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UrinaryTractInfection.pdf
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Point-of-Care Testing for the Treatment of Urinary Tract Infections in Symptomatic Older
Adult Patients Residing in a Long-Term Care Facility:
An Evidence-Based Quality Improvement Project
Kerri Sauer
University of Phoenix
Dr. Amanda Hundley
June 26, 2023
Signatures:
DNP Project Chair
Raelene Brooks, PhD, RN Dean, College of Nursing
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Abstract
Persons 65 years and older are at risk for significant complications related to Urinary Tract
Infections (UTI) including hospitalizations, sepsis or even death. This evidence-based practice
(EBP) project aimed to improve geriatric patient health with earlier treatment of symptomatic
urinary tract infections and the prevention of unnecessary antibiotic use. In doing so, the
objective was to enhance the quality of life of the elderly living in a long-term care facility.
Although research has shown the effectiveness of the urine dipstick, no study has compared the
implementation of treatment for symptomatic UTI patients using the urine dipstick as compared
to the laboratory results of urine analysis. A retrospective, quantitative methodology was utilized
in this EBP project with a pre and post-test design. The sample size was 50 with 25 pre-
intervention and 25 post-intervention. Statistical analysis was used to determine the time
differences for treatment implementation comparing standard laboratory urine testing time with
the use of a Point-of-Care (POCT) urine testing time. This evidence-based practice project
proposed improvement in practice by reducing the time from UTI symptom onset to treatment in
the elderly residing in a long-term care facility. This EBP Quality Improvement analysis
concluded a clinical and statistical significance, demonstrating a 97% reduction in treatment
time with the use of bedside urine POCT vs. standard laboratory urine testing. Evidence-based
clinical applications are essential for advanced practice nurses to understand the connection
between science-based evidence and its contribution to improvement in clinical practices that
enhance the quality of life for patients and populations.
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Dedication
To my amazing, supportive family! Thank you from the bottom of my heart for your
encouragement and compassion throughout this journey! To ME! It’s amazing the things one
can accomplish with a clear mind! #Clarity
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Acknowledgements
This manuscript would not be complete without the undying support, guidance, and
friendships I have made along this DNP journey. Thank you to the amazing team of leaders
within the University of Phoenix DNP program. To my DNP chair, Dr. Amanda Hundley, my
personal cheerleader, my ROCK, who far exceeds any academic facilitator I have ever had the
pleasure to encounter. I cannot thank you enough for everything you have guided me through to
accomplish this. To my “girl” from across the country Josephine, I thank you for your friendship,
support, and encouragement along the way.
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Table of Contents Abstract ......................................................................................................................... 2 Dedication ..................................................................................................................... 3 Acknowledgements ...................................................................................................... 4 LIST OF TABLES .......................................................................................................... 7 LIST OF FIGURES ......................................................................................................... 8 Introduction to the Problem ......................................................................................... 9 Problem Statement ......................................................................................................... 9 Purpose of the Project ...................................................................................................10 Practice Question ..........................................................................................................11
Theoretical Framework ...............................................................................................11 Literature Synthesis ....................................................................................................12 Introduction ...................................................................................................................12 Point-of-Care Testing ....................................................................................................13 Benefits of POCT ..........................................................................................................14 An Aging Population ......................................................................................................15 Age-Related Changes ...................................................................................................16 Risk Factors for Urinary Tract Infections ........................................................................17 Atypical Presentation of UTIs in the Elderly ...................................................................18 Antimicrobial Resistance ...............................................................................................21 Urine Point-of-Care Testing in Long-Term Care ............................................................22 Misuse of Antibiotics for Urinary Tract Infections ...........................................................24 Gap in Practice ..............................................................................................................25 Summary .......................................................................................................................26 Project Stakeholders ...................................................................................................27 Barriers to Change ........................................................................................................29 Facilitators to Change ....................................................................................................29 Ethical Considerations ................................................................................................30 Informed Consent/Assent ..............................................................................................32 Project Methodology ...................................................................................................32
Project Design ...............................................................................................................32 Population and Sample .................................................................................................33 Project Setting ...............................................................................................................34 Description of the Evidence Based Intervention .............................................................34 Outcomes and Project Objectives ..................................................................................35 Instrument Tool .............................................................................................................35 Data Sources and Collection .........................................................................................36 Data Analysis ................................................................................................................37 Project Implementation ...............................................................................................38 Description of the Evidence-Based Intervention ............................................................38 Project Findings ..........................................................................................................39
Results/Outcomes .........................................................................................................40
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Strengths and Limitations ..............................................................................................44 Discussions and Recommendations ..............................................................................45 Implications for the Discipline of Nursing .................................................................47 Project Alignment to the AACN DNP Essentials .......................................................47 Dissemination ................................................................................................................51
References ...................................................................................................................53 Appendices ..................................................................................................................61
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LIST OF TABLES
Table 1: Level of Measurement for Variable………………………………………….37
Table 2: Treatment Time Comparisons (Minutes)……………………………………41
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LIST OF FIGURES
Figure 1: Time Difference (Minutes)……………………………………………………42
Figure 2: Time Difference (Hours) ……………………………………………………..42
Figure 3: Time Difference (Days)……………………………………………………….43
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Introduction to the Problem
According to Bentley et al. (2001), the elderly population (persons aged > 65 years) in
the United States is rapidly expanding and will nearly double in number over the next 30 years.
It is estimated that greater than 40% of persons aged over 65 years will require care in a long-
term care facility (LTCF) at some point during their lifetime. Long-term care facilities (LTCF)
offer 24-hour comprehensive care including medical, personal, recreational, and social services
coordinated to meet the physical, social, and emotional needs of people who are chronically ill
or disabled. Those admitted to LTCFs inherently have more health problems and multiple co-
morbidities necessitating a skilled level of care. Particularly, Bentley et al. (2001) conveyed that
residents of LTCFs are the ‘older’ of the old and have age-related immunologic changes,
chronic cognitive and/or physical impairments, and diseases that alter immune response to
illness: therefore, they are highly susceptible to infections and complications of such. Lack of an
intact immune response predisposes this population to becoming sicker faster.
Problem Statement
Consistent with Bentley et al. (2001), infections in the elderly can be detrimental to
health and wellness. The practice at the long-term care facility implicated in this evidence-based
practice (EBP) project was to send urine samples of symptomatic patients to an outside
laboratory located at the local hospital. Processing time and receipt of preliminary results took
24-48 hours, resulting in delays in treatment. Improvement in the processing time and receipt of
preliminary results permitted timelier implementation of treatment for UTIs in this vulnerable
population. Possessing the availability to promptly assess symptomatic UTI patients for the
presence of nitrites, leukocytes, and blood in the urine can significantly impact the patients’
quality of life. In line with Thomas et al. (2022), utilization of point-of-care testing (POCT) at the
bedside resulted in less time for diagnosis than the current standard of using a centralized
laboratory for urinalysis.
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According to Thomas et al. (2022), point-of-care testing for UTIs can potentiate many
benefits. For example, POCT for UTIs can decrease the time involved in getting an accurate
diagnosis which in turn provides practitioners the opportunity to apply specific guidance on
which antibiotics to prescribe for maximum therapeutic benefit. Additionally, POCT reduces the
laboratory load of urine specimens, associated costs, and subsequently mitigates the increasing
prevalence of antibiotic resistance with inappropriate antibiotic prescribing. POCT for UTIs also
minimizes the number of practitioner visits and hospital admissions associated with
mismanaged urinary tract infections or adverse effects of inappropriately prescribed antibiotics,
including improved symptoms, quality of life, and a decrease in mortality.
Purpose of the Project
The purpose of this evidence-based quality improvement analysis was to improve the
time for initiation of treatment of urinary tract infections in symptomatic older adult patients
residing in a LTCF. This was performed by comparing traditional centralized laboratory testing
time to Point-of-Care Testing (POCT) time for urinary tract symptoms of elderly patients residing
in a long-term care facility. The underlying concept behind POCT is that when testing is
performed at the bedside the results are immediately available for medical decision making.
