UTIs in the Nursing Home: Systems for Prevention ...sdfmc.org/.../Files/2804/QIOWebinar_UTI_Systems_2013_07_18_final.pdf · Systems for Prevention, Assessment and Treatment Jeri Lundgren,

©Pathway Health 2013

UTIs in the Nursing Home: Systems for Prevention,

Assessment and Treatment

Jeri Lundgren, RN, BSN, PHN, CWS, CWCN

Director of Consulting Services, Pathway Health


• Change Package

– Improve care for nursing home residents

– Instill quality and performance improvement practices

– Eliminate Healthcare Acquired Conditions (HACs)

– Improve Resident Satisfaction

National Nursing Home Quality Care Collaborative


• Change strategies can be utilized with any system that impacts quality

– There are 7 Strategies 1. Lead with a sense of purpose

2. Recruit and retain quality staff

3. Connect with residents in a celebration of their lives

4. Nourish teamwork and communication

5. Be a continuous learning organization

6. Provide exceptional compassionate clinical care that treats the whole person

7. Construct solid business practices that support your purpose

System Change


• QAPI

– Quality Assurance

– Performance Improvement

QAPI


• Quality Assurance (F520 QA&A, Quality assessment & assurance)

– Identifies and corrects quality issues

– Retrospective

– Focus on outliers or individuals

– Efforts end once achieved

– DON, Physician and 3 staff members

– Meet quarterly

QAPI


• Performance Improvement

– Proactive approach

– Efforts are on-going

– Focus on system changes

– Plan involves input from staff representing all roles and disciplines within the organization

– Meet at more frequent intervals

QAPI


Assessing Systems • QAPI (Quality Assurance

Performance Improvement)

– Systematic

– Comprehensive

– Data-driven

– Proactive approach

QAPI

QAPI

System Changes


Assessing Systems SYSTEMATIC - ON-GOING - CHANGE

Change Package/QAPI


• Today’s Quality System Focus:

Urinary Tract Infections (UTI)

System Change


• Infections are a significant source of morbidity and mortality for nursing home residents and account for up to half of all nursing home resident transfers to hospitals.

– Infections result in an estimated 150,000 to 200,000 hospital admissions per year at an estimated cost of $673 million to $2 billion annually.

– When a nursing home resident is hospitalized with a primary diagnosis of infection, the death rate can reach as high as 40 percent.

(CMS SOM Appendix PP)

UTI Rates


• It is estimated that an average of 1.6 to 3.8 infections per resident occur annually in nursing homes

– Urinary tract, respiratory (e.g., pneumonia and bronchitis), and skin and soft tissue infections (e.g., pressure ulcers) represent the most common endemic infections in residents of nursing homes (Nicolle 1996)

– The urinary tract is one of the most common sites of healthcare-associated infections, accounting for 20-30% of infections reported by long-term care facilities (CDC.gov)

UTI Rates


• The prevalence of bacteriuria in elderly institutionalized populations without indwelling catheters varies from 25% to 50% for women and 15% to 40% for men (Nicolle 2001)

• Approximately 12% of NH residents had an infection at the time of the national nursing home survey interview. The most common infections were urinary tract infection (3.0–5.2%), pneumonia (2.2–4.4%), and cellulitis (1.6–2.0%) (Dwyer et al 2013)

• National average for Quality Measure for UTI in long term stay resident is 7.1

UTI Rates


Clinical Foundation

UTI Prevention


• Urinary Tract Infection (UTI):

It is an infection in any part of the urinary system — kidneys, ureters, bladder and urethra. Most infections involve the lower urinary tract — the bladder and the urethra.

Urinary Tract Infection (UTI)


• Risk factor for nursing home residents:

– Indwelling catheters

– Incontinence of bowel and/or bladder

– Urinary overflow

– Dehydration

– Low estrogen

Risk Factors


• Risk factor for nursing home residents:

– Recent hospitalization with indwelling catheterization

– Systemic antibiotic therapy (risk for fungal infection)

– Diabetes

– Steroid Therapy

– Renal insufficiency

Risk Factors


• Assess for risk factors

– Pre-admission

– Upon admission

– Change in continence status

– With a change of condition

– With MDS assessments

Risk Factors


• Eliminate Indwelling Catheters

• Appropriate indications for a catheter:

