I was reading an item in the McKnight’s Clinical Daily newsletter and it totally touched on one of my pet peeves. It’s a habit we just can’t seem to get nurses and families to break. And it may be an example of the American mentality of, “We want a pill to fix everything.”
Yes, you guessed it, the infamous, “It must be a UTI so give them an antibiotic.” I love this quote from the article related to the false diagnoses: “The analysis found a randomness to some of the assessments. ‘Overall, clinicians’ rate of false positive diagnoses of patients without UTI was not much better than flipping a coin,’ wrote lead author Christine E. Kistler, M.D., of the University of North Carolina.”
Whoa, flipping a coin. Even though we have easy to understand AMDA guidelines and Centers for Medicare & Medicaid Services guidance on using fact-based clinical criteria to diagnose a Urinary Tract Infection (UTI). As a matter of fact, under F690 in the state operations manual, a UTI is defined as “a clinically detectable condition.”
No coin flipping here!
The guidance further gives the minimum criteria for initiating antibiotics for an indication of urinary tract infection.
1. For residents who do not have an indwelling catheter, minimum criteria for initiating antibiotics include: >105 CFU/mL (positive) or pending urine culture and dysuria alone or two or more of the following: fever (>37.9ºC [100ºF] or 1.5ºC [2.4ºF] increase above baseline temperature on two occasions over last 12 hours), new or worsening urgency, frequency, suprapubic pain, gross hematuria, costovertebral angle tenderness (flank pain), urinary incontinence, or shaking chills.
2. For residents who have an indwelling catheter or a suprapubic catheter, minimum criteria for initiating antibiotics include the presence of: >105 CFU/mL (positive) or pending urine culture and one or more of the following: fever (>37.9ºC [100ºF] or 1.5ºC [2.4ºF] increase above baseline temperature on two occasions over last 12 hours), new costovertebral tenderness, rigors (shaking chills), or new onset of delirium.
And, you have to be living under a rock if you are unaware of either the Loeb criteria or the McGeer’s criteria for a UTI. CMS references the Loeb criteria. Most of us with electronic health record systems have one of these built in.
But no. Daughter comes up to a nurse when Mom has some general malaise of “just not herself” and tells nurse, “The last time Mom was like this she had a UTI.”
So, off goes nurse, calling an attending who’s busier than a one-armed wallpaper hanger and adds that this 87-year-old female has cloudy, funky smelling urine and the doc orders an antibiotic. No assessments, no evaluation.
Come on, somebody! What 87-year-old doesn’t have funky urine? As you age, all of your organs shrink and your connective tissues harden. Therefore, we have a small bladder that no longer can stretch and completely empty. So, YES, you have cloudy urine. It’s a normal thing. You can pretty much count on a culture showing asymptomatic bacteriuria.
As an aside, take a tip from Nurse Jackie: If your practitioner does want a urine diagnostic, order a urinalysis with reflex. This way, the lab will only add the culture if the urine has enough white blood cells to support getting a culture. Way less confusion and all labs do it!
If the nurse doesn’t evaluate the resident to gather pertinent clinically valid information (can I at least have some vitals PLEASE!) to report to the practitioner and if you don’t get the doc’s butt in there to do a medically necessary visit, or at least order blood work and some diagnostics, you won’t know what’s really brewing inside of this resident. You’re not doing anyone a service by ordering a pill, for goodness sakes.
This discussion on this has been going on for close to 20 years now. It’s not new (though CMS updated its guidance in 2017, they did list clinically valid criteria in 2005). And I guess I am just getting older and grumpier but come on, let’s make some clinical sense.
No more coin flipping, OK?
Just keeping it real,
Nurse Jackie
The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, Senior Director of Clinical Innovation and Education for Mission Health Communities, LLC and 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. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