The practice at this long-term care facility was to send urine specimens to an outside
laboratory located at the local hospital. Consistent with testing performed in a central laboratory,
a urinalysis requires 24-48 hours before receipt of results within the LTCF. Furthermore, urine
culture results require another 24 hours before results were available at the LTCF. Longer turn-
around times delay treatment for patients and can lead to unnecessary hospitalizations as
indicated by Nagar and Davey (2015). Additionally, longer turn-around times contribute to the
inappropriate prescribing of antibiotics to remedy symptoms. Thomas et al. (2022), detailed that
point-of-care testing would afford the practitioner with information to guide antibiotic treatment if
indicated, consistent with an antibiotic stewardship program, developed to avoid overuse of
antibiotics and subsequent drug-resistant infections.
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Practice Question
The practice question was, what influence will the use of point-of-care testing (POCT) for
patients with suspected urinary tract infections (UTI) have on the implementation time of
treatment as compared to the implementation time of treatment for patients with suspected
urinary tract infections diagnosed using traditional centralized laboratory testing in patients aged
65 and older living in a long-term care facility (LTCF) during the acute illness phase?
Theoretical Framework
The Quality-Caring Model by Joanne Duffy exposes and demonstrates the value of
nursing within the evidence-based practice setting of modern health care. The model favors a
course that challenges modern standards and highlights the power of relationships.
Relationships that have been characterized by caring are theorized to influence positive
outcomes for patients/families, health care providers, and health care systems. According to
Duffy and Hoskins (2003), the Quality-Caring Model helps to translate the work of nursing into
objective terms that can be verified, thus scientifically demonstrating its worth. In turn,
advancing professional nursing work while simultaneously improving the quality of health care.
Salinas et al. (2020) indicated that within the Quality-Care Model, caring relationships dominate
the process and lay the groundwork for the patient-nurse relationship. With use of the Quality-
Care Model, health care workers can benefit from evidence-based practices to improve job
performance. The importance of a therapeutic nurse-patient relationship can enhance both the
care the nurse provides and the care the patient receives. The model advises that people will
heal faster in an environment where they feel cared for. Further, it is proposed that people who
feel cared for are more likely to engage in health-promoting activities such as following the
treatment plan and maintaining healthy life choices.
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Literature Synthesis
A thorough review of the literature related to Point-of-Care Testing (POCT) was
conducted. Only peer-reviewed, full text, problem-focused articles were selected. Systematic
searches of medical literature databases (Medline, SAGE, EMBASE, PubMed, SCOPUS,
ProQuest, University of Phoenix Library, and CINAHL) between the years 2001 to 2022 were
reviewed. Key words included near-patient testing, bed-side testing, point-of-care testing,
turnaround time, rapid diagnostics, urinalysis, elderly, geriatrics, aging, long-term care, sepsis,
urosepsis, nosocomial infections, atypical presentation in elderly, urinary tract infections, and
antimicrobial resistance. A combination of sixty peer reviewed journal, qualitative, and
quantitative research articles were appraised.
Introduction
This chapter provides a review of the literature and secondary data that exists in relation
to the elderly population, urinary tract infections (UTI), the difficulty in diagnosing UTIs of those
with physical and cognitive disability, and the potential for inadequate diagnosis of UTIs that can
lead to consequential outcomes in the vulnerable elderly population. Accordingly, this chapter
will discuss the definition and components of Point-of-Care Testing (POCT) and provide an
analysis of age-related changes potentiating misdiagnosis of UTIs, atypical UTI presentation in
the elderly, and judicious use of antibiotics. The purpose of this evidence-based quality
improvement project was to improve the time for initiation of treatment of urinary tract infections
in symptomatic older adult patients residing in a LTCF.
The delivery of healthcare is continuously changing in infrastructure, communication,
diagnostics, and the effective delivery of quality healthcare has emerged to suit an ever-growing
population with various health care needs. An important component to the effectiveness of
treatment is the securement of a proper diagnosis or comparable differentials for improved
treatment and health outcomes. Distinct clinical diagnoses as well as considerable differential
diagnoses can provide valuable insight to support healthcare provider decisions in appropriate
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treatment with a subsequent plan of care to ensure quality healthcare outcomes for patients.
Juthani-Mehta et al. (2007) has indicated that patient outcomes can be greatly improved with
bed-side testing when it is used to diagnose infection, exclude disease, or modify current
treatments for healthcare providers and patients alike. Patient-focused treatment that can be
initiated quickly and effectively has led to the development of bed-side testing, also known as
Point-Of-Care testing (POCT).
Point-of-Care Testing
The delivery of healthcare is evolving to meet the changing needs of patients, healthcare
providers, and medical technology. Since the onset of the pandemic, changes in healthcare
structure, work, and physician interaction with patients have been modified. Healthcare
organizations have had to become resourceful at managing patient illnesses with less means to
do so, especially over the course of the past few years. Healthcare practices are busier,
emergency rooms are fuller, and patients are sicker with more underlying comorbidities.
According to Nicholas (2020), point-of-care testing (POCT) is defined as laboratory
testing conducted close to the site of patient care. POCT provides rapid test results with the
potential for improved patient care. Point-of-care testing (POCT) is a laboratory-medicine
discipline that is evolving rapidly in analytical scope and clinical application and has been used
in various forms for a number of decades. In fact, Lee-Lewandrowski and Lewandrowski (2001)
indicated that in ancient times practitioners advocated the tasting of urine samples as a test for
diabetes mellitus. Additionally, Lee-Lewandrowski and Lewandrowski (2001) reported that for a
long time, POCT existed under the radar screen of the laboratory profession and was limited to
a few tests, such as dipstick urinalysis, physician performed microscopy, and fecal occult blood
testing. In the early 1990s, handheld glucose meters originally designed for home use began to
find their way into hospital settings as an aid to manage diabetic patients during the hospital
stay. The ability of clinical staff to adjust insulin dosages by rapidly measuring a patient’s
glucose value at the bedside using a simple finger-stick capillary blood sample provided a level
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of convenience and timeliness that the central clinical laboratory could not match. It soon
became apparent that other types of testing beyond blood glucose monitoring (i.e., fecal occult
blood testing, dipstick 5 urinalysis, rapid strep A testing) fell under the purview of these new and
evolving regulations as reported by Nicholas (2020).
The decision of which tests to offer in the POCT format depends on a number of factors.
The most important of these factors is turnaround time. As indicated by Nicholas (2020), the
need for urgent results may arise for clinical reasons, but more often is due to the impact of
turnaround time on workflow, patient illness, and healthcare operations. Consistent with Lee-
Lewandrowski and Lewandrowski (2001), the ability to obtain a test result quickly during clinical
care potentially avoids costly delays as patients progress through their course of illness. The
status of POCT will, for the foreseeable future, be driven by many of the same factors that affect
clinical laboratories, staff shortages, and acuity of patient illness.
Benefits of POCT
The largest benefit of using POCT, according to Florkowski et al. (2017), is that it can be
done rapidly and be performed by clinical personnel who are not trained in clinical laboratory
sciences. Rapid test results can provide physicians or other clinical personnel with answers that
can quickly help determine a course of action or treatment for a patient. This has obvious
benefits for the elderly in the long-term care setting. Having faster access to test results when
being presented with an atypical presentation of an elderly patient during the acute illness
phase provides healthcare providers with answers in a matter of minutes. POCT diagnostics
such as the urine dipstick in the long-term care setting may prove to be beneficial for the elderly
in LTCFs as well as improve workload by moving testing from a centralized lab to bedside,
improving diagnosis-to-treatment time and decreasing pre-analytical errors including mislabeling
of specimen, patient identification errors, lost specimen, or poor storage of a specimen.
