The implementation of a standardized workflow for the diagnosis and management of urinary tract infections (UTIs) in patients using home health care did not increase emergency department visits or hospitalization rates, according to the results of a pilot study presented at the 2022 American Association of Nurse Practitioners (AANP) National Conference held June 21 to June 26, 2022, in Orlando, Florida.
“Antimicrobial use for suspected UTI among older adults is very common and often inappropriate,” said the study authors, led by Maria Mendoza De la Garza, MD, from the Division of Community Internal Medicine, Senior Services at the Mayo Clinic, Rochester, Minnesota. Homebound older adults are at higher risk for infection and UTI diagnosis can be challenging. “This often results in high antibiotic use, which can lead to multidrug-resistant infections, drug interactions, and medication-related adverse effects,” noted the authors. Delay in administering empiric antibiotics raises the risk of sepsis in older patients.
The lack of a clinical standard for diagnosis and management of UTIs in homebound older adults led the team to embark on a quality improvement project. This included the development of a standardized workflow protocol for the initial diagnosis and management of urinary symptoms. “The goal of the workflow was to ensure that all patients have urine testing in place when appropriate, and to identify patients at risk for sepsis — escalating or de-escalating treatment as needed,” the researchers noted.
Half of patients enrolled in the Senior Services Homebound Program received the intervention. Calls from patients and caregivers were managed by a nurse care coordinator who triaged symptom-based calls. The nurse would then report findings to a nurse practitioner or PA. The researchers compared infection rates among 15 enrolled patients with those among nonenrolled homebound patients.
Among the patients enrolled in the protocol, 73% were women, 53% lived in assisted living facilities, and 53% were between 80 to 90 years. The total number of UTIs in the protocol group was 23 compared with 20 in the control group; the number of UTI-related hospitalizations was lower in the protocol group than in the control group (2 vs 6).
“Urinary tract infections in the elderly are very common and are so often treated unnecessarily with antibiotics. Overuse of antibiotics in this population brings its own set of problems of antibiotic resistance and secondary infections among others,” commented Mary Koslap-Petraco, DNP, PPCNP-BC, CPNP, FAANP, clinical assistant professor at Stony Brook University School of Nursing in Stony Brook, New York.
”This clinically significant project offers a standardized method for addressing this condition in an evidence-based paradigm. A workflow protocol for urine testing for these patients resulted in appropriate treatment based on laboratory results rather than just taking an often inappropriate educated guess. Hospitalization in this population results in another myriad of problems and this easy to implement framework decreases the chance that hospitalization will be the treatment outcome,” Dr Koslap-Petraco said.
The UTI workflow protocol was easy for nurses to implement, according to the authors. Patients who were triaged for urinary testing were more likely to receive testing following the implementation of the protocol; those with symptoms not appropriate for empiric treatment were provided with supportive care instructions and revisited 2 days later, the authors concluded.
The researchers are expanding the UTI workflow protocol to all patients in the Senior Services Homebound Program.
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Mendoza De la Garza M, Verdoorn B, Mohammad N, Di Tommaso M, Bicknese A, Kaffine K. Diagnosis and initial management of urinary tract infection (UTI) in homebound older adults. Poster presented at: AANP 2022; June 21-26, 2022; Orlando, Fl.