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Don’t Bug Out About UTIs

By Jane Belt, RN, MS, RAC-MT, RAC-CT, QCP - December 19, 2017

As you well know, the October 2017 RAI updates included new criteria for coding item I2300 for a urinary tract infection in the last 30 days. Oh, a sigh of relief! We have struggled with that item. But alas, as we dig deeper into the weeds and consider the ramifications related to the new survey process, it gets more complicated.

The RAI User’s Manual details the coding instruction for the item on page I-8:

 

Item I2300 Urinary tract infection (UTI):

The UTI has a look-back period of 30 days for active disease instead of 7 days.

— Code only if both of the following are met in the last 30 days:

1. It was determined that the resident had a UTI using evidence-based criteria such as McGeer, NHSN, or Loeb in the last 30 days,

AND

2. A physician documented UTI diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days.

 

And that all sounds simple enough. However, the next page is what the NAC and the administration have to carefully consider as we move into the new age of the survey process. Continuing on page I-9, the manual indicates:

 

In accordance with requirements at §483.80(a) Infection Prevention and Control Program, the facility must establish routine, ongoing and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections. The facility’s surveillance system must include a data collection tool and the use of nationally recognized surveillance criteria. Facilities are expected to use the same nationally recognized criteria chosen for use in their Infection Prevention and Control Program to determine the presence of a UTI in a resident.

Example: if a facility chooses to use the Surveillance Definitions of Infections (updated McGeer criteria) as part of the facility’s Infection Prevention and Control Program, then the facility should also use the same criteria to determine whether or not a resident has a UTI.

 

And here is where the nursing facility staff is faced with tying in the surveillance and monitoring of those UTIs. The resources listed in the manual for the evidence-based criteria are Loeb’s, McGeer, and the National Healthcare Safety Network (NHSN). In searching these, we find they are not all alike—so which should the facility staff use? This is the question that cannot be answered by the NAC alone, as the differences do affect what could be reported as a UTI on the MDS versus the Antibiotic Stewardship Program monitoring and analysis.

 

A high-level review of the different criteria reveals that the Loeb criteria use broad guidelines and have traditionally been used by medical schools and practicing physicians when initiating treatment for UTIs. The updated McGeer criteria are more geared to surveillance and a retrospective analysis of the event. And the NHSN information is a combination of both. Not much help so far, right? Well, let’s dig a bit deeper. Reviewing the Loeb and McGeer criteria side by side, we see this:

Loeb

Updated McGeer

UTI—No indwelling catheter

Acute dysuria

OR

Fever (> 37.9°C [100°F] or a 1.5°C [2.4°F] increase above baseline temperature)

 

AND at least one of the following:

New or worsening:

Urgency

Frequency

Suprapubic pain

Gross hematuria

Costovertebral angle tenderness

Urinary incontinence

 

 

 

UTI—No indwelling catheter

Both criteria 1 AND 2 must be met:

 

1. At least one of the following:

a) Dysuria OR acute pain, swelling, tenderness of

testes, epididymis, or prostate

 

b) Fever OR leukocytosis AND at least one of the

following:

Costovertebral angle tenderness

Suprapubic pain

Gross hematuria

New or increased incontinence

New or increased frequency

 

c) If no fever or leukocytosis then two or more of the following:

Suprapubic pain

Gross hematuria

New or increased incontinence

New or increased urgency

New or increased frequency

 

2. One of the following:

a) > 105 CFU/mL of < 2 organisms in voided urine

b) > 102 CFU/mL of any number of organisms of

in/out catheter sample

UTIWith indwelling catheter

At least one of the following:

Fever (> 37.9°C [100°F] or a 1.5°C [2.4°F]

increase above baseline temperature)

New costovertebral tenderness

Rigors

New onset of delirium

UTI—With indwelling catheter

Both criteria 1 AND 2 must be met:

1. At least one of the following:

Fever, rigors, OR new-onset hypotension with no

alternate site of infection

Leukocytosis AND either acute change in mental

status OR acute functional decline with no

alternate diagnosis

New-onset suprapubic pain OR costovertebral

angle pain/tenderness

Purulent discharge from around the catheter OR

acute pain, swelling, or tenderness of testes,

epididymis, or prostate

2. > 105 CFU/mL of any number of organisms from urinary catheter specimen

· Loeb, M., et al. (2001). Development of minimum criteria for the initiation of antibiotics in residents of longterm-care facilities: Results of a consensus conference. Infection Control and Hospital Epidemiology, 22(2), 120124.

· Stone, N. D., et al. (2012). Surveillance definitions of infections in long-term care facilities: Revisiting the McGeer Criteria. Infection Control and Hospital Epidemiology, 33, 965977.

 

As you look at these criteria, think about this: how will the MDS be coded if the physician uses Loeb criteria, and what will UTI data look like if the infection control person uses McGeer? We must take note of the RAI section I instructions for the Infection Prevention and Control Program (§483.80[a]), quoted above, and think about the new regulations regarding surveillance and what data collection tool will be used.

 

In the NHSN Long-Term Care Facility Component for Urinary Tract Infection (https://www.cdc.gov/nhsn/pdfs/ltc/ltcf-uti-protocol-current.pdf), the Background Information section states:

 

Efforts to examine antibiotic-use practices for UTI have demonstrated a discrepancy between the number UTI events identified through the application of evidence-based surveillance criteria and the numbers of clinically identified and treated UTI. Consistent tracking and reporting of symptomatic UTIs using surveillance criteria will help identify opportunities to examine, understand, and address differences between surveillance events and clinically identified events.

 

The above-mentioned 14-page document from NHSN also contains tables with three defined criteria that lead to algorithms like the one below as well as “Catheter Associated Symptomatic Urinary Tract Infection (CA-SUTI)” and “Asymptomatic Bacteremic Urinary Tract Infection (ABUTI) Resident With or Without an Indwelling Catheter.” Resources on the NHSN website (https://www.cdc.gov/nhsn/ltc/uti/index.html) include collection tools and data analysis forms, such as analysis of UTI events per month, determinations of the denominator (for statistical analysis), monthly reports, and an annual report.

 

Remember, the NAC needs to be aware of which evidence-based tool is being used by the Antibiotic Stewardship Program within the facility, as that is what will be needed to code UTIs on the MDS to ensure accurate tracking, monitoring, and surveillance. 



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