Florkowski et al. (2017) also noted that the health cost benefit of using POCT has been
shown to be beneficial to the facilities who utilize such. The speed in which a clinician receives
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an answer, provides a diagnosis, and executes a treatment plan is increased significantly with
POCT. The technology used to test at the point-of-care has advanced, providing ease of use.
This provides a better-quality assurance (QA) environment for data exchange and ensures that
the patient data is up-to-date and readily available for healthcare provider treatment as indicated
by Florkowski et al. (2017).
Ransohoff et al. (2019) have stated that point-of-care testing (POCT) has the potential to
improve turnaround time, increase efficiency, and decentralize diagnostics in rural and
underserved communities. In the long-term care setting specifically, the introduction of POCT
could potentially keep patients’/residents from having to be transported to the hospital for
treatment if an adverse physiological condition could be identified and treated sooner than later.
Sumita et al. (2018) revealed the use of POCT in various clinical areas is validated by the fact
that the final result time is shortened, therefore permitting the health care provider with an
earlier diagnosis or differential and appropriate patient treatment initiated in a shorter time.
An Aging Population
The United States healthcare industry is facing the challenging needs of an aging
population. According to Sabharwal and Wilson (2015), medical research often defines a person
as elderly at the age of 65 or above. This definition varies and conventionally elderly has also
been defined as a chronological age of 65 years or older. Martinez-Lacoba et al. (2021)
indicated that population aging is an economic and social challenge in most countries around
the world because aging generates dependency rates and increases the demand for long-term
care. In turn, long-term care is a growing industry for the elderly who can no longer care for
themselves.
Due to lack of reserve to fight infection coupled with cognitive and physical impairments,
many elderly patients are unable to effectively communicate discomfort or symptoms of illness
such as a Urinary Tract Infection (UTI). The risk of long-term care needs generally increases as
people get older. Poor self-care, failure to thrive, nutritional decline, and compounding
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comorbidities all contribute to necessitating LTC. According to the National Institute on Aging
(NIA) (2021), those that enter LTC facilities are the sickest of the sick, necessitating multiple
healthcare and physical needs.
Age-Related Changes
The American 85 years old and over population will triple by 2050 according to Jaul and
Barron (2017). Clinicians and the public health community need to develop a culture of
sensitivity and understanding to the needs of this population and its subgroups of various
comorbid conditions. There are many changes that occur as one ages including hearing loss,
visual changes and loss, vestibular dysfunction leading to balance difficulty, loss of muscle
mass and fat, loss of immune function, and urologic changes. Metabolic, physiological, and
physical changes associated with the aging process contribute to multiple comorbidities that
subject the elderly population to nosocomial infections in long-term care facilities.
Those that reside in long-term care facilities are generally those with multiple
comorbidities, physical, and cognitive impairments which can potentiate the risk for infections.
Consistent with Cristina et al. (2021), an ageing population coupled with multiple comorbidities
lead to more complex pharmacological therapies (polypharmacy). Generally, chronic conditions
and polypharmacy can lead to a greater need for healthcare according to Almodóvar and
Nahata (2019). Elderly patients are identified as being in the high-risk group for the
development of healthcare-associated infections (HAIs) due to the age-related decline of the
immune system. Comorbid conditions can often complicate infections and alter typical
presenting symptoms thereby diminishing the ability to treat them effectively. According to Alpay
et al. (2018), the diagnosis and treatment of UTIs specifically are more complicated in the
elderly than in younger patients due to overall impaired general condition both physiologically
and physically. Healthcare providers who are not astute in identifying atypical symptoms of UTI
in the elderly can potentiate delays in treatment.
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Risk Factors for Urinary Tract Infections
A Urinary Tract Infection (UTI) is a bacterial infection of the bladder and associated
structures as defined by Bono and Reygaert (2021). Urinary tract infections (UTIs) are common
in the elderly and cover a range of conditions from asymptomatic bacteriuria to UTI-associated
sepsis requiring hospitalization. UTI is the second-most common infection in elderly women
living in the community, and the most common cause of infection in hospitalized elderly women
or those in long-term care consistent with Rodriguez-Mañas (2020). Factors that increase the
likelihood of developing UTIs in older adults include age-related changes in immune function
(immunosenescence), exposure to nosocomial pathogens, a higher number of comorbidities,
bowel and bladder incontinence, and decreased mobility—risk factors found in those requiring
long-term care.
A variety of risk factors predispose LTC residents to developing UTIs. According to
Genao and Buhr (2012), patient risk factors result from a combination of physiological changes
of aging and accumulation of comorbidities. Additionally, Genao and Buhr (2012) have indicated
that aging disrupts acquired immunity because of T-cell dysfunction and blunted cytokine-
mediated inflammatory response. This impaired cellular function is accentuated in the setting of
diabetes, cancer, and autoimmune disorders. Subsequently, comorbidities (i.e., dementia,
stroke, Parkinson’s disease) result in bladder and bowel incontinence and functional decline, of
which disrupt the body’s innate defense mechanisms. Stamm and Norrby (2001), reported that
in women, estrogen deficiency can cause vaginal prolapse and urinary incontinence. Estrogen
deficiency also impairs the protective action of bacterial colonization of the vagina with
Lactobacillus, which normally suppresses the growth of pathogenic bacteria. Conversely, in
older men, hypertrophy of the prostate causes urinary retention and turbulent urine flow,
predisposing them to chronic prostatitis. The chronically inflamed prostate can form calculi that
entrap bacteria, causing recurrent UTIs.
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According to the Center for Medicare and Medicaid Services (CMS) (2021), one goal of
a shared partnership with the US Department of Health and Human Services is to reduce the
number of individuals living in long-term care facilities (LTCF) who experience a preventable
complication requiring hospitalization. The effort aims to improve the quality of care and
services for individuals cared for in LTCFs. Consistent with the DNP essential of clinical
prevention and population health for improving the nation’s health, initiating POCT in regard to
early identification of UTIs for earlier treatment to prevent hospitalization of elderly patients in
LTCFs exemplifies a strategic movement in meeting the shared partnership goal.
Atypical Presentation of UTIs in the Elderly
Anyone who has ever worked with the elderly in LTC can attest that this population does
not present with the textbook symptoms of UTIs. Symptoms of a typical urinary tract infection
such as dysuria, urinary frequency, fever/chills, hematuria, and bladder tenderness/pelvic pain
are not the same for those with cognitive impairment or advanced age. Many signs and
symptoms of infection that are common in younger adults, present less frequently or not at all in
older adults. Consistent with Mouton et al. (2001), elderly patients with infections commonly
present with cognitive impairment or a change in mental status and frank delirium occurs in 50
percent of older adults with infections. Additionally, symptoms of infection in the elderly can also
include anorexia, functional decline, falls, and weight loss. If a healthcare provider is not adept
at noticing such changes in this population, the risk of mortality for the sick patient increases
exponentially.
Undiagnosed Urinary Tract infections in the elderly can have significant poor outcomes.
In a retrospective, observational, monocentric study by Laborde et al. (2021), all patients older
than 75 years and hospitalized between January 1, 2018, and January 1, 2019, who presented
with gram-negative bacillus (GNB) bacteremia and simultaneous bacteriuria (with the same
germ on urinalysis) were included. As expected, the diagnosis of UTI-related sepsis was more
frequent in the presence of UTI symptoms (81.6% vs. 44.8%, p < 0.01) and antibiotic therapy
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targeting GNB was also more frequently introduced within 24 h (81.6% vs. 62.7%, p = 0.04).
The diagnosis of UTI is a major issue in geriatrics. It is one of the most common diagnostic
errors and the leading cause of inappropriate antibiotic therapy in the geriatric setting. In this
cohort of older inpatients with UTI-related bacteremia, typical UTI symptoms were found in only
one-third of patients and an initial diagnosis of UTI was made in only 58%. The absence of UTI
symptoms including afebrile presentation, found in 40% of patients, was associated with an
increased mortality. While the presence of bacteriuria is not sufficient for UTI diagnosis, this
data supports that typical UTI symptoms are absent in most older patients. The diagnosis of UTI
is, therefore, particularly difficult in geriatrics, but remains of significant prognostic interest since
appropriate early diagnosis appears to be associated with lower mortality.
