Running head: PREVENTION OF URINARY TRACT INFECTIONS

Community Assessment:
Prevention of Urinary Tract Infections in Whatcom County Skilled Nursing Facilities
Dani Woodley, Debra Bevens, and Nicole Marsyla
Western Washington University

PREVENTION OF UNINARY TRACT INFECTIONS

Community Assessment: Prevention of Urinary Tract Infections in Whatcom County Skilled

Nursing Facilities
The prevalence of infections amongst residents in skilled nursing facilities (SNFs) is on
the rise, and this increasing trend does not appear to be leveling off any time soon. Infections in
SNFs are one of the most serious medical problems in the United States (US), which has
accounted for an increase in complications, cost of care, re- hospitalization, extended hospital
stays, morbidity, and mortality. A skilled nursing facility is an ideal environment for bacteria to
spread from host to host through shared living spaces, food, healthcare workers, and frequent
visitors to the facility, all putting the residents at risk. Emerging infections and antibioticresistant organisms in an institutional environment where there is substantial antimicrobial
overuse and the population is older, frailer, and sicker, create unique challenges for infection
control (Montoya & Mody, 2011, p. 889).
The Whatcom County Health Department (WCHD), in Bellingham, WA, has tasked our
Practical Experience group to conduct research regarding infection prevention in local SNFs, and
develop a presentation regarding our findings for an infection prevention conference in June of
2016. They also presented us with the Center of Disease Control and Preventions (CDCs) new
Antimicrobial Stewardship Program to integrate into our presentation. The WCHD is
responsible for monitoring the outbreaks that occur in the local SNFs, preventing the outbreaks
from occurring, which is extremely important for our elderly population.
The most common endemic infections in SNFs are respiratory, urinary, skin and soft
tissue, and gastrointestinal infections, with urinary tract infections (UTIs) being the most
common nosocomial infection, and perhaps the most over-diagnosed in SNFs (Mathei, Niclaes,
Suetens, Jans, & Buntinx, 2007). The US Department of Health & Human Services (2013)

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reports that currently, 1 in 10 nursing home residents have a urinary tract infection. The
following factors have been shown to increase a SNF residents chances of having a UTI: use of
indwelling and external catheters, neurogenic bladders with increased residual urine,
incontinence of urine and feces, recent admission to an acute care facility, and multiple comorbidities. Montoya and Mody (2011) explain that the risk of residents obtaining a UTI is
9.1/1000 resident-days for residents with an indwelling urinary catheter, and 2.8/1000 residentdays in residents who have no devices placed. An informal interview, conducted with infection
prevention specialists and registered nurses, in four Whatcom county nursing homes, also reports
that the most common infection they experience is UTIs. Because of the national data and the
informal local data that we obtained, we decided to narrow our focus toward the prevention of
urinary tract infections, and the over-prescription of antibiotics for this type of infection.
Several of the local Whatcom County nursing homes use the McGeer Criteria for their
surveillance definitions of infections in their facilities. This criterion provides SNFs with proper
evidence-based guidelines that assist them in defining when an infection is probable in a
resident. As it pertains to UTIs, several different criteria must be met to diagnose a UTI
according to the McGeer criteria (Stone et al., 2012). The criteria include a positive urine
culture and at least three of six symptoms including: fever, suprapubic pain, gross hematuria,
urgency or frequency or burning associated with urination, deteriorating function or mental state,
or new or increased incontinence (Stone et al., 2012). The problem with a UTI in a SNF, is that
antibiotics are being over-prescribed and/or used longer than intended. Span (2011) reasons that
under treatment of UTIs has not harmed patients. However, overtreatment, with broad-spectrum
antibiotics, wipes out all bacteria, even the patients own competing bacteria, making it more
likely to be struck by the dangerous C. difficile bacterium which flourishes in the gut. These

