Diagnosis and Treatment of Bacteriuria in Nursing Homes

A CARE BY DESIGN MODEL

Introduction

Objective: 1. To increase the accuracy of clinical diagnosis of UTIs for residents in

LTC. 2. To improve resident outcomes and safety through decreased

morbidity and mortality. 3. To optimise the use of testing and laboratory services. 4. To optimise inappropriate prescribing of antibiotics for residents with

asymptomatic bacteriuria. 5. To optimise antibiotic therapy for residents with UTIs.

Methodology

-This information was prepared by the Academic Detailing Services, Continuing Medical Education at Dalhousie University and the Palliative and Therapeutic Harmonization (PATH) Program. - Capital Health District Authority became the first to use this care protocol in 2009.- The protocol is widely used by all the nursing homes across Nova Scotia as part of care by design initiative.

Diagnosis and Treatment of Bacteriuria

Bacteriuria is simply the presence of bacteria in the urine which could produce clinical symptoms or not.

The focus of this model of care is on residents with clinical symptoms, who has indwelling catheter or without an indwelling catheter.

Diagnosis and Treatment of Bacteriuria

Research ConcludesConfirmed UTIs are the commonest infection in LTC and the most common cause for use of antibiotics in LTC An individual with a chronic indwelling catheter will always

have bacteriuria, but antibiotic treatment is only warranted if the person is symptomatic.

Changes in the character of the urine such as odor, color, or turbidity are associated with bacteriuria, but are not a reliable predictor of UTI and are usually attributed to other diagnoses such as incontinence or dehydration.

Acute symptoms may be difficult to recognize because of impaired communication, dementia, or comorbid illnesses.

Description of clinical workflow in BPMN(indwelling catheter)

In a resident with an indwelling catheter, the presence of at least one of the following is an indication for treatment: • New costovertebral angle tenderness • Fever • Unexplained delirium • Rigors with or without identified cause PLUS A positive Urine sample to bacteria.

Yes

Positive

Fever or severe systemic symptoms

No

Yes

BPMN diagram for residents with indwelling catheter

Reasons for BPMN constructs

Bonita BPML is chosen for the work flow design because: * BPMN is a project requirement * Using BPMN can visualize the clinical work flow * It is inexpensive and free  * Business process management (BPMN) uses programming notation

that computer can easily understand and interpret.

Data Model

Task 1: Residents physician encounter Input: ResidentsData Output: ScoreData

Task 2: Residents lab test Input: ResidentsData PhysicianData Output: LabData

Labmessage

Task 4: Additional symptoms check Input: ResidentsData Output: ScoreData

Task 5 and 6: Condition for Treatment Input: ResidentsData Output: TreatmentData

Task 7: Residents Treatment Input: ResidentsData Output: TreatmentData

Data Model

PhysicianDataName Type physicianid String firstname String lastname String specialty String schedule String

ResidentsDataName Type id String Firstname String Lastname String Gender Boolean Age Integer Conditions String Symptoms String History String

LabMessage Name Type Messageid

String Mtime

String Mdate

Date

Data Model

ScoreData Name Type ScoreNum

Integer

LabDataName Type LabId

String Dateofsample Date Dateofsampleprocessed Date Labresult

String

TreatmentDataName Type Tid String Ttime String Tdate Date Medication String

Description of clinical workflow in BPMN ( without catheter)

Acute Signs and Symptoms: Dysuria alone Unexplained deliriumFever AND at least one of the following New or worsening urgency, frequency, or urinary incontinence Suprapubic pain Costovertebral angle tenderness Gross hematuria

Description of clinical workflow in BPMN (without catheter)

Lab test: urine specimen obtained.Treatment: For elderly-------7days antibiotics treatment For elderly in the presence of fever or more severe systemic

symptoms---------- 10-14 days antibiotics treatment

Yes

Positive

Fever or severe systemic symptoms

No

Yes

BPMN diagram for resident without indwelling catheter

What we expect from the project exercise?

It will increase the accuracy of clinical diagnosis of UTIs for residents in Long Term Care.

It will improve residents outcomes through decreased morbidity and mortality associated with UTIs and bacteremia.

laboratory services will be optimized To reduce inappropriate prescribing

Challenges

In the process of mapping the clinical work flow into the BPMN, we encountered so many problems. Actors may misunderstand the diagram structure Creating a model is complex. Modeling mistakes may happen.

Lesson learned from the project exercise

BPMN is a business strategy can be used to improve clinical performance and sustainability.

Using BPMN for the clinical work flow makes it easy to trace the task performance and results.

Modeling makes it possible to bring together every components related to the data flow.

A misunderstood clinical information will produce a wrong work flow diagram.

Conclusion

The workflow provides a comprehensive approach to diagnosis of urinary tract infection in elderly population in nursing homes, but little information is provided on how a physician decides on the choice of antibiotics that is suitable for individual resident.

Having enough information on treatment workflow as well would have provided us the opportunity to compute a balance workflow diagram on BPMN that covers both the diagnosis and treatment of UTI. However, it is a good learning opportunity for both of us.

With the BPMN diagram mapping, all the actors involved in the process know their responsibilities and duties.

References

[1] Marshall E.G; Clarke, B; Peddle, S; Jensen, J Care by Design (2015) New model of coordinated on-site primary and acute care in long-term care facilities. JFPC Canadian Family Physician March 2015 vol. 61 no. 3 e129-e134

  [2] Care by Design. (2014) A Provincial Model of Care for Long Term Care. Retrieved on Nov 20. 2015 from

http://www.cdha.nshealth.ca/care-by-design. [3] Retrieved on Nov 20. 2015 from http://medical-dictionary.thefreedictionary.com/indwelling+catheter [4] Retrieved on Nov 20. 2015 from http://www.medicinenet.com/script/main/art.asp?articlekey=3163 [5] Care by Design, Retrieved from http://www.cdha.nshealth.ca/care-by-design [6] S. Andrew Josephson, MD, November 6, 2010, Delirium and a Neurologist’s Approach to AMS in the Hospital

Setting, Retrieved from https://www.cme.ucsf.edu/2011/slides/MNR11004/08%20Josephson.pdf [7] Retrieved on Nov 20. 2015 from http://www.rightdiagnosis.com/sym/suprapubic_pain.htm#intro [8] Retrieved on Nov 20. 2015 from: http://www.wisegeek.org/what-is-costovertebral-angle-tenderness.htm