A delay in the diagnosis of urinary tract infection (UTI) is not uncommon. Atypical
presentation is often cited as one of the causes of diagnostic delays. Urinary tract infection (UTI)
is one of the most common infections requiring hospitalization and can be an important
contributor to sepsis. Sepsis mortality due to UTI is reported to be 10–30% according to
Schmiemann et al. (2010). Given that a delay in appropriate antimicrobial therapy is associated
with poor patient outcomes, it is important to make a correct diagnosis early and initiate
appropriate antimicrobial therapy for UTIs in the elderly. Atypical presentation is often cited as
one of the causes of diagnostic delays because typical UTI signs and symptoms, such as
dysuria, frequency, fever, and costovertebral angle tenderness, are often lacking in patients with
delayed diagnosis of UTI. Based on past and recent studies, one of the risk factors associated
with the absence of urinary tract signs and symptoms in patients with UTIs is advanced age, as
indicated by Schmiemann et al. (2010).
In another study conducted by Komagamine et al. (2022), of 285 patients, the median
age was 82 years, 186 (65.3%) were women, 53 (18.6%) had dementia, 26 (9.1%) had benign
prostatic hypertrophy, and 102 (35.8%) had diabetes. The most common symptom at
presentation was fever or chills (81.8%), followed by altered mental status (32.6%) and
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weakness (30.2%). On physical examination at initial presentation, lower abdominal tenderness
and costovertebral angle tenderness were present in 24 (8.4%) and 91 (31.9%) patients,
respectively. Among all the cases, 82 (28.8%) and 169 (59.3%) were cases of complicated UTI
and pyelonephritis, respectively. The most common pathogen was Escherichia coli (74.0%),
followed by Klebsiella species (9.5%), both organisms are commonly found in the
gastrointestinal tract. In the present study, advanced age and dementia were independent
predictive factors for the absence of urinary tract signs and symptoms. This result supports past
and recent studies reporting that UTI patients who were older were less likely to have urinary
tract symptoms. In addition, the research revealed that the absence of urinary tract signs and
symptoms at initial presentation was associated with an incorrect initial diagnosis for UTI and
delayed initiation of antimicrobial therapy. Given that elderly UTI patients are more likely to die
than younger UTI patients and that diagnostic and treatment delays may result in the poor
prognosis of elderly patients, efforts to diagnose UTI correctly and quickly among elderly
patients with dementia is certainly defensible. Diagnostic and treatment delays may result in the
poor prognosis of UTI elderly patients, further studies are justified to investigate risk factors
associated with the absence of urinary symptoms among the elderly.
The diagnosis of UTI is a major issue in geriatrics. It is one of the most common
diagnostic errors and the leading cause of inappropriate antibiotic therapy in the geriatric setting
as indicated by Laborde et al. (2021). Given the high uncertainty in UTI diagnosis in this older
population, another study by Laborde et al. (2021) aimed to evaluate the frequency and
prognostic burden of atypical presentation in an unselected cohort of older inpatients with UTI-
related bacteremia. The main results were as follows: (1) UTI symptoms were found in only one-
third of patients and were not associated with prognosis; (2) conversely, apyrexia, found in 40%
of patients, was associated with a higher risk of death; (3) early UTI diagnosis was made in 58%
of patients and associated with a better prognosis. Nearly two-thirds of patients over 85 years of
age are reported to have atypical symptoms in bacteremia. Impaired instrumental ability of daily
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living is thought to be a predictive sign of UTI. These atypical presentations are well known by
clinicians and motivate the prescription of urinalysis in patients with unexplained functional
decline, at the cost of potentially unnecessarily prescribing antibiotics. While the presence of
bacteriuria is not sufficient for UTI diagnosis, this data is a reminder that typical UTI symptoms
are absent in a majority of older patients. The diagnosis of a UTI is, therefore, particularly
difficult in geriatrics, but remains of significant prognostic interest since appropriate early
diagnosis appears to be associated with lower mortality. The aforementioned studies commonly
take account of information supporting atypical UTI presentation in the elderly population which,
if a UTI is not identified early on in its disease state, can lead to poor outcomes for this
vulnerable population.
Antimicrobial Resistance
Antimicrobial resistance of pathogens occurs when viruses, bacteria, fungi, and
parasites modify their configuration over time and no longer respond to medication treatment.
This causes enhanced difficulty in treating infections and potentiates the risk of disease spread,
severe illness, and death according to the World Health Organization (WHO) (2021).
Antimicrobial resistance is on the top-ten global health threats facing humanity in line with WHO
(2021). Consistent with Rodriguez-Manas (2020), the increasing antimicrobial resistance of
uropathogens is challenging the paradigm of empirical antibiotic therapy for symptomatic UTIs,
underscoring the need for alternative treatment strategies. Mouton et al. (2001) ascertained that
the diagnostic and therapeutic nuances of managing infections in older adults create special
challenges for physicians. The diagnosis of infection in older adults is more challenging, yet
early diagnosis and treatment in these patients are imperative because of the higher incidence
of morbidity and mortality.
Antimicrobial resistance (AMR) is a major public health concern. Elderly residents in
long-term care facilities (LTCFs) are frequently prescribed antibiotics, particularly for urinary
tract infections without a definitive assessment, test, or diagnosis. In a retrospective longitudinal
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cohort study by Thornley et al. (2018), data was extracted from a national pharmacy chain
database of prescriptions dispensed for elderly residents in UK LTCFs over a 12-month period.
Half of LTCF residents were prescribed at least one antibiotic over the 12 months, suggesting
that there is an opportunity to optimize antibiotic use in this vulnerable population to minimize
the risk of AMR and treatment failure. Inappropriate or empirical antibiotic prescribing has the
potential for antimicrobial resistance and side effects associated with antibiotic use such as
diarrhea, nausea, vomiting, anorexia, and clostridium difficile infection. Consistent with Eure et
al. (2017), antibiotics are among the most commonly prescribed drugs in nursing homes (NHs),
and between 25% and 75% of antibiotic prescriptions in this setting may be inappropriate. A
frequent driver of antibiotic use is UTI symptoms which accounts for 20%–60% of systemic
antibiotic courses administered in nursing homes. Antibiotic stewardship is especially critical in
older populations to reduce their risk of acquiring difficult-to-treat multidrug-resistant organisms
and to avoid the common sequalae of antimicrobial therapy on the vaginal and gastrointestinal
tracts. Urinary tract infections (UTIs) are commonly suspected in residents of long-term care
(LTC) facilities, and it has been common practice to prescribe antibiotics to these patients, even
when they are asymptomatic. This approach, however, often does more harm than good,
leading to increased rates of adverse drug effects, recurrent infections with drug-resistant
bacteria, and secondary infections from antibiotic use.
Urine Point-of-Care Testing in Long-Term Care
What influence can the implementation of point-of-care testing (POCT) for urinary tract
infections lead to faster treatment times compared to traditional centralized laboratory testing for
UTIs in those aged 65 and over living in a long-term care facility (LTCF) during the acute illness
phase? POCT has been defined by Navarro et al. (2020) as a test to support clinical decision
making, performed nearby the patient and on any part of the patient’s body or its derivates, to
help the patient and healthcare professional on the best management approach during or very
close to the time of the consultation, with results available at the time of clinical decision making.
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According to Thomas et al. (2022), point-of-care testing for UTIs can potentially
decrease the time involved in getting an accurate diagnosis, provide practitioners with specific
guidance on which antibiotics to prescribe for maximum therapeutic benefit, reduce laboratory
load of urine specimens and associated costs, mitigate the increasing prevalence of antibiotic
resistance with inappropriate broad-spectrum antibiotic prescribing, and minimize the number of
practitioner visits and hospital admissions associated with mismanaged urinary tract infections
and adverse effects of inappropriately prescribed antibiotics.
