Diagnosis and Treatment of Bacteriuria in Nursing Homes

1. Diagnosis and Treatment of
Bacteriuria in Nursing
Homes
A CARE BY DESIGN MODEL

2. 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.

3. 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.

4. 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.

5. Diagnosis and Treatment of Bacteriuria
Research Concludes
Confirmed 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.

6. 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.

7. Yes
Positive
Fever or severe systemic symptoms
No
Yes

8. BPMN diagram for residents with
indwelling catheter

9. 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.

10. 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

11. Data Model
PhysicianData
Name Type
 physicianid String
 firstname String
 lastname String
 specialty String
 schedule String
ResidentsData
Name 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

12. Data Model
ScoreData
Name Type
 ScoreNum Integer
LabData
Name Type
 LabId String
 Dateofsample Date
 Dateofsampleprocessed Date
 Labresult String
TreatmentData
Name Type
 Tid String
 Ttime String
 Tdate Date
 Medication String

13. Description of clinical workflow in BPMN (
without catheter)
Acute Signs and Symptoms:
 Dysuria alone
 Unexplained delirium
Fever AND at least one of the following
 New or worsening urgency, frequency, or urinary incontinence
 Suprapubic pain
 Costovertebral angle tenderness
 Gross hematuria

14. 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

15. Yes
Positive
Fever or severe systemic symptoms
No
Yes

16. BPMN diagram for resident without
indwelling catheter

17. 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

18. 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.

19. 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.

20. 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.

21. 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