– Urinary retention that cannot be managed with intermittent catheterization

– Comfort measures for the terminally ill

– Prevent urinary contamination to a stage III or IV wound

Prevention Interventions


• Proper management of catheters

– Use proper sterile insertion technique

– Maintain drainage bag and tubing below the bladder

– Maintain tubing in a straight line without kinks or loops

– Keep drain bags off the floor

– Empty drainage bag when one-half to two thirds full to avoid traction on the catheter tubing




– When emptying the drainage bag, the spout should not touch the collection container or the floor

– Disinfect urine collection containers after use

– Provide each resident with his or her own drainage container




– Routine perineal care is recommended, however catheter manipulation should be avoided

– Change catheter when signs of blockage & encrustation ONLY

– Do not interrupt the closed catheter system

– Use smallest suitable-bore catheter

– Avoid irrigation unless needed to prevent or relieve obstruction



• Manage or eliminate the cause of incontinence

– Identify the type of incontinence

– Minimize episodes of incontinence

– Utilize proper incontinence supplies

– Provide proper peri-care

• Set up an individualized toileting program



• Hydration

– Provide adequate fluid intake

• Small amounts throughout the day

– Limit caffeinated fluids (irritant and bladder spasms)

– Discourage carbonated beverages (promotes alkaline urine)

– Cranberry juice (4oz twice a day)



• Encourage resident to:

– Not hold urine

– Use proper peri-care

– Use proper and clean absorptive products



• Symptoms caregivers should report

– ANY change in continence status

– Dribbling or leakage

– Trouble starting urination

– Weak stream

– Once finished urinating still feel the need to urinate

– No urination for more then 5 hours

Symptoms to Report



– New or marked

• Urgency

• Increase in incontinence

• Increase in frequency

– Purulent discharge from around the catheter

– Blood or redness in the urine

Symptoms to Report



– Complaints or signs of pain during urination

– Complaints of pain in lower back or rubbing lower back

– Pain or swelling in the testes or lower abdomen

Symptoms to Report



– Fever

– Rigors (episodes of shaking or exaggerated shivering)

– New-onset hypotension

– Acute change in mental status or acute functional decline

Symptoms to Report


• McGeer Definitions

– Must be symptomatic, meeting McGeer Definitions AND positive urine culture

– A diagnosis of UTI can be made without urinary tract symptoms ONLY if:

• a blood culture isolate is the same as the organism isolated from the urine AND

• There is no alternate site of infection

Diagnosing UTI


• UA/UC

– Urine Analysis

• Leukocyte estrase (released when WBC present)

• Presence of nitrites (bacteria change nitrates to nitrites)

• Dipstick and microscope examinations for WBCs

• If positive then UC

– Urine Culture

• Identify type of infection

Diagnosing UTI


• UA/UC Collection

– Chronic Indwelling catheter (14 days or longer), specimen should be obtained with a new catheter

– Urine cultures should be processed within 1-2 hours

– If the culture can not be processed within 30 minutes it should be refrigerated

– Refrigerated specimens should be used within 24 hours

Diagnosing UTI


1. At least one of the following sign or symptom subcriteria

•Acute dysuria or acute pain, swelling or tenderness of the testes, epididymis or prostate

• Fever or leukocytosis and at least 1 of the following localizing urinary tract subcriteria

•Acute costovertebral angle pain or tenderness

• Suprapubic pain

•Gross hematuria

•New or marked increase in incontinence

•New or marked increase in urgency

•New or marked increase in frequency

• In the absence of fever or leukocystosis, then 2 or more of the following localizing urinary tract subcriteria

• Subrapubic pain

•Gross hematuria

•New or marked increase in incontinence

•New or marked increase in urgency

•New or marked increase in frequency

2. One of the following microbiologic subcriteria

•At least 105 cfu/mL of no more than 2 species of microorganisms in a voided urine sample

•At least 102 cfu/mL of any number of organisms in a specimen collected by in-and-out catheter

For Residents without an indwelling catheter: (both criteria 1 and 2 must be present)


1. At least 1 of the following sign or symptom subcriteria

• Fever, rigors, or new-onset hypotension, with no alternate site of infection

• Either acute change in mental status or acute functional decline, with no alternate diagnosis and leukocystosis

• New-onset suprapubic pain or costovertabral angle pain or tenderness

• Purulent discharge from around the catheter or acute pain, swelling or tenderness of the testes, epididymis or prostate