Bedside urine testing can be especially useful in assisting the healthcare provider in
determining the appropriate course of action for the treatment of patients with changes in
condition or with urinary symptoms. In a two-year retrospective study performed by Mambatta et
al. (2015), urine dipstick analysis of 635 urine culture-positive patients were studied. The
sensitivity of nitrite alone and leukocyte esterase alone were 23.31% and 48.5%, respectively.
The sensitivity of blood alone in positive urine culture was 63.94%, which was the highest
sensitivity for a single screening test. The presence of leukocyte esterase and/or blood
increased the sensitivity to 72.28%. The sensitivity was found to be the highest when nitrite,
leukocyte and blood were considered together. This study concluded that a POCT urine dipstick
test alone is not reliable in predicting UTIs, however the urine dipstick is helpful in determining
immediate course of treatment for symptomatic patients.
In another research study by Juthani-Mehta (2007), in 101 nursing home residents with
suspected urinary tract infection (UTI), it was determined the negative predictive value of
dipstick testing for leukocyte esterase and nitrite to be 100% (95% confidence interval, 74%‐
100%), compared with laboratory evidence of UTI (greater than 10 white blood cells/mm3 on
urinalysis and greater than 100,000 colony forming units/mL on urine culture). This study
concluded that urine dipstick testing effectively excluded the possibility of UTI in nursing home
residents. This information is helpful to determine a differential diagnosis and plan of care for
those demonstrating symptoms consistent with a UTI. This study also supports less need for
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inappropriate antibiotic prescribing consistent with the antibiotic stewardship program directed
by the Center for Disease Control and Prevention (2021).
In a research analysis by Deville et al. (2004), the objective of the meta-analysis was to
summarize the available evidence on the diagnostic accuracy of the urine dipstick test,
considering various pre-defined potential sources of discrepancy. This review demonstrated that
the urine dipstick test alone seems to be useful in all populations to exclude the presence of
infection if the results of both nitrites and leukocyte-esterase are negative. Seventy publications
were included. Positive predictive values were ≥80% in elderly. The combination of both nitrite
and leukocyte-esterase test results showed an important increase in sensitivity.
Point-of-care urine test characteristics are important to understand to conclude that
asymptomatic bacteruria exists. The objective of a study conducted by Ginting et al., (2018),
was to estimate the test characteristics of the urine dipstick test in relation to the results of a
urine culture in patients suspected of having a UTI and concluded that the use of a urine
dipstick test in a rule-out strategy can reduce the need for urine culture and avoid the
prescription of ineffective and inappropriate antibiotics. The study shows that the urine dipstick
test is an adequate tool to assess the probability of a positive urine culture in patients with
asymptomatic bacteruria.
Misuse of Antibiotics for Urinary Tract Infections
As indicated by Navarro et al. (2020), up to 90% of patients presenting to primary care
with urinary symptoms receive an antibiotic but it is usually without further investigation, so it is
unclear how many will have a proven infection. Available evidence on how well symptoms
predict the presence of a true UTI has shown differing results, when compared with the gold
standard (urine culture). The probability of a female patient presenting to primary care with
typical UTI symptoms and having a confirmed infection is estimated to be between 50%–80%,
with the greatest predictability for hematuria, when combined with a positive urine dipstick.
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Therefore, enhanced diagnostic accuracy could potentially reduce inappropriate antimicrobial
use in this context.
The gold standard for UTI diagnosis is urine culture from a midstream, clean urine catch,
but as previously mentioned, urine culture is not always performed, especially in primary care
and emergency departments, where diagnosis of most UTIs occurs. Urine culture is slow,
requiring at least 24–48 hours to report the causative microorganism and provide an antibiotic
resistance profile. Even a laboratory processed urinalysis can take up to 24 hours for results.
UTI symptoms are usually distressing enough to prompt empirical management because
acutely unwell patients with UTI symptoms may not be prepared to wait up to 48-hours for a
culture result. Current clinical guidelines also advocate empirical treatment if symptoms are
sufficiently suggestive of a diagnosis of UTI, again promoting the development of antibiotic
resistant organisms. Empirical decision-making will often result in the patient getting an
antibiotic without infection confirmation. As a result of this, point-of-care tests (POCT) have
been developed and aim to provide a more rapid and accurate method for detecting a UTI.
Gap in Practice
The purpose of this evidence-based quality improvement project was to improve the time
for implementation for treatment of urinary tract infections in symptomatic older adult patients
residing in LTC by comparing time of treatment following traditional centralized laboratory
testing and Point-of-Care Testing (POCT). The objective was to improve patient treatment and
outcomes. The underlying concept behind POCT is that when testing is performed at the
bedside the results are immediately available for medical decision making. This contrasts with
testing performed in a central laboratory where results for commonly ordered tests may take
hours to days for final results. Longer turn-around times delay treatment of patients and can
lead to unnecessary hospitalizations as indicated by Nagar and Davey (2015).
Latour (2022) has indicated that the diagnosis of a UTI in the elderly cannot be solely
based on signs/symptoms. In the elderly, signs and symptoms can be atypical. Additional
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diagnostic testing is required to improve antimicrobial prescribing in LTCF residents suspected
of having a UTI. Bacteriological urine culture has become a standard test in the diagnosis of UTI
and is also recommended for older people as their microbiology differs from the young person.
The time between initial onset of urinary symptoms or change in condition to the time of a final
urine culture received in a nursing home can be 24-48 hours. A second commonly used
instrument for diagnostic testing is the urine dipstick. A meta-analysis by Deville et al. (2004),
concluded that urine dipstick tests are useful to exclude the presence of an infection provided
the results for both nitrites and leukocyte-esterase are negative. A cross-sectional study by
Juthani-Mehta et al. (2007) confirmed this in a LTC setting. Extrinsic factors that lead to delay in
treatment include lost specimen, mislabeled specimen, improperly stored specimen, and delay
in transfer of specimen. Intrinsic factors to consider are alteration in patient mental status,
incontinence, hydration status, and lack of immune response.
Summary
Our world is facing a rapid growth of population accompanied by an increase in the
average lifetime of individuals. The rate of deaths in chronic diseases is increasing and will
reach 66% in 2030 according to Orimo (2006) who also reported that one of the reasons of the
increasing rate of deaths is the late diagnosis of patients. Early detection and effective infection
management would mitigate the impact of drug-resistant diseases and decrease the healthcare
expenditures and resources.
The knowledge gained from biostatistical research is intended to improve the efficiency
of healthcare delivery and prevention of disease. Urinary Tract Infections are a common
debilitating infection for the elderly in the long-term care setting. Elderly with cognitive
impairments do not present with typical UTI symptoms, placing this vulnerable population at risk
for worsening of illness, functional decline, and subsequent death. The implementation of a
simple urinary dipstick used in the LTCF setting can benefit this population by confirming the
presence of nitrates, leukocytes, and blood in the urine prompting further laboratory review of
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the urine specimen and earlier treatment of the elderly patient. In turn, earlier treatment
enhances earlier resolution of the infection and subsequent enhanced quality of life and comfort
for the patient who is incapable of expressing symptoms due to existing cognitive deficits.
Mouton et al. (2001) ascertained that the diagnostic and therapeutic nuances of managing
infections in older adults create special challenges for physicians. POCT for UTIs in LTC
supports the diagnosis of infection in older adults and supports tangible diagnostics for
physicians to make informed treatment decisions.
POCT diagnostics such as the urine dipstick in the LTCF setting may prove to be
beneficial for the elderly as well as improve workload by moving testing from a centralized lab to
bedside, improving diagnosis-to-treatment time and decreasing pre-analytical errors. POCT for
urinary tract infection detection for the elderly within the long-term care setting have positive
outcomes allowing for the development of protocols in treatment.
