this review focused on using

the five levels of evidence seen in Appendix D to grade the methodological quality of each

article’s “…design, validity, and applicability to patient care” (LibGuides, 2019).

Literature Synthesis

Inappropriate antibiotic use for UTIs. In a search of general terms including “UTIs”

and “antibiotic resistance,” many guidelines and articles were found with a similar theme:

antibiotic resistance is increasing with inappropriate treatment of UTIs (Cooper, Mcfarland,

Petrilli, & Shells, 2018; Crnich et al., 2015; Feldstein et al., 2018; Genao & Buhr, 2012; Rowe &

Juthani-Mehta, 2014). In prospective studies it was found that without antibiotic criteria, many

residents in LTCFs received antibiotic prescriptions inappropriately (Buul et al., 2015; Gee et al.,

2018; Lemoine et al., 2018; Olsho et al., 2013; Pulia et al., 2018). Findings of a review by Nace,

et al. (2014) stated that clinicians rarely evaluated residents in the LTCF setting personally

before diagnosing and treating UTI with antibiotics “…citing concerns over missing an infection,

delaying treatment, or not meeting a resident’s or family’s expectations” (p. 136). In doing this,

the benefit of immediate antibiotic treatment became overvalued and the strong likelihood of

negative outcomes became highly undervalued (Nace et al., 2014).


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Assessing urinary tract infection (UTI) versus asymptomatic bacteriuria (ASB). In

selected guidelines it was identified that determining the difference between UTIs and

asymptomatic bacteriuria (ASB) can be difficult (Genao & Buhr, 2012; Rowe & Juthani-Mehta,

2014) but necessary to accurately diagnose UTI. The guidelines provide information on

appropriate diagnosis and successive treatment of UTIs—and not ASBs—as this topic is a

growing concern for the elderly, especially those residing in LTCFs, which are recognized as

reservoirs of multi-drug resistant bacteria (Olsho et al., 2013). Refer to Appendix A outlining the

difference in definition between UTI and ASB.

Antibiotic stewardship programs. Multiple studies showed successful implementation

of antibiotic stewardship programs (ASPs) to promote appropriate diagnosis and treatment of

UTIs in the elderly population living in LTCFs (Cooper et al., 2018; Crnich et al., 2015;

Feldstein et al., 2018; Fleet et al., 2014; Fleming, Browne, & Byrne, 2013; McMaughan et al.,

2016; Pettersson et al., 2011). Though there was no single definition of ASPs found in the

literature, multiple modalities for assessing and treating UTI have been studied and included

such interventions as algorithms, educational strategies, and change champions. It was important

that each implemented ASP be individualized to the facility (McElligott et al., 2017), which may

have contributed to the inconsistency of results in publication. Overall, diagnostic accuracy and

the resulting reduction in inappropriate antibiotic treatments was a major outcome found by

multiple studies assessing different methods of ASPs (Cooper et al., 2018; Feldstein et al., 2018;

McMaughan et al., 2016).

Quality, Quantity, and Consistency of Evidence

The articles chosen for this literature review represent a wide range of evidence from

clinical practice guidelines, prospective cohort studies, randomized controlled trials, and


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systematic reviews. All studies provided evidence on the importance of appropriate antibiotic

treatment for suspected UTI. Through various methods including combinations of educational

interventions, algorithms, and diagnostic criteria, many ways to achieve the goal of decreasing

unnecessary antibiotic prescription were found. The literature supported positive results when

using algorithms (Cooper et al., 2018; Crnich et al., 2015; Fleet et al., 2014; McMaughan et al.,

2016) and showed stronger evidence when education was combined with algorithm tools (Crnich

et al,. 2015; Cooper et al., 2018). Overall, there is no current consensus on the best method of

antibiotic stewardship but all have shown some degree of success in achieving the goal of

decreasing unnecessary antibiotic prescription for UTI.

Limitations in Literature

While multiple studies have been published since 2013, a consistent limitation was the

small number of LTCFs that were included in each study. Most articles were categorized as

Level III prospective studies and Level II systematic reviews, which are susceptible to selection

bias and may not have been up to date, having included articles outside of the publication date

parameters for this project.

