MDS Alert

Protect the facility's residents, QIs and PPS dollars.

To diagnose, code and treat UTIs accurately is no easy feat, but one where your expertise can ease the facility's quality and fiscal profile.
 
Facilities that over-diagnose and/or over-code UTIs on the MDS drive up their quality indicators and measures unnecessarily. "And over-treating for UTI is not only expensive - antibiotics have side effects and they breed resistant bacteria," warns Joseph Ouslander, MD, chief medical officer for the Wesley Woods Center of Emory University in Atlanta.
 
Yet untreated UTIs can lead to urosepsis, and the resulting confusion as a symptom of UTI can cause falls, cautions Clare Hendrick, RN, ARNP, vice president of education and clinical development with Health Essentials in San Clemente, CA. "So there are risks to under-treating UTIs with antibiotics."
 
Further clouding the issue: Studies show that clinically stable nursing home residents' urine samples often show bacteruria and even white blood cells, Ouslander notes. "When someone gets ill and the doctor is called or the patient goes to the ER, the patient will by chance oftentimes have a urinalysis done," he points out. "And the person may be treated for a UTI when something else is really going on."

Follow These 7 Steps for Success
 
UTI presents a clinical conundrum, but one that providers can work their way around with these key strategies:
 
1. Know what counts for coding UTI on the MDS and make sure it jibes with how UTI is being diagnosed in the facility. The MDS team should know the coding criteria and make sure it's consistent with how the prescribing clinicians are diagnosing and documenting UTI. "Generally a positive culture in the absence of symptoms is not classified as a true UTI," advises Barbara Nodiff, a nursing consultant and principal of Associated Geriatric Information Network in New Rochelle, NY. "So if the prescribing clinician decides to treat in such a case, he or she should document the rationale in the medical record - for example, if the resident has a history of UTI." 
 
2. View UTI as a diagnosis of exclusion. Considering the prevalence of bacteriuria in nursing home populations, you have to make sure nothing else is going on with the resident, such as diverticulitis, cholecystitis or some other infection, Ouslander suggests. "Residents who are sick (low-grade fever, mental status change, not eating, etc.) require a careful evaluation. That's especially true for the more clinically and functionally impaired resident," Ouslander stresses. 
 
3. Develop a policy/procedure for collecting urine specimens. "Nursing staff should be careful how they collect the urinary specimens, as contamination can lead to a false positive lab report," Nodiff cautions. Obtain urine using aseptic technique, she advises.
 
Clinical Tidbit: "If there appears to be an increased incidence of contamination, ask the infection control nurse to observe the staff's technique to determine if there are problems with obtaining specimens," Nodiff suggests.
 
4. Use the urine culture as a basis for antibiotic selection. "Look at the results of the urine culture and select the appropriate antibiotic," suggests Hendrick. Also follow the patient clinically to see if his/her symptoms resolve with treatment, which will clue you in to whether the diagnosis is on the mark.
 
5. Avoid the trap of automatically diagnosing residents with behavioral changes as having UTI. Such residents may simply be showing a fluctuation in behaviors, Ouslander cautions. "Medical treatment of urinary tract infections should be done on a very individual basis," emphasizes Nodiff. "Facility staff should try and identify indicators of UTIs in residents with cognitive impairment and chronic UTIs. Look for a pattern and care plan accordingly," she suggests. Follow up to see if treatment for a diagnosed UTI does resolve the resident's behavioral symptoms.
 
6. Identify residents at risk for UTI for more careful monitoring. The list of risks for UTI runs the gamut from low fluid intake, fecal incontinence, diabetes, and/or immobility to a history of chronic UTI. "Some residents have recurrent UTIs or may have interstitial cystitis that an antibiotic isn't touching," notes Beth Klitch, president of Survey Solutions Inc. in Columbus, OH. Residents whose UTI symptoms recur in spite of antibiotic treatment might benefit from a urology work-up, which Medicare Part B should cover.
 
7. Use nursing approaches to prevent UTI. "Keeping the urine really dilute helps [prevent UTI] by washing out bacteria and avoiding bladder irritation," Klitch advises. Cranberry juice also really works.
 
Clinical Gem: Cranberry extract in gel caps is preferable to juice in preventing recurrent UTI, according to the National Multiple Sclerosis Society's recently published guidebook, Nursing Home Care of Individuals with Multiple Sclerosis: Guidelines and Recommendations for Quality Care. The gel caps can be opened and added to applesauce or pudding for residents with dysphagia, or flushed into gastrostomy tubes, the guidelines suggest.