The use of urine POCT dipstick testing may be helpful in serving as a screening test for
the presence of a UTI in the elderly, as well as a differential test for other infections. Urine
POCT in LTC settings with atypical UTI presentation can potentially enable faster treatment time
and aid in a differential diagnosis to reduce needless or inappropriate antibiotic prescribing
among the elderly population. Decisions to prescribe antibiotics or order screening tests should
take into account the goals of care, risks, benefits, and lag-time to treatment. The intended goal
of this evidence-based project was to produce positive patient outcomes and generate new
knowledge through the integration of best research evidence and clinical expertise.
Project Stakeholders
In clinical research, the focus is on supporting the process of program development to
enhance quality outcomes and is grounded on evidence-based practices. The underlying
motivation for such is to improve healthcare delivery, become aware of dysfunctionalities that
may exist in healthcare, and to improve the outcomes of proposed changes. It is essential then
that research and program processes are assisted by those who are most directly affected by
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the research, the stakeholders. In the case of this evidence-based practice (EBP) project, the
stakeholders included the residents of the long-term care facility (LTCF), the families of the
residents, the physicians and providers affiliated with the facility, the administration of the
facility, the nurses of the facility, and the DNP faculty at the University of Phoenix.
It is important for the stakeholders to understand their specific role and responsibility
within the project team. Having clearly delineated roles will help the stakeholders understand
their position along the continuum within the EBP project. The stakeholders included in this
project include the residents/patients who are the sample subjects of which this EBP project
aims to assist the most by way of enhancing health and wellness. The patients’ families are
stakeholders because they often are witnessed to become concerned when their family member
(patient) is not feeling well or has had a change in condition. The physicians/providers
associated with the facility are stakeholders because the point-of-care testing (POCT) for
symptomatic patients can be readily used at the facility to determine subsequent treatment.
POCT will potentially save the physician/provider time as well by not having to call the facility
several times as the plan of care develops. The administration is a stakeholder because if a
patients’ illness is identified and treated early, there is less potential for a hospital transfer or
hospital admission, thereby contributing to maintenance of census and costs associated with a
patient transfer. The nurses as stakeholders were involved in the assessment of the patient,
notifying the physician, obtaining UA orders, obtaining the urine sample, and medicating the
patient for comfort while waiting for results of the UA. Once the UA results were received, the
nurse then notified the physician again of the results to obtain subsequent orders. With the
implementation of POCT for urinary symptoms, the nursing process associated with a patient
demonstrating urinary symptoms will be reduced.
Finally, the professors at the University of Phoenix that are guiding this EBP project are
important members of the stakeholder group. According to Concannon et al. (2019), all study
teams—even those in basic and clinical sciences—have experience working with independent
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peers who review study protocols and manuscripts. This is a form of stakeholder engagement,
in which external researchers with an interest in safeguarding the ethical conduct and rigor of
research use commonly held standards to review the proposed or completed work.
Barriers to Change
Barriers to change include lack of staff understanding of the importance of evidence-
based quality improvement, lack of support and accountability from the nursing staff, lack of
communication with the facility nurse educator, unclear policy and procedure, and multiple new
implementations at once. Established barriers of this EBQI project included nurses not wanting
to take the time to perform the POCT so instead would request a UA/C & S from the healthcare
provider and send the urine to the lab for initial testing. Additional barriers noted were nurses
not reading the policy/procedure thoroughly and therefore were not performing the quality
control and POCT correctly. Per the facility infection preventionist nurse, a 3-day watch of UTI
symptoms was recommended to prevent needless antibiotic treatment. After the 3-day watch, if
the patient still had UTI symptoms, then a point-of-care urine dip was recommended. The issue
with this practice is that it contributed to the potential delay in treatment time from onset of
symptoms to treatment. Barriers frequently reported include lack of nursing time, staff shortage,
heavy patient caseload, limited knowledge of EBP with vague beliefs toward it, and limited
academic skills. Training nurses on how to use the innovation before it was implemented
contributed to successful adoption.
Facilitators to Change
Change in healthcare is inevitable. Change for the welfare of improving patient health
and quality of life should be a priority. This project was facilitated by the support from the DNP
faculty, facility administration, medical director, and nurse leaders within the organization,
persistence oversight from the project leader, and the unfolding of progressive positive results.
Contrary to the identified barriers, there were nurses who enveloped the notion of autonomous
practice and early treatment with use of the urine POCT for the welfare of the patients. The
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eagerness of nurses and physicians to use the POCT for earlier diagnostics and appropriate
treatment exemplified the model of improving patient care. Patient families were supportive and
appreciative for early testing contributing to earlier treatment and the potential for prevention of
patient hospital admission. The leadership support provided by the administration and project
manager for the advancement of treatment facilitated nursing autonomy and knowledge for the
wellness of patient care and outcomes. Training of staff in the policy, procedure, and use of the
urine POCT was performed during working hours making it convenient for staff and cost
effective for the facility. Consistent with Carpenter et al. (2021), a major goal for a DNP project
is for the student to demonstrate the ability to lead and practice at the highest level, using
research and evidence to improve patient care, either directly or indirectly.
Ethical Considerations
Ethics are moral principles that govern how a researcher will behave or operate
throughout the research process. The focus pertains to the right and wrong of actions and
encompasses the decision-making process of determining the ultimate consequences of those
actions. Recupero (2008) reported that distinctive care is due regarding thoroughness and
honesty, collaboration and cooperation, autonomy and dignity, and confidentiality of the
patient(s) and family members, while maintaining objectivity and neutrality of communications
and professional activities. Ethical considerations related to this evidence-based practice (EBP)
project include informed consent, confidentiality, anonymity, privacy, beneficence, transparency,
communication, bias, and obtaining institutional approval for the research. Informed consent is a
principle in medical ethics and medical law that a patient should have sufficient information
before making their own free decisions according to Shah et al. (2022). This EBP translation
project did not involve any physical human subjects. A retrospective data chart review was
performed to gain information regarding treatment times from the initial symptom of a Urinary
Tract Infection (UTI) to the implementation of treatment. A quality improvement QI checklist was
completed (Appendix A).
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To maintain the confidentiality and anonymity of the project subjects, the data collection
form that was developed for medical record data abstraction was structured to disassociate any
recognizable characteristics of the patients. No identifiers such as names, gender, medical
record number, room number, unit of residence, or date of birth on the data abstraction tool was
collected. The completed data abstraction forms were maintained in a locked drawer in a private
office to which only the project manager had access to. Following conclusion of this EBP
project, the data collection tools will be destroyed in compliance with Federal regulations which
require research records to be retained for at least three years, each page will be shredded
within the facility by the project manager. Electronic data collected throughout the quality
improvement project will be deleted using specialized software such as Eraser. Eraser is an
advanced security tool for Windows which allows for complete removal of sensitive data from
the hard drive by overwriting it several times with carefully selected patterns.
Transparency was maintained throughout the progression of the EBP project with verbal
communication among the facility administration team at quarterly Corporate Compliance
meetings and through the process of the University of Phoenix IRB application. Obtaining
institutional approval for the research and ensuring the agency permission agreement form was
complete prior to initiating research within the facility was imperative.
According to Simundić (2013), bias is any trend or deviation from the truth in data
collection, data analysis, interpretation, and publication which can cause false conclusions. In
research it is important to maintain the highest level of objectivity in discussions and analyses.
Bias was achieved with the use of a standard data collection tool for retrospective chart review.
Bias in this EBP project was reduced by avoiding data fabrication, eliminating data which did not
support the hypothesis (clearly identifying inclusion and exclusion criteria), ensuring the
appropriate statistical test was used to analyze the data, testing multiple endpoints, and
performing secondary analyses. Data collection and analysis was a very important component
to this quality improvement project. The establishment of a clear understanding for the purpose
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of the project assisted the project manager to stay on task and establish the goal for the
outcome through the project. Decisively positioning and thoroughly understanding the
components of data collection and analysis was necessary to determine the efficacy of the
project.