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infections should first be treated with a narrow-spectrum antibiotic after a culture is obtained,
and for the appropriate length of time. Span (2011) reports that women, diagnosed with a UTI,
should only need to take antibiotics for three days, whereas men need to be treated for seven to
fourteen days. If a resident has asymptomatic bacteriuria, treating this with antibiotics may
increase the likelihood of development of drug-resistant microorganisms and adverse reactions to
antibiotics (Mody, 2009). A nursing home [NH] can reduce infections and colonization with
resistant pathogens by emphasizing hand hygiene compliance, developing an antimicrobial use
program, encouraging evidence-based clinical evaluation and management of infections, and
ensuring that the facility has a well-established individualized infection control program (Mody,
2007, p. 205).
Community Demographics
Whatcom County is nestled in the upper northwest corner of Washington State
surrounded by the Puget Sound, the Canadian border, Skagit County to the south, and Okanogan
County to the East. According to the United States (US) Census Bureau (2010), Whatcom
County is ranked the 12th largest county in land area, and the 10th largest county for persons per
square mile for Washington State. According to the same census, the population of Whatcom
county is estimated to be at 212,284, for 2015, with 15.4% of the population being 65 years of
age and older.
Vulnerable Population
As the baby boomers are advancing toward retirement age, the number of people 65 years
of age and older is on the rise. Nationally, it is estimated that by the year 2025, there will be a
projected 63.5 million adults over 65 years of age in the United States (Mody, 2007). Montoya
and Mody (2011) demonstrate that over 1.5 million US citizens live in 16,000 nursing homes and

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experience, on average, 2 million infections a year, and more than 88% of these people are 65
years of age and older. By the year 2030, it is estimated that, the aforementioned numbers, will
reach as high as 5.3 million citizens requiring SNF care. With the ever growing increase in
citizens needing the aid of a SNF, the acuity of medical conditions is also beginning to rise, and
the rate of infections in this population is growing exponentially.
Assessment
Data Gathering and Generation
Informal qualitative interviews were conducted at four SNFs in Whatcom County to
evaluate the local nursing homes infection prevention strategies and their use of antibiotics
compared to national trends. Upon compiling the results of the informal interviews, it was found
that the most common infection found in the Whatcom County SNFs interviewed was UTIs (see
Appendix). Nationally, the same statistics prevailed, with UTIs accounting for the largest group
of infections in nursing homes (Montoya & Mody, 2011). Approximately 75% of all UTIs are
associated with a urinary catheter and UTIs are the most common type of healthcare-associated
infection (HAI) reported to the National Healthcare Safety Network (CDC, 2016).
Antibiotics save millions of lives each year in the US; however, the misuse or overuse is
a growing national concern. The rise of antibiotic-resistant bacterial strains represents a serious
threat to the health of US citizens. The CDC (2016) has estimated that at least two million
illnesses and 23,000 deaths are caused by antibiotic-resistant bacteria in the US annually. If the
effectiveness of antibiotics continues to diminish, we will no longer be able to consistently and
promptly treat bacterial infections. As more strains of antibiotic-resistant bacteria surface, the
availability of effective choices will gradually become more limited, more expensive, and in
some situations nonexistent.

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The US Department of Health and Human Services has made the prevention of HAIs a
top priority. To address this priority, the CDC has created tools to assess the infection prevention
practices of acute care settings, hemodialysis facilities, and SNFs. These tools are part of the
CDCs Infection Control Assessment and Response (ICAR) movement. In 2015, Washington
State Department of Health received federal funding from the CDC to conduct enhanced ICAR
assessments (Washington State Department of Health, 2016, p.2). This funding permitted the
state to hire Patricia Montgomery, ICAR RN, to lead the ICAR program. The focus of her
position is to strengthen the infection prevention capacity at the county level. The goal of the
ICAR is to build stronger relationships with the healthcare community by making visits to their
healthcare facilities, including SNFs, in order to learn about innovative infection prevention
practices and to share in the ICARs public health resources and expertise in infection prevention
(Washington State Department of Health, 2016).
The CDC (2016), in conjunction with the ICAR movement, has developed an
Antimicrobial Stewardship Program (ASP) that is committed to improving the use of antibiotics
to help slow the emergence of antibiotic-resistant bacteria, while optimizing treatment and
minimizing costs to patients. The program guides healthcare providers to prescribe the right
antibiotic for the right amount of time and prevent prescription of antibiotics for nonbacterial
infections (CDC, 2016). Starting with the acute care setting, the CDC introduced the Core
Elements of Hospital Antibiotic Stewardship document in 2014 and is currently expanding their
ASP to SNFs (Smith, Watkins, Miller, VanSchooneveld, 2011). In 2015, the CDC released The
Core Elements of Antibiotic Stewardship for Nursing Homes document to improve antibiotic
usage, reduce adverse events, prevent antibiotic-resistant bacteria, and therefore, facilitate better
outcomes for residents in SNFs (CDC, 2016). Similar to the Hospital Antibiotic Stewardship

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Program, there are seven steps in implementing Antibiotic Stewardship Program for Nursing
Homes. The following is a summary of the seven steps that the CDC recommends to SNF:
1.