A major limitation of ASPs has been the lack of continued use of the intervention in

LTCF settings. According to McMaughan et al. (2016), the algorithm intervention had not been

embedded in the daily routine of nursing staff due to busyness of the nursing unit. Fleming et al.

(2013), in their review of randomized controlled trials, concluded that the interventions including

local consensus procedures, educational strategies and locally developed guidelines may have

improved inappropriate antibiotic prescription rates for UTI but the quality of evidence was low.


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Intervention

After reviewing the literature, an algorithm assessment tool (Appendix B) was chosen for

use at PCH due to the fast-paced work setting with limited health care provider availability and

the need for immediate information regarding steps to take if UTI is suspected. The UTI

algorithm was created by the DNP student using updated criteria (Stone, et al., 2012) and was

adapted from Cooper et al. (2018) and Nace et al. (2014). The signs and symptoms section of the

algorithm was adapted from the Cooper Urinary Tract Infection Program (Cooper et al., 2018)

after receiving permission from the author (Appendix E). Observation for instances when

minimum criteria were not met was adapted from Nace et al. (2014). Consensus based criteria

published by Stone et al. (2012) provided the basis for the steps outlined in the algorithm

(Appendix B) for ordering UA and antibiotics.

The algorithm was available as a hard copy and included steps that allowed nurses to

create electronic reminders for successive shifts, document appropriately, and communicate with

health care providers appropriately. By following steps in the algorithm, nurses had the

opportunity to assess suspected UTI and provide a strong recommendation for either observation

or diagnostic testing to the health care providers. Appropriate nursing assessment could

potentially reduce rates of UA orders (Crnich et al., 2015) and result in a decreased rate of

antibiotic orders in a busy setting where health care providers are not consistently present to

perform immediate assessments (Nace et al., 2014).

Conceptual Framework

The Iowa Model found in Appendix F (Buckwalter et al., 2017) was the basis for this

quality improvement project which focused on ensuring practice changes were based on most

recently-published evidence while also being tailored to individual institutions. In the beginning


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of this seven-step process, triggers in practice were identified. The issue was deemed a priority

for the organization and a team was assembled to conduct a literature search of current evidence.

Based on sufficient evidence, a plan to pilot the practice change was developed by the team.

Once implemented, the team assessed the appropriateness of adopting the change into practice

and made adjustments based on feedback from those affected by the change. The final step in

this process was to disseminate results and ensure continuity of the practice change.

This project focused on decreasing unnecessary orders for UA, which was identified as a

trigger for quality improvement at PCH. While antibiotic prescription rates were relatively low at

PCH (about three per month), the rate negative UA results (49%) for suspected UTI were

deemed a priority to reduce. During a thirteen-month period prior to implementation of the

intervention, an average of five UAs were ordered per month and the team decided on a goal of

reducing the average number of UAs ordered per month by half. The DNP student conducted an

extensive literature review. A team consisting of the DNP student, Director of Nursing (DON),

and Chief Executive Officer (CEO) of PCH was formed to create a plan to pilot the use of an

algorithm and educational intervention to address this issue and improve antibiotic stewardship

practices. During the process of implementation, meetings among team members were held

periodically to discuss effectiveness of the intervention and addressed any adjustments that

needed to be made based on staff feedback. Continuity of practice change was monitored by the

DON and the DNP student.

PICO Question/Statement of Problem

In residents greater than 65 years old living at PCH (population), how did the use of an

algorithm for assessment of UTI (intervention) affect the number of UAs ordered (outcome)

when compared to UTI assessment and treatment practices used in the pre-implementation


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period (comparison)? Results were compared to practices in the pre-implementation period

which did not include the use of an algorithm and requests for UA orders were based on

individual nursing judgment.

Purpose, Project Goals, and Aims

The purpose of this evidence-based quality improvement project was to decrease

unnecessary UA orders for suspected UTI and evaluate processes for implementing practice

change using a two-fold intervention of educational training sessions coupled with a UTI

algorithm for adults greater than 65 years old at PCH. Project aims were to: (a) provide

educational training on using the UTI assessment algorithm to greater than 90% of registered

nurses (RNs) and greater than 60% of certified nursing assistants (CNAs) by November 8, 2019;

(b) assess ease of use of the algorithm and RNs’ satisfaction with the education process; (c)

implement the UTI algorithm greater than 60% of the time beginning November 1, 2019 for

residents under SNF or ICF care exhibiting symptoms of UTI; and (d) identify if at least a 50%

decrease in UA orders occurred after implementation.