Informed Consent/Assent
An application to pursue this quality improvement project was submitted to the University
of Phoenix Institutional Review Board (IRB). After the necessary data for permissions were
reviewed, it was determined by the IRB that this project was exempt from informed consent
(Appendix B). It was with the upmost intent that this EBP project was conducted consistently to
uphold moral, ethical, and principal standards in order to conduct a reputable quality
improvement evidence-based research project.
Project Methodology
The patient medical record is often used as a primary source of retrospective data for
the purposes of epidemiological analysis and is considered to be the gold standard in any study
to identify demographic factors, clinical data variables, specific aspects related to treatment
regimens, and ultimately patient mortality and morbidity according to Gregory and Radovinsky
(2012). The advantages of using data obtained from the medical record via retrospective record
review include the ability to access large amounts of clinical data at a relatively low cost, the
ability to study associations between exposure and disease over long periods, and the ability to
evaluate hypotheses pertaining to clinical research questions, which may then be tested using
prospective trials. A data access and permission agreement was authorized by the health care
organizations administrator (Appendix C).
Project Design
The selection of an appropriate approach to answer research questions can be one of
the most important phases of the research process. The design chosen for this DNP project was
a quantitative data analysis with a pre and post-test intention to evaluate the outcome of time
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between use of urine POCT compared to that of standard urine laboratory testing. A
retrospective medical chart review was performed to collect data.
Convenience sampling was used to determine study subjects based on inclusion and
exclusion criteria. The inclusion criteria consisted of patients 65 years and older, current
inpatient at the LTCF, and documented symptomology of urinary tract infection including
complaints of urinary discomfort, urinary frequency, change in character of urine, bladder
tenderness, new urinary incontinence, change in mental or behavioral status from patient
baseline, change in physical mobility from patient baseline, and prescription antibiotic or urinary
anti-spasmodic treatment for urinary symptoms. Exclusion criteria included patients without
urinary symptoms, those with a diagnosis and treatment of a vaginal infection, and those with a
diagnosis of stress, overflow, and urge incontinence. The convenience sample was divided into
two groups, one received the standard urinalysis conducted by a centralized laboratory, and one
received urine POCT.
Data was obtained through medical record review using a researcher-developed data
abstraction tool. Interval level data indicating the time of initial onset of urinary symptoms, and
the time of antibiotic initiation was collected from the patients’ medical record. The independent
t-test using the Microsoft Excel and Statistics Kingdom platforms was used to compare the data
from the two groups. According to Kim (2015), this statistical analysis is aligned with the
collected data because an independent samples t-test is used to determine whether there is a
difference between two sample means that are independent of each other. Descriptive statistics
of central tendencies were used for interval level data and frequency, while percentages for
nominal or ordinal data were used to describe the sample.
Population and Sample
A population of residents aged 65 and older, residing in a long-term care facility (LTCF)
was utilized for this quality improvement project. A convenience sample of patients with signs
or symptoms of a urinary tract infection were selected from the population of residents of the
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LTCF. Convenience sampling is a non-probability form of sampling and is less objective than
probability techniques. With this type of sampling, the researcher uses sampling that does not
provide for each member of a target population to participate in a study and rather the
participants are selected by the researcher as stated by Stratton (2021). One disadvantage of
convenience sampling is that subjects in a convenience sample may not be representative of
the population the researcher is interested in studying. However, an advantage of convenience
sampling is that data can be collected quickly and for a low cost.
Project Setting
Data collection can potentially present a challenge for researchers, and it requires time
and effort. The data sources can be either the existing data or the new data. Existing data such
as from the existing records and documents can be of great value in some of the research
studies. The medical record review and data collection took place at the credenzas near each of
the four nurses’ stations within the LTCF. This area permitted for confidential medical record
review. Only pertinent data related to this evidence-based project was accessed and assessed
within the medical record.
Description of the Evidence Based Intervention
The goal of this DNP project was to justify the use of POCT for rapid treatment and
prevention of poor outcomes in those demonstrating symptoms consistent with a UTI living in a
long-term care facility. Today, commercially available urine dipsticks have evolved to be a
highly efficient tool for investigating, detecting, and screening diseases with rapid, high-quality
results, all while maintaining ease of use as stated by Lei et al. (2020). Prior to the intervention,
this LTCF did not utilize POCT for UTI symptoms or treatment.
The ability to quickly diagnose and implement treatment for the elderly ailing from UTI
symptoms was beneficial in preventing further compromise, and demise. Genao & Buhr (2012)
reported that urinary tract infections (UTIs) are commonly suspected in residents of long-term
care (LTC) facilities, and it has been common practice to prescribe antibiotics to these patients,
35
even when they are asymptomatic. This approach, however, often does more harm than good,
leading to increased rates of adverse drug effects and more recurrent infections with drug-
resistant bacteria as indicated by Genao & Buhr (2012).
Outcomes and Project Objectives
The project objectives aimed to improve patient care with earlier treatment of urinary
symptoms, prevent unnecessary treatment with judicial use of antibiotics, and enhance patient
outcomes with less symptom time and discomfort from urinary symptoms. The project outcomes
were met by performing a systematic analysis through retrospective chart review to verify faster
treatment time with the use of a POCT for UTI symptoms compared to the use of the standard
centralized laboratory urinalysis of the elderly living in a long-term care facility. This evidence-
based practice project proposed improvement in practice by filling gaps in practice with the
implementation of reducing the treatment time from UTI symptom onset to treatment in the
elderly residing in LTCFs to enhance patient quality of life.
Instrument Tool
Reliability and validity are among the most important and fundamental domains in the
assessment of any measuring methodology for data-collection in good research according to
Ahmed and Ishita (2021). The data collection tool used in this evidence-based practice project
was developed by the project manager and was found to demonstrate consistent results within
the sample group. The instrument was considered reliable because it measured the same items
in each medical record resulting in consistency in the data collection method. The data tool was
piloted by the project manager and expertly reviewed by three University of Phoenix DNP
faculty, a geriatric physician and facility medical director, and two geriatric nurses. The data
collection tool was considered valid because it performed reliably and accurately attained the
data necessary for the intended research analysis.
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Data Sources and Collection
The data collection was performed specifically by the project manager. Health Care
Provider (HCP) orders within each medical record were reviewed to determine if there was an
antibiotic, or urinary anti-spasmodic (for example Phenazopyridine) prescribed to the patient. If
so, nursing notes identified the symptoms for which the antibiotic was prescribed. If the
antibiotic was prescribed for urinary symptoms, the medical record was further reviewed to
assess for a urinalysis and/or urine culture report. The following information was recorded,
date/time of symptom onset and what the symptoms were, date/time of HCP notification of
symptoms, date/time the HCP corresponded back to the nurse for subsequent plan of care (i.e
UA/C&S, empiric antibiotic order, antispasmodic medication, etc…), if a Urinalysis (UA) / reflex
Culture (CIC) or UA / Culture and Sensitivity (C&S) was ordered, and the date/time urine was
collected. At this point, the urine sample was placed in a specimen refrigerator for the lab
courier to pick up and bring to the lab at the hospital where the urine was processed.
Subsequently, the date/time the respective patient’s urinalysis report was received in the facility
was recorded followed by date/time of HCP notification of the urinalysis results. The date/time of
HCP treatment orders were recorded followed by the date/time of actual treatment
implementation. Finally, the time interval from initial symptom onset to actual patient treatment
was recorded.
The data instrument that was used for this evidence-based practice project was a data
abstraction tool created by the project-manager (Appendix D). Consistent with Apuke (2017),
quantitative research involves the collection of data so that information can be quantified and
subjected to statistical treatment in order to support or refute alternative knowledge claims. The
content of the data abstraction tool was based on methodologies used in systematic reviews,
expert opinions, and pilot-testing. The tool was used to classify and describe key characteristics
of the intervention and evaluation, and to assess the quality of the research execution. Table 1
details the level of measurement for each variable.
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Table 1
Level of Measurement for Variable
Data Analysis
The statistical analysis used to analyze collected data was an independent t-test.