2. Urinary catheter specimen culture with at least 105 cfu/mL of any organism(s)

For residents with an indwelling catheter: (both criteria 1 and 2 must be present)


• Please note F315 criteria for diagnosing UTI has not been updated

Surveillance Definitions for UTI


• Antibiotics specific to the culture results

• Encourage fluids-hydration

• Cranberry Juice (4oz, 2 times/day)

• Urinate when the need arises (prompt toileting)

• Proper peri-care

• Incontinence management

• If possible removal of catheter

Treatment of UTI


• Do not re-culture when antibiotics are finished

• Follow McGeer criteria

Treatment of UTI


Change Package Strategies for

Implementing a

UTI prevention system

UTI Prevention System


1. Strategy: Lead with a Sense of Purpose

– Be the leader you would want to follow

– Let the mission drive your actions

– Plant now-harvest later: Nurture professional growth and foster innovation in others

– Focus on systems for change



• Be the Leader You Want to Follow

• Routinely spend time in all neighborhoods and during all shifts

• Assist with toileting requests as appropriate

• Offer fluids

• Talk with the residents and families

• Talk with staff to ensure they have the tools and resources needed

• Encourage staff, resident and family input on toileting programs



• Be the Leader You Want to Follow

• Routinely spend time in all neighborhoods and during all shifts

• Monitor for catheter bags on the floor

• Ensure catheter bags have a privacy cover

• Do you note any urine or fecal odors

• Residents well groomed, clean and dry

• Utilizing the correct incontinence product

• Attend shift change report



• Be the Leader You Would Want to Follow

– Ensure staff have the proper supplies and equipment

• Bladder scanner

• Peri-care items

• Dignified absorptive products

• Catheters

• UA/UC containers

• Privacy covers for catheter bags

• Cranberry juice and variety of fluids

• Grab bars, commodes, urinals, etc



• Let the Mission Drive Your Actions

– Ensure mission, values and performance improvement projects (PIPs) are resident-centered and honor their wishes

– Ensure PIP goal to prevent UTIs is clearly communicated & involves all staff, residents and families

– Ensure regular surveys of staff, residents and families address toileting needs, wishes and concerns



• Nurture Professional Growth and Foster Innovation in Others

– Encourage staff to attend educational conferences on incontinence & UTI prevention

– Ensure all staff are adequately trained on your bowel, bladder and UTI prevention program

• Upon orientation

• At least yearly



• Focus on Systems for Change

– Ensure a root cause analysis is utilized if someone develops a UTI

– Encourage and utilize PDSA cycles to prevent UTIs

– Support team efforts, meetings and ensure it stays on track

– Allow staff time to collect data and monitor charting/cares

– Acknowledge and celebrate milestones

– Encourage feedback from staff, residents and family, good or bad!!



2. Strategy: Recruit and retain quality staff

– Hire only the best fit for your organization

– Welcome new staff-make them part of the team

– Set high expectations-support success

– Give the best staff a reason to stay



• Hire Only the Best Fit For Your Organization

– During the interview process discuss the PIP to prevent UTIs

– Include opportunities for neighborhood staff and resident involvement in the selection process

– Tour the candidate throughout the facility and neighborhoods

– Ask candidates about their values

– Ask candidates about their thoughts and feelings on managing incontinence



• Welcome new staff – make them part of the team

– Ensure bowel and bladder program, including PIP to prevent UTIs is part of orientation

– Provide education on prevention, assessment and treatment of UTIs

– Provide a mentor to train on proper technique and management of incontinence



• Set High Expectations – Support Success

• Ensure competency of new employees

– Proper peri-care

– Accurate completion of bowel and bladder diaries

– Proper catheter management

– Proper insertion of a catheter

– When and how to test for a UTI

– What signs and symptoms to report

– Implementation of individualized toileting program

– Proper utilization of products



• Set High Expectations – Support Success

– Solicit feedback from new employees

– Before making any changes to current program solicit input from all staff, residents and families

– Hold short stand-up meeting between manager and staff for each shift to identify concerns, resource needs, etc.



• Set high expectations – Support success

– Develop cross-training among departments to create blended roles

• All staff can provide toileting as appropriate

• All staff involved with providing fluids

• All staff ensuring catheter bags are not on the floor, properly hung with privacy covers

– Foster interdepartmental collaboration



• Set high expectations – support success

– Conduct annual skills testing on incontinence management, prevention, assessment and treatment of UTIs

– Do random audits on the incontinence management and prevention of UTIs

– Utilize results on audits to identify opportunities for improvement – keep it positive for growth!!