Methods and Procedures

Project Design

Setting. PCH is a 113-bed facility in Honolulu, Hawaii serving adult and geriatric

residents under SNF, ICF or hospice care. This long-term care facility is staffed with 30

registered nurses (RNs) and 60 certified nurse aides (CNAs), hired by PCH and outside agencies.

Sample. Staff hired by PCH were included while those hired by agency working at PCH

were excluded due to limited availability of RNs and CNAs not hired by PCH. The number of

participants was 20 RNs and 10 CNAs. RNs and CNAs who were able to attend educational

training sessions were included. CNAs were included in this project as they were crucial to the


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nursing team as individuals who provided incontinence care and toileted residents who were

continent. While CNAs do not conduct assessments, they should be aware of urinary changes or

abnormalities and report them promptly to nurses who can further assess.

Human Subjects Consideration

The DNP student has completed the Collaborative Institutional Training Initiative (CITI)

Training for research ethics and compliance, and Health Insurance Portability and Accountability

Act (HIPAA) Training on patient privacy protections. This DNP project involved making

judgments about a program to improve or further develop program effectiveness and inform

decisions about future programming within an organization (University of Hawaii Human

Studies program, personal communication, August 2, 2018). All these tasks were related to

quality improvement and did not produce generalizable knowledge. Thus, this project did not

require IRB application and review.

Procedures

Measurements. Measurement tools included two Likert-scale surveys (Appendices G

and H) created by the DNP student to evaluate RNs’ perception of the education process and

their comfort with using the algorithm after receiving training. Counting the number of RNs and

CNAs in attendance at each educational training session showed how many staff received

training. Additionally, a communication log found in Appendix I documenting resident name,

room, symptoms, start and end date of monitoring, and result (either discontinuation of

monitoring or a new prescription for antibiotics) was developed by the DNP student and placed

in a communication book for health care providers. The number of UA orders was derived from

Diagnostic Lab Services (DLS) reports with permission from the DON.


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Data collection. In the first phase focused on providing education, from October 18 to

November 8, 2019, engaging staff in the new algorithm included flyers and word-of-mouth to

disseminate information about educational training sessions. Four days of in-person educational

training sessions were provided at change-of-shift throughout one month in order to reach as

many staff as possible from all shifts (day, evening, and night) and ensure continuity of practice

change. The staff meeting room was utilized to present interactive case studies, information on

the timeline and process, and the importance of antibiotic stewardship. Staff had the opportunity

to ask questions throughout the meeting. RNs learned how to use the algorithm seen in Appendix

B. A more detailed list of activities, inputs, and outputs can be seen in the logic model in

Appendix J. Upon completion of the educational training sessions, RNs were asked to complete a

Likert-scale survey (Appendix G) assessing their satisfaction with the educational process and

their comfort with implementing the algorithm.

In the second phase of implementation, from November 1, 2019 to December 31, 2019,

another Likert-scale survey (Appendix H) was administered to RNs at midpoint of the

implementation period assessing ease of use of the algorithm. Comfort with using the algorithm

was included in order to evaluate overall change of RNs’ attitude over time (increased,

decreased, or no change). By providing anonymous, non-matched pre- and post-intervention

surveys, RNs were able to freely share their thoughts regarding the practice change.

Evaluation of change occurred each month during the implementation phase by

reviewing the communication log and DLS reports. Number of algorithm starts and number of

UAs ordered were counted. For a detailed outline of the timeline including tasks and

responsibilities see Appendix K.


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Data analysis. Number of algorithm starts and number of UA orders were monitored

monthly during the implementation period via communication logs, DLS reports, and chart

review. Counting algorithm starts and comparing to the number of UAs ordered provided

evidence on how often orders were being made with algorithm use or the lack thereof. Trend

analysis was used to determine whether there was a change (increase, decrease, or no change) in

UAs ordered for suspected UTI and usage of algorithm in the implementation period. Likert-

scale survey results for process evaluation questions were averaged and assessed to determine

any changes in RN comfort with algorithm usage (increase, decrease, or no change) over time.