Leadership commitment: Demonstrate support and commitment to safe and

2.

appropriate antibiotic use in your facility

Accountability: Identify physician, nursing and pharmacy leads responsible for

3.

promoting and overseeing antibiotic stewardship activities in your facility

Drug expertise: Establish access to consultant pharmacists or other individuals with

4.
5.

experience or training in antibiotic stewardship for your facility

Action: Implement at least one policy or practice to improve antibiotic use
Tracking: Monitor at least one process measure of antibiotic use and at least one

6.

outcome from antibiotic use in your facility

Reporting: Provide regular feedback on antibiotic use and resistance to prescribing

7.

clinicians, nursing staff and other relevant staff

Education: Provide resources to clinicians, nursing staff, residents and families about
antibiotic resistance and opportunities for improving antibiotic use (CDC, 2016, p. 6)

SNFs are encouraged to take a step-by-step approach and implement one or two activities
initially, and if improvement is noted, add more elements of the ASP to improve antibiotic use in
their facilities (CDC, 2016).
On May 24th, we had the privilege of meeting Patricia Montgomery, ICAR RN and her
colleague, Kelly Kauber, MPH, the Antimicrobial Stewardship Coordinator for Washington State
Department of Health (WA DOH). Patricia shared her professional background with us along
with the ICARs active role with Washington State SNFs. Kelly also shared her background and
gave us a brief description of the WA DOHs introduction of the Antibiotic Stewardship Program
for SNFs. After our meeting, we traveled to a local SNF and observed Patricia conduct a
voluntary infection control assessment. By conducting the voluntary assessments/visits and
providing the results to the SNFs, it is the objective of the WA DOH and the CDC to strengthen

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the relationship between themselves and the local community SNFs across the state. Providing a
friendly and valuable assessment, WA DOHs goal, with the leadership of Patricia and Kelly, is
to identify the gaps in infection prevention and antibiotic stewardship for Washington State
SNFs. By bridging the gaps in infection prevention in community SNFs, the WA DOHs and the
CDCs aim is to build a stronger healthcare system, which will result in better evidence-based
outcomes for its residents.
Recommended Interventions
Systems Level: Annual mandatory online infection prevention training
Due to the growing number of UTIs in SNFs that are being treated with antibiotics, it is
imperative to properly train the nursing staff caring for these residents. One way to improve staff
education is by developing a mandatory annual online refresher course for all staff, nursing
assistants and skilled nurses to complete. The training would cover ways to prevent a UTI, as
well as non-pharmacological treatment methods. We would propose that the training be reviewed
yearly by a designated infection prevention control specialist to ensure it is continually accurate,
as evidence-based practice recommendations can change. This recommendation is a primary
level of prevention due to the focus on prevention of UTIs in our local SNFs. This intervention
also aligns with the secondary level of prevention because it also focuses on nonpharmacological methods of treatment.

Community Level: Poster presentation at WCHD infection prevention conference

Our practical experience group has been asked to complete a poster regarding the CDCs
Antibiotic Stewardship Program to be presented at the June 2nd Infection Prevention Conference.