• Set high expectations – Support success • Recognize and reward staff for performance

and commitment to the program



• Give the best staff a reason to stay

– Support staff in their professional development

– Provide flexible schedules and work environment to support incontinence management – move away from q2 hours medical model

– Coach and support floor nurses and supervisors to ensure oversight of the program and they are actively involved



3. Strategy: Connect with residents in a celebration of their life

– Treat residents as they want to be treated, remembering that your facility is their home

– Foster relationships

– Create connections with the community

– Provide compassionate end of life care



• Treat residents as they want to be treated, remembering that your facility is their home – Interview the resident and family members

before or during “move in” on:

• toileting habits

• Schedules

• products utilized

• Foods utilized to promote regularity

• fluid preference

• History of UTIs, symptoms, TX, organism if known and prevention techniques



• Treat residents as they want to be treated, remembering that your facility is their home

– Ensure resident and family wishes on managing incontinence are honored and communicated to ALL staff

– Ensure incontinence management is provided in an individualized, dignified manner at all times

– Ensure care plans are updated as changes are identified




– Ensure new staff are trained on each individual resident’s toileting plan of care

– Ensure prompt response to resident’s toileting needs is a top priority for all staff and disciplines




– Utilize the “Resident Life Committee” to discuss the overall incontinence management program, products and approaches



• Foster relationships

– Promote and encourage independence & family involvement in managing incontinence or catheters

• Provide resident & family proper incontinence management training

• Provide resident & family appropriate utilization of supplies

• During family visits is a great time to provide preferred fluids



• Create connections with the community

– Develop relationships with community resources such as:

• Urology physicians/clinics

• WOCN nurses



• Provide compassionate end of life care

– Discuss preferences and wishes for incontinence management with resident and family

– Provide high end absorptive products and skin care products

– Consider catheters as appropriate



• Provide compassionate end of life care

– Discuss resident and family wishes on treatment of UTIs (risk vs benefit)

• Antibiotics use for treatment

• Conservative (fluids, cranberry juice)

• Clear understanding of potential for urosepsis

• Clearly document and care plan UTI management



4. Strategy: Nourish teamwork and communication

– Expect and support effective communication with staff and between staff

– Be a collaborator among collaborators



• Expect and support effective communication with staff and between staff

– Ensure the plan of care to prevent UTIs is communicated to all staff

• Individualized toileting program

• Products to be utilized

• Peri-care products

• Catheter care

• Symptoms to look for




– Implement a formal method for communication between shifts to report

• Last time toileted

• Fluid intake

• Any concerns

• Pending UTI labs

• If a resident has a UTI and plan of care

• Results of bowel and bladder diary should be discussed face to face with the care giver and nurse




– Ensure staff knows what to report immediately to supervisor verses end of shift

• Blood/red urine

• No urination for 5 hours

• Complaints of pain with urination or back pain

• Any changes in cognition

• Fever or signs of a fever (shaking)

• Change in toileting routine (urgency, frequency)

• New-onset hypotension




– Ensure communication with physician, medical director and practitioners

• Diagnosis of type of incontinence

• Treatment for low estrogen (topical estrogen)

• Ensure UTIs are only treated per the McGeer guidelines

• Ensure antibiotic use is targeted

• Appropriate orders for catheter change & care



• Be a collaborator among collaborators

• Support collaboration between disciplines for

– An accurate bowel and bladder diary

– Fluid promotion

– Toileting

– Reporting incontinence immediately

• Ensure everyone feels comfortable and is welcome to report issues or concerns




– Be a collaborator among collaborators

• Ensure UTI prevention PIP team meets regularly and involves all staff and disciplines

• Ensure goals and benchmarking progress are communicated to all staff



5. Strategy: Be a continuous learning organization

– Make systems thinking the norm

– Track your progress

– Test, Test, Test!



• Make systems thinking the norm

– Ensure the prevention of UTIs is part of the daily routine

• Part of shift to shift report

• Toileting routine is maintained

• Offering fluids with interaction of resident

• Use prompts such as Stop and Watch to remind staff to report changes



• Track your progress

– Benchmark UTI rate against national, state and local rates

– Set stretch goals, however ensure staff is involved with goal setting

– Openly and transparently share your performance data with staff, board, residents and families



• Test, Test, Test!