Results and Evaluation

Phase I–Educational Training

In this phase, a total of 20 RNs and 10 CNAs were reached throughout the four

educational training sessions. Out of 30 total RNs hired by PCH, about 66% of RNs were

reached. The objective of educating at least 90% of RNs employed by PCH was therefore not

met. The percentage of CNAs reached by the educational training sessions was about 16%

considering a staff of 60, a rate that does not meet the objective of educating at least 60% of

CNAs.

After each educational training session, RNs were given a survey to complete. The

completion rate was 100% of RNs who attended the educational training sessions. Question one

asked RNs to rate their satisfaction with the availability of educational training sessions.

Question two of the survey was not applicable to assess satisfaction with receiving notifications

via e-mail as they were not distributed due to time constraints of a changing timeline and the

time it would take to receive approval to send a mass e-mail to all staff. The third and fourth

questions asked RNs to rate their satisfaction with receiving notifications about educational


12

training sessions via flyer and word-of-mouth, respectively. The fifth and sixth questions were

both evaluations of the tools used to teach the algorithm in the educational training sessions. The

seventh question asked RNs to rate their agreement regarding knowledge of who to contact if

they had questions about the UTI algorithm. The average rating on a five-point Likert scale for

each question on the survey can be seen in Table 1 below. The eighth and final question on the

survey was an optional open-ended question requesting comments regarding any areas of

improvement or concern. The following were the responses of six of the respondents: “Nice!,”

“None,” “A++ presentation,” “You’re amazing!,” “Thank you very much! So helpful. J,” and

“None J Great!”

Table 1 “Educational Training Feedback” Survey Results

Question Number

Q1 Q2 Q3 Q4 Q5 Q6 Q7

Average Rating

4.6 - 4.7 4.55 4.8 4.8 4.9

Phase II–UTI Algorithm

The second phase of implementation allowed participants to complete their daily routines

and use the UTI algorithm as they believed to be appropriate for any residents under SNF or ICF

level of care. UA orders were requested from DLS, which provided data between November 1,

2019 to December 31, 2019. The data from the pre-implementation period (Figure 1) was

compared to data from the implementation period (Figure 2) and showed an overall decrease in

the number of UA orders after providing education to PCH staff. In the pre-implementation

period, an average of 5.8 UAs were ordered per month and only an average of three were

positive for UTI. In the post-implementation period, PCH was averaging four UA orders per

month, equating to an overall 31.5% decrease in UA orders. The objective of decreasing UA

orders by 50% in the post-implementation period was therefore not met. Interestingly, during the


13

implementation period, staff did not document use of the UTI algorithm or use of the

communication log that was readily available at each nursing unit in each of the health care

provider’s communication books. This resulted in an unmet objective of a use of the UTI

algorithm greater than 60% of the time for cases of suspected UTI.

Figure 1. Number of UAs ordered per month in the pre-implementation period, from October 2018 to October 2019.

0

2

4

6

8

10

12

Octobe

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Novem

ber

Decembe

r

Janua

ry

Februa

ryMarc

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# UAs Ordered per Month - Pre-Implementation Period


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Figure 2. Number of UAs ordered per month during the implementation period, from November 1, 2019 to December 31, 2019.

At midpoint of the implementation period, RNs who participated in educational training

sessions were given the “Algorithm Feedback” Likert-scale survey. Results for each question

were then averaged and can be seen below in Table 2. The first and second questions asked RNs

to assess their likelihood of using the UTI algorithm and if it could be incorporated in their daily

routine smoothly. The third and fourth questions asked RNs to rate their sense of satisfaction

with the process of communication with team members. The final two Likert-scale style

questions asked RNs to rate their level of comfort with using the UTI algorithm as well as their

awareness of resources for assessing suspected UTI. The final question was an optional open-

ended question regarding any areas of improvement or concern. One RN commented, “Good!”

and another commented, “More of a push from management or super-user to promote or assist

w/use.” Out of 20 RNs who attended the educational training sessions, 13 RNs completed the

follow-up survey. Seven RNs were missed due to the days the DNP student conducted follow-up

surveys not coinciding with those RNs’ scheduled work days. Since no attendance was being

01234567

November December

# UAs Ordered per Month - Implementation Period


15

tracked at educational training sessions in order to protect participants’ identities, this added to

the difficulty in reaching all RNs.