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The purpose of this poster is to bring attention to the ASP within our community, as well as
educate local healthcare providers in the prevention of UTIs. The poster will include the most
current evidence based practice regarding infection prevention, UTI rates, the ASP, and
recommendations for non-pharmacological interventions. This recommendation is a primary
level of prevention because our focus is going to reflect prevention techniques. The poster also
touches on the secondary level, with the CDCs recommendations to improve antibiotic use,
which will decrease emergent antibiotic-resistant organisms and improve residents outcomes.
Family Level: Infection prevention pamphlets
Patients and families need to be aware of how to prevent UTIs, of non-pharmacological
treatment measures, as well as statistics about the overuse of antibiotics. In order to spread this
information to the patients and their families, a pamphlet will be given to each resident of the
local SNF and their immediate family members. By educating the patients and families, the
knowledge of antibiotic overuse and prevention interventions can be spread out into the
community. The pamphlet is also a primary level of prevention, because the information
provided will outline interventions to prevent UTIs for not only the residents of SNFs, but also
their families and the community as a whole.
Deliverable Intervention
The deliverable intervention for this infection prevention project is a poster presentation
aimed at healthcare workers regarding UTI prevention in SNFs (See Appendix B for poster). We
have decided to present the poster for our practical experience project because our mentors at the
WCHD believed that this would be the most effective use of our time. They also wanted us to
plant the seed of knowledge surrounding infection rates and the CDCs ASP. The poster will be
presented on June 2, 2016 at an Infection Prevention Conference hosted by the WCHD in

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Bellingham, WA. The poster will cover not only information on preventing UTIs and nonpharmacological treatments, but also will outline the CDCs ASP. We will make several
replications of this poster to provide this information to the WCHD, Whatcom County Infection
Control Taskforce, and willing infection prevention specialists at local SNFs within our
community.
As a community, it is imperative that we protect our vulnerable populations. The
growing number of elderly citizens, not only nationally, but locally, will increase the needs of
SNFs by those individuals 65 years and older. In turn, the rate of infections will continue to
increase as the population in these facilities continue to grow. The Antimicrobial Stewardship
Program, as well as increased trainings and/or knowledge surrounding how to properly manage
infections, will help decrease the rates of not only infections in general, but also the rates of
antibiotic resistant superorganisms. The WCHD allowing us to do a poster presentation at their
infection prevention conference will hopefully begin to plant the seed that we for better infection
prevention in our local SNFs.

References
Center of Disease Control and Prevention (CDC). (2016). The core elements of antibiotic

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stewardship for nursing homes. Retrieved from

http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
Mathe, C., Niclaes, L., Suetens, C., Jans, B., & Buntinx, F. (2007). Infections in residents of
nursing homes. Infectious disease clinics of North America, 21(3), 761-72, ix.
Mody, L. (2007). Infection control issues in Older Adults. Clinical Geriatric Medicine, 23, 499vi. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3061471/
Mody, L. (2009). Infections: Nursing home infections. Retrieved from
http://www.thedoctorwillseeyounow.com/content/infections/art2748.html
Mody, L., Bradley, S. F., Galecki, A., Olmsted, R. N., Fitzgerald, J. T., Kauffman, C. A.,
Krein, S. L. (2011). Conceptual model for reducing infections and antimicrobial
resistance in skilled nursing facilities: Focusing on residents with indwelling devices.
Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of
America, 52(5), 654661. Retrieved from http://doi.org/10.1093/cid/ciq205
Montoya, A., & Mody, L. (2011). Common infections in nursing homes: A review of current
issues and challenges. Aging Health, 7(6), 889899. Retrieved from
http://doi.org/10.2217/AHE.11.80
Smith, P., Watkins, K., Miller, H., VanSchooneveld, T. (2011). Antibiotic Stewardship Program
in long-term care facilities. Annuals of Long-Term Care, Clinical Care and Aging, 19(4),
1-10. Retrieved from http://www.annalsoflongtermcare.com/article/antibioticstewardship-programs-long-term-care-facilities
Span, P. (2011). A common infection, commonly overtreated. The New Old Age: Caring and
Coping. Retrieved from http://newoldage.blogs.nytimes.com/2011/04/07/in-nursinghomes-a-common-infection-is-commonly-overtreated/?_r=0