– Use a change methodology PDSA



• Test, Test, Test

– Develop surveillance of UTIs

• With or without catheter

• Incontinent

• Location within the facility

• Type of incontinent products utilized

• Type and fluid intake amount

• Male or female

• Symptoms

• Type of organism

• Did it require hospitalization and why

• Did it cause urosepsis



Assessing Systems • Correct team members • Start small • Root Cause Analysis:

• Review what ACTUALLY happens verses what NEEDS to happen

• Identify performance gaps • Identify the data to be used

and set a goal • Develop an action plan



Assessing Systems • Correct Team Members

• Nursing assistants/caregivers

• Floor nurses • Nurse managers • Activities • Therapy • Housekeeping • Physicians and practitioners



Assessing Systems • Start small

• Neighborhood with the highest rate of UTIs,

OR • Neighborhood with

highest rate of catheters,

OR • Neighborhood with

highest rate of incontinence



Assessing Systems • Look at Systems

• Pre-admission/admission • B & B Program:

• Identification of type & causes/triggers of incontinence,

• 3 day diaries • Individualized plans

• Hydration Program • Catheter use and care • Assessment & Treatment of UTI • Equipment/supplies

• Bladder scanner • Absorptive & peri-care products • Grab bars, raised toilet seats, etc.

• Communication



• Root Cause Analysis

– Seeks to identify the origin of a problem

– Physical Causes

–Human Causes

–Organizational Causes



• Root Cause Analysis Goal

– Determine what happened

– Determine why it happened

– Figure out what to do to reduce the likelihood that it will happen again



• Sign of Insanity:

– Doing the same thing over and over again and expecting different results

• Albert Einstein


http://www.google.com/url?sa=i&source=images&cd=&cad=rja&docid=L07U_0vufyHOfM&tbnid=WZRmOvlEFoLRaM:&ved=0CAgQjRwwAA&url=http://www.npr.org/blogs/13.7/2011/09/28/140839445/is-einstein-wrong&ei=_HCIUaCVBeS7igLt7oDwBQ&psig=AFQjCNHf5eGooduGNnIYO3iF0MQ-wHffZg&ust=1367982716128824



Map out what actually happens verses what should happen

Identify Performance Gaps




• Root Cause Analysis: Fishbone Diagram

http://www.google.com/url?sa=i&source=images&cd=&cad=rja&docid=VJaMS2ajRhL5bM&tbnid=jYCundA1DJT-vM:&ved=0CAgQjRwwAA&url=http://www.vertex42.com/ExcelTemplates/fishbone-diagram.html&ei=pQmJUaj4AeGjigK3rIHYDA&psig=AFQjCNFGG2YhWwd31KuePMc9gyUXKwOzxQ&ust=1368021797076637



• Root Cause Analysis: Fishbone Diagram for UTI:

– Education (McGreer, Catheter use & care, peri-care,

toileting programs, etc)

– People (Buy in, implementation, staffing, interdisciplinary,

etc.)

– Supplies and Equipment (Absorptive & peri-care

products, bladder scanner, etc.)

– Management & Monitoring (Leadership support,

daily monitoring, shift report)

– Admission Process (3 day B & B diary, involvement of

family and resident for information, etc.)

– Environment (grab rails, contrasting colors in bathroom,

raised toilet seats, lighting)


Assessing Systems • Once the performance Gaps are

identified: • Identify the data to be used

and set a goal – UTI national, state and local rates

• Develop an action plan



Assessing Systems • Implement the program



Assessing Systems • Review the progress of

the program

– Where are you compared to the goal

– What is working

– What is not working



Assessing Systems • Make adjustments to the program based on the analysis

• Start a new PDSA cycle

OR

• If successful, roll out to the entire facility and start a PDSA cycle for the facility



• Test, Test, Test!