Table 2 “Algorithm Feedback” Survey Results

Question Number

Q1 Q2 Q3 Q4 Q5 Q6

Average Rating

4.5 4.4 4.1 4.2 4.3 4.5

Discussion

This pilot project conducted at PCH was focused on addressing a common problem in

long-term care facilities—that of infection prevention and control in relation to urinary tract

infections. While the rate of positive UTIs was low, there was room for improvement in nursing

assessment and the number of UA orders completed at this facility. Owing to busy routines

demanded by long-term care facilities and the lack of in-house health care providers, current

guidelines were often not utilized and proper and thorough assessment relied on individual

nursing judgment that was relayed to health care providers at a later time. The UTI algorithm

was adapted from current literature by the DNP student in order to guide nursing assessment of

suspected UTI. In this way, nurses would deliver accurate real-time assessments to health care

providers and request orders that promoted resident comfort and patient-centered care based on

published guidelines rather than relying on individual nursing judgment which varies for each

nurse.

Although nurses did not document utilization of the UTI algorithm or the communication

log, the rates of UA orders decreased drastically in the second month after nurses received the

education provided by the DNP student. While other factors such as rates of UTI could have

been lower or PCH having a low census in the last quarter of 2019, the intervention of education

can be attributed as an influence of change. The educational training sessions stressed the


16

importance of encouraging fluids for the two common abnormalities—foul or cloudy urine—

reported from nurse to nurse in an attempt to monitor for signs and symptoms of UTI. One nurse

commented that the educational training sessions helped improve her practice and she often

encouraged fluids to residents exhibiting foul or cloudy urine, both of which are not considered

positive signs of UTI and resulted in improvements in the appearance of the urine. Another nurse

commented that she used the UTI algorithm as a guideline for assessment and monitoring but did

not document use of it for residents who did not meet criteria. This same nurse also commented

that it was helpful when she needed to talk to health care providers about their residents and

clarify orders for what intervention would be necessary and what could be monitored before

ordering urinalysis.

Facilitators of Project Implementation

In the first phase of implementation, wherein educating staff about the UTI algorithm was

a central focus, PCH’s CEO, DON, and Human Resources manager helped coordinate the time

and space for conducting the educational training sessions. PCH’s CEO and DON were also

instrumental in facilitating and maintaining an ongoing discussion of proper UTI assessment and

treatment with health care providers for the facility.

In the second phase, collecting data was the most important task. Facilitators included

PCH’s Unit Clerk who periodically requested UA data from DLS. PCH’s CEO and DON also

helped monitor antibiotic orders which facilitated a more robust investigation into all new

antibiotic orders during the implementation period. The initiation of this project also allowed the

facility’s infection control nurse to review the UTI algorithm and ensure it complied with the

most current published guidelines.


17

Barriers and Limitations

A major barrier was the shifting timeline as a result of accommodating changes occurring

within PCH. This project was originally supposed to start in September 2019 but had to be

delayed by one month due to the process of switching electronic medical records systems. This

process resulted in the data collection period starting later and losing one to two extra months of

potential data had the project been started according to schedule. As a result, thirteen months of

data was collected in the pre-implementation period and only two months of data were collected

in the post-implementation period.

During phase I of the implementation period, the objective of reaching 90% or 27 RNs

was not met owing to some RNs not scheduled to work on days the educational training sessions

were available. Educational training sessions were held on the same day of each week due to

scheduling constraints and lack of availability of the training room on weekends, which were

other potential meeting days that would have been scheduled in order to reach the most staff.

Considering there were 60 CNAs employed at PCH at the time of implementation, the objective

of reaching 60% of CNA staff was not met. Many CNAs reported they would not be able to

attend educational training sessions due to family commitments after completion of their shift

and not being aware of scheduled meetings. It was also not considered a priority, as expressed by

some CNAs, to attend a meeting advertising UTI algorithms as it did not sound like a topic

relating to their duties.

