Ignoring the old impulses
Jacqueline Vance, RNC, CDONA/LTC
So, I have this song from Disney's animated film “Frozen” stuck in my head. The part of the song that goes, “Let it go, let it go …”
See, that's how I feel about urine cultures. Let's face it: The majority of them are unnecessary. It's time to break bad habits, people. Change of mental status, cloudy urine and/or urine odor do not necessarily mean someone has a urinary tract infection and needs an antibiotic.
It really matters now — federal regulators and your main payer sources say so. In short, you have to become more discriminating.
Antibiotic stewardship is a requirement for participating in the Medicare and Medicaid programs. We now have the first regulatory, national standard aimed at improving antibiotic use, emphasizing the appropriate use of antibiotics, minimizing adverse effects from their use, and slowing the spread of resistance in long-term care facilities.
And it's not a choice to do so. It's a Phase II rule that has to be in place by the end of November. To comply — at least if we wish to continue to receive reimbursement for Medicare and Medicaid — we're going to have to break some bad habits. And the indiscriminate ordering of urinary cultures, the number one culprit for overuse of antibiotics in LTC, has to go.
First of all, what 85-year-old does NOT have cloudy and funky smelling urine?! That is not a clinical indication of an infection. Neither is a change in mental status. Calling the practitioner and saying you need a culture because of a mental status change might actually harm the resident. Something really serious might be going on that requires a practitioner's medically necessary visit to determine the cause. Waiting for a culture result delays that evaluation.
Some of our “veteran” (see, I didn't say “older”) nurses are so conditioned to have that knee-jerk response to request and sometimes demand a culture from the practitioner, they have trouble adapting to evidence-based criteria such as the modified McGeer, SHEA or CDC.
And the other problem is, if the unwarranted culture does return with a level of bacteria that is not clinically indicative of an infection, these “veterans” will still request the practitioner prescribe an antibiotic. This is due to the fallacy of believing the surveyors are going to “get you” if you don't. (So now the old Bob Dylan song is playing in my head, “The times, they are a-changing.”)
OK, so control yourself, people. Just say no to cultures.
And, truly, if you and the practitioner feel there is clinically valid evidence to suspect a UTI, order a urine analysis with reflex. That way if the UA is OK, the culture won't be done. If the UA is positive for leukocyte and/or nitrites or the microscopic shows high WBCs, the culture will be performed.
So relax and take a deep breath. Sing a few songs and we can get through this antibiotic stewardship stuff, no problem!
Just keeping it real,
Nurse JackieThe Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, an APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.