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Stone, D., Ashraf, M., Calder, J., Crnich, C., Crossley, K., Drinka, P., . . . Bradley, S. (2012).
Surveillance definitions of infections in long-term care facilities: Revisiting the McGeer
criteria. Infection control and hospital epidemiology, 33(10), 965-977.
United States Department of Commerce. US Census Bureau (2010). Quick facts: Whatcom
County, Washington. Retrieved from
http://www.census.gov/quickfacts/table/PST045215/53073
United States Department of Health & Human Services. National Quality Measures
Clearinghouse. (2013). Long-stay nursing home care: Percent of residents with a urinary
tract infection, 80. Retrieved from https://www.qualitymeasures.ahrq.gov/content.aspx?
id=38345
Washington State Department of Health. (2016). Public health and infection prevention:
Preventing healthcare associated infections together. EpiTRENDS, 21(4), 1-4. Retrieved
from http://www.doh.wa.gov/Portals/1/Documents/5100/420-002-epitrends2016-04.pdf

Appendix A
Summary of Four Skilled Nursing Facilities Informal Interviews

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Whatcom County Health Department is currently collaborating with Western Washington

University RN to BSN program in their community assessment research, regarding infection
prevention strategies, specifically prescription of antibiotics to skilled nursing facility residents.
Dani Woodley, RN, Debra Bevens, RN and Nicole Marsyla, RN
Questionnaire for Infection Task Force:
1. What is the average age of your residents?
a. Average age of residents was 65 years and older.
2. What do you find as the most common infection(s) that occurs in your facility?
a. Does this infection(s) occur in one gender more predominantly over the other?
The most common infections are urinary tract infections (UTIs) and respiratory
infections. The UTIs occur more often in females, but are still seen in males.
Respiratory infections are seen about equal in both sexes.
3. What location, long term care vs rehab vs dementia unit (if applicable) do you find the
highest rate of infections amongst residents?
a. A mixed result from informal interviews. One interviewee stated that dementia
units have the highest rate of infection, one interviewee stated that long-term care
units have the highest rate, and two interviewees stated that it was unknown
because they do not track units separately for infections.
4. What are the most common risk factors (ie: chronic indwelling catheters, handwashing,
etc) you have found associated with an increased risk of infection in your facility?
a. Risks were indwelling catheters, age of residents (elderly), close proximity to
other residents, improper handwashing, poor fluid intake, and incontinence.
5. Have you found an increase of infection rates amongst residents with certain
comorbidities? If so, which ones are the most common?
a. Yes, patients with dementia and/or diabetes.
6. Who are your main prescribing physicians?
a. This question was not answered by interviewees.
7. Does your facility have a policy or algorithm in place to determine when antibiotics are
prescribed?

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a. Not to the best of their knowledge for two facility interviewees, however, two
interviewees stated that they follow the McGeer Criteria protocol ~ the nurses are
expected to chart the symptoms and follow the policy. The doctor then checks the
results of the UA and determines if the antibiotic that was prescribed is the
correct antibiotic for the bacteria found. The nurse are also instructed to follow
up to insure that the resident needs to stay on the antibiotic, change antibiotics or
stop if no infection.
8. How is antibiotic usage tracked by your facility?
a. The interviewees at three facilities did not known if antibiotic usage was tracked.
One facilitys interviewee stated that antibiotic use is tracked only in association
with the infection, but not separately. In other words, if the resident has a UTI,
then it is assumed that the resident is on an antibiotic (the number of UTIs equals
the number of antibiotics prescribed).
9. Do you have any non-pharmacological interventions in place for preventing or
managing UTIs before prescribing antibiotics? If so, please describe.
a. Yes ~ hydration, monitoring & documentation of residents, handwashing, staff
education, online training, cranberry capsules, and flushing catheters.
10. Do you have an infection prevention control specialist?
a. Three interviewees said yes, and one interviewee is unaware if they have an
infection prevention control specialist.
11. Have you heard of the Center of Disease Controls (CDC) new Antibiotic Stewardship
Program? If so, please elaborate.
a. Three facility interviewees said no and one said yes. The interviewee that said
yes, stated that she had heard of the Antibiotic Stewardship Program and that the
Infection Control Task Force is trying to implement the program into the SNFs in
Whatcom County.
12. In your infection prevention education for staff, do you provide education concerning
antibiotic usage and resistance?

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a. All four interviewees stated that they do not have any formal training about

antibiotic usage and resistance, but do try to guide staff on the floor in regards to
proper antibiotic stewardship. Proper handwashing and PPE are topics that are
covered in all staff training upon hire.

Appendix B
Place holder for poster

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