– Celebrate success and reward and recognize staff who contribute to achievement goals



• 6. Strategy: Provide exceptional compassionate clinical care that treats the whole person

– Carefully build care teams and keep them together

– Choose medical leadership wisely

– Transition with care (between shifts, departments, and all care settings)

– Strive to prevent problems and treat when necessary

6. Strategy: Provide exceptional compassionate clinical care that treats the whole person


• Carefully build care teams and keep them together

– Assign each staff member consistently

• Best way to ensure individualized toileting program is implemented

• Enhance fluid program by provided resident preferences

• Consistent staff tend to pick up on subtle changes that may indicate UTI or identify risk factors for UTI

• Easier to track staff involvement



• Choose medical leadership wisely

– Medical Director should be supportive and actively involved in the UTI prevention PIP

– Ensure ALL physicians and practitioners are aware and actively involved in the UTI prevention PIP



• Choose medical leadership wisely

– Ensure physicians and practitioners follow current standards of practice for:

• Assessing & treating UTIs (McGeer, targeted antibiotics, etc)

• Permanent catheter placement verses straight catheter

• Catheter care (not ordering routine changes, disruption of continuous system, etc)



• Transition with care (between shifts, departments, and all care settings)

– Walking rounds with team at shift change

– Written or recorded report if unable to have cross over between shifts

– Bowel & Bladder diaries have to be reviewed together, not just handed off




– Communication verbally with physician/practitioners

– Utilize SBAR template to ensure comprehensive assessment and information regarding a UTI before calling physician/practitioner

– Stop and Watch forms for care givers




– Prior to admission get information on:

• Currently has a UTI or history of UTI, type of organism, symptoms and treatment

• Catheter use (permanent, straight cath or recent temporary use)

• Type of incontinence & current management

• Dehydration

• Steroid use

• Renal insufficiency

• Bowel & Bladder habits and products, etc.



• Strive to prevent problems and treat when necessary

– Collect data/information with regard to hospital admission/re-admission secondary to UTIs

• Conduct root cause analysis of residents going to the ED or hospital secondary to UTIs

• Review hospital re-admissions secondary to UTIs with staff to identify opportunities for improvement



• Strive to prevent problems and treat when necessary

– Provide standardized communication tools such as SBAR, Care Path for symptoms of a UTI (Interact), and McGeer guidelines for UTI

– Ensure family members and providers know what equipment and medications you have available to treat the resident in the facility (IV antibiotics, subcutaneous fluids, etc)



7. Strategy: Construct solid business practices that support your purpose

– Seek strategic and creative approaches to expand your resource base to meet your mission and serve your residents

– Maximize your efficiency

– Ensure you are making the most of your physical assets



• Seek strategic and creative approaches to expand your resource base to meet your mission and serve your residents

– Market:

• UTI prevention PIP and the results

• Your dignified, individualized incontinence prevention & management program

• Re-hospitalization rate in regards to UTI

• Resident satisfaction data on managing incontinence and preventing UTI

• Fluid program



• Maximize your efficiency

– Work with incontinence suppliers for cost savings and rebate options

– Ensure incontinent product performance

– Utilize consultants and manufacture reps for UTI programs

– Analysis cost savings verses UTI and skin maceration rates

– Solicit staff ideas for cost savings and product use



• Ensure you are making the most of your physical assets

– Room set up to promote resident’s ability to get to the bathroom

• Path to bathroom clear and lite

• Toilet identifiable (dark color or wall/floor contrasting color from toilet)

• Raised toilet seat

• Hand rails

• Clothing & incontinent products that can be easily removed and are dignified

• Commodes and urinals



• Ensure you are making the most of your physical assets

– Bladder scanners available and in good working condition

– Incontinent products available to care givers

– Thermos type water/fluid cups and pitchers

– Privacy bags for catheter collection bags

– Proper/dignified storage of incontinent products



• A UTI prevention program can also improve:

– Falls

– Skin breakdown

– Dehydration

– Pain

– Dignity

UTI Prevention


Assessing Systems

Quality Improvement Process Can Improve Resident Outcomes and Workflow

Happy Residents, Families and Staff

Change Package/QAPI


Jeri Lundgren, RN, BSN, PHN, CWS, CWCN

Director of Consulting Services

Pathway Health

[email protected]

612-805-9703

This webinar provided by:

Thank you!!

This material was prepared by the Oklahoma Foundation for Medical Quality and Stratis Health, the National Coordinating Center (NCC) for Improving Individual Patient Care

(IIPC) Aim, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents

presented do not necessarily reflect CMS policy. 10SOW-IIPC NCC-C7-279 071813

mailto:[email protected]

Documents

UTIs in the Nursing Home: Systems for Prevention ...sdfmc.org/.../Files/2804/QIOWebinar_UTI_Systems_2013_07_18_final.pdf · Systems for Prevention, Assessment and Treatment Jeri Lundgren,