The most common limitation relating to the second phase of the implementation period

was the nursing routine that prevented use of the UTI algorithm. One nurse simply stated, “I

don’t have time for that,” when discussing the busy schedule of this setting. One nurse also


18

expressed simply defaulting to provider’s orders even if she knew the resident did not meet

criteria for ordering urinalysis.

Implications for Sustainability and Future Practice

This DNP project adds to current evidence by showing there is potential for improving

nursing assessment that is reported to health care providers who are not in-house or quickly

available to assess for signs and symptoms of UTI. Health care providers base their decision to

order costly and sometimes invasive testing based on the clinical picture provided by nurses.

Thus, it is imperative nurses are equipped with appropriate and up-to-date resources to ensure

they report accurate assessments to health care providers.

One suggestion to ensure continuity of this practice change is having a “super-user” or

change champion who can assist nurses in the initial use of the algorithm until they are more

comfortable with the process. The change champion may be influential in continuing the

conversation amongst nurses and health care providers in order to further this project.

Historically, pilot projects such as this have been successful during the implementation

period but have not been sustainable after the study period. The problem is implementing a new

assessment as seamlessly as possible for nurses working in very busy LTCF settings. Perhaps in

the future, more electronic charting for nurses in LTCFs can become commonplace despite the

slow transition from paper charts to electronic charts. Ultimately, the education of nurses

regarding common infections and problems in long-term care brings hope for prevention of

infectious disease processes affecting the vulnerable elderly population. Building a better-

prepared workforce of new graduate Nurse Practitioners will promote better care for the aging

population.


19

Conclusion

Overall, this DNP project demonstrated the need for improvement of nursing assessment

for residents residing in LTCFs in order for health care providers who are not on site to prescribe

accurate interventions based on a precise clinical picture. Relying on the nursing workforce to

assess in real-time and provide accurate assessments according to guidelines is important for

promoting safety, comfort, and patient-centered care for elderly populations. Guidelines made

into algorithms help streamline the work and decrease the time it takes to assess for suspected

infections thoroughly while not completely disturbing daily routines. Combining easy-to-read

material with education is also helpful to improve nursing assessment and prevent unnecessary

testing or the prescription of unnecessary antibiotics for elderly patients who are vulnerable and

susceptible to resistant bacterial infections. This project demonstrated a decreased trend in UA

orders after education. With the availability of a UTI algorithm there is room for improvement in

sustainability even in a busy setting.

This project met the DNP Essentials of Doctoral Education for Advanced Nursing

Practice (Appendix L) by designing, implementing, and evaluating a quality improvement

project using nursing interventions to improve outcomes in health care for the elderly, a

vulnerable population (American Association of Colleges of Nursing, 2006).


20

References

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education for advance nursing practice [website]. Retrieved from

https://www.aacnnursing.org/dnp/dnp-essentials

Buckwalter, K. C., Cullen, L., Hanrahan, K., Kleiber, C., Mccarthy, A. M., Rakel, B. . . . Tucker,

S. (2017). Iowa Model of Evidence-Based Practice: Revisions and

validation. Worldviews on Evidence-Based Nursing,14(3), 175-182.

doi:10.1111/wvn.12223

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

Centers for Disease Control and Prevention. (2013). Antibiotic resistance threats in the United

States, 2013. Retrieved from https://www.cdc.gov/drugresistance/threat-report-

2013/pdf/ar-threats-2013-508.pdf

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

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


21

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

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.

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

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

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

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 Directors Association,20(4), 33–38.

LibGuides: Evidence Based Practice Toolkit for Nursing: Levels of Evidence. (2019, April 2).

Retrieved from https://libguides.ohsu.edu/ebptoolkit/levelsofevidence


22

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

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

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

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

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

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


23

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

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

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


24

Appendix A

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.


25

Appendix B


26


27


28

Figure 3. UTI Algorithm


29

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


30

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.



31

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


32

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.


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;



33

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.



34

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.


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


35

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.


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.



36

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


37

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.


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.



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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


40

Appendix F

Figure 5. Conceptual Framework: Iowa Model. Used with permission from the University of Iowa Hospitals and Clinics, copyright 2015.


41

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).


42

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


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Appendix J

Table 7 Logic Model

Objectives Activities Inputs/Resources Outputs Outcomes Indicator/Data Source

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


46

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


47

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.

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