According to Kim (2015), a t-test is a type of statistical test used to compare the means of two
groups. Group (1) was the mean time it took from symptom onset to treatment initiation using
standard laboratory urine testing, and group (2) was the mean time it took from symptom onset
to treatment initiation using POCT. This statistical analysis was aligned with the collected data
because an independent t-test was used to determine whether there was a difference between
two sample means that are independent of each other, which is what this evidence-based
quality improvement project sought to establish. Assumptions of the t-test included that first, the
scale of measurement applied to the data collected followed a continuous scale. Time was
measured by which there is a true zero point, this followed a continuous scale. The second
assumption was that the data collected was from a representative portion (those with UTI
symptoms) of the total population (those >65 years old). The third assumption was that data
was input to reflect a normal distribution, bell-shaped curve. A normal distribution was assumed
because the level of probability of 5% was used as the criteria for acceptance. The fourth
assumption was that a reasonably large sample size was to be used. When using the A Pyori
Variable Level of Measurement Age Ratio Gender Nominal Date/Time of Symptom Onset Interval Number of Symptoms Nominal Date/Time of HCP Notification Interval Date/Time HCP Corresponded back to nurse Interval Date/Time Urine Collected Interval Date/Time Patients’ UA report received Interval Date/Time HCP notified of UA results Interval Date/Time HCP treatment orders received Interval Date/Time of actual treatment implementation Interval Time interval from initial symptom to treatment Interval
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power analysis with one tail, effect size of 0.5, and power of 0.8, the total sample size needed
was 27. A larger sample size meant the distribution of results should approach a normal bell-
shaped curve. The fifth and final assumption as that homogeneity of variance was established
by ensuring the standard deviations of the samples were approximately equal. Using the
aforementioned analysis settings and the means of both groups, the standard deviation of both
groups was equal.
Project Implementation
The purpose of this evidence-based quality improvement project was to improve the time
for initiation of treatment of urinary tract infections in symptomatic older adult patients residing in
a LTCF. This was performed by comparing the time from initial symptom onset to treatment
initiation using traditional centralized laboratory testing and Point-of-Care Testing (POCT) for
those aged 65 and over meeting the inclusion criteria. The underlying concept behind POCT is
that when testing is performed at the bedside the results are immediately available for medical
decision making.
Description of the Evidence-Based Intervention
An IRB application was submitted, and informed consent was exempt for this project. A
urine dipstick test Clinical Laboratory Improvement Amendment (CLIA) waiver for urine POCT
was already on file within the facility. Since an additional CLIA waiver was not needed, the
policy and procedure (Appendix E), quality control log (Appendix F) and urinalysis reporting
form (Appendix G) was developed for the implementation of this evidence-based quality
improvement project. The urinalysis reporting form is the main correspondence between the
nursing staff and the health care providers. This form has been developed to not only
communicate results of the urinalysis dipstick, but also as the recording form of the urinalysis
dipstick. Once the HCP has provided new orders, the urinalysis reporting form is then placed in
the patients’ medical record for further referencing as indicated.
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During weeks one and two, 103 medical records were reviewed to gather retrospective
data for the use of standard laboratory urine testing. In weeks three through five, the nurses
throughout the facility were informed of and educated on the policy and procedure, the use of
the urinalysis dipstick test and urinalysis reporting form, and the use and documentation within
the quality control log. Initially there were errors with the use of the urinalysis reporting form and
quality control log, further investigation of such demonstrated that nurses did not in fact read the
policy and procedure. Therefore, daily facilitation and education was provided to nurses
throughout this time span. In weeks six through 12, data was obtained on patients who met the
inclusion criteria with use of POCT.
Once the nurses were reeducated as to the clinical interpretation, and understanding of
all forms, policy/procedure, and intended use of the quality control, the process flowed
seamlessly. A healthcare provider (HCP) order was not required for the nurses to perform the
dipstick urinalysis which provided nurses with the autonomy to perform the POCT based on
patient presentation. However, correspondence to the HCP with the results and rationale for
assessing a urine dipstick urinalysis was warranted.
Data sources included the medical records of those patients 65 years and older with
signs/ symptoms of a urinary tract infection meeting the inclusion criteria. This included a fever,
dysuria, hematuria, urinary frequency, urinary urgency, change in behavior, new incontinence,
change in mental status, suprapubic tenderness, and/or rigors or shaking chills. Each urinalysis
reporting form was reviewed, and the following data was collected, patient presentation of
symptoms, the time of onset of symptoms, new orders from the HCP, and treatment initiation
time. This was measured in minutes and entered into an excel spreadsheet.
Project Findings
The expected outcome of this EBQI project was to ascertain that the use of urine POCT
could reduce the time between initial symptom onset to the treatment initiation time for the
elderly residing in a long-term care facility. Microsoft Excel and Statistics Kingdom were used to
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statistically analyze the data of this EBQI project. A total of 50 samples were assessed, 25 prior
to the intervention and 25 post intervention. All samples met the inclusion criteria. An
independent sample t-test (Welch), using T(df:24) and a two-tailed distribution was used to test
the hypothesis that POCT for the identification of a UTI in the elderly living in a nursing home
leads to earlier treatment and prevention of poor outcomes compared to traditional standard
laboratory urine testing. POCT was found to be positively correlated with improved treatment
times, antibiotic stewardship, and avoidance of unnecessary antibiotic prescribing.
Results/Outcomes
The difference between pre-intervention and post-intervention treatment time was
statistically significant with α=0.05 using the independent t-test (Welch), and T-distribution
(df=24.7213) (two-tailed). Results of this statistical analysis indicated that there is a significant
difference between before (M = 5899.2, SD = 2686.8) and after (M = 186.6, SD = 329.4), t (24)
= 10.6, p < .001 the intervention. Since the p-value is <α, the Null hypothesis is rejected. The
effect size was large at 2.98. This indicates that the magnitude of the difference between the
average of the differences and the expected average of the differences is large. Project findings
concluded that there was a (97%) reduction in treatment time for the patients with symptomatic
UTI using POCT urinalysis versus standard laboratory testing. Table 2 demonstrates the time
differences (measured in minutes) between symptom onset and treatment using standard
laboratory testing and POCT.
41
Table 2
Treatment Time Comparisons (Minutes)
Sample # Laboratory Testing Point of Care Testing 1 4740 1440 2 10080 15 3 3240 30 4 6360 60 5 8640 840 6 6300 720 7 3420 30 8 2880 120 9 6240 30 10 9300 90 11 4740 60 12 4320 240 13 10560 60 14 1440 60 15 3360 30 16 6240 120 17 9120 120 18 2880 60 19 10080 120 20 6240 90 21 9120 90 22 4320 30 23 6240 60 24 4740 90 25 2880 60
Mean 5899.2 186.6
The following figures demonstrate time differences between urinalysis results using standard
laboratory testing, and POCT. Figure 1 represents the time measured in minutes, figure 2
presents this information in hours, and figure 3 represents this information in days.
42
Figure 1
Time Difference (Minutes) between Standard Lab Testing and POCT
Figure 2
Time Difference (Hours) between Standard Lab Testing and POCT
5899.2
186.6 0
1000
2000
3000
4000
5000
6000
7000
TI M
E (M
IN U
TE S)
S YM
TO M
O N
SE T
TO
TR EA
TM EN
T
Standard Laboratory Testing POCT
LAB TESTING VS. POCT
98.544
3.11 0
20
40
60
80
100
120
TI M
E (H
O U
RS ) O
N SE
T O
F SY
M PT
O M
S TO
T RE
AT M
EN T
LAB TESTING POCT
Lab Testing vs. POCT
43
Figure 3
Time Difference (Days) between Standard Lab Testing and POCT
This EBQI analysis concluded an average of four days from the time of initial symptom to time
of treatment using standard laboratory testing compared to three hours from symptom onset to
treatment initiation using POCT.
In addition to the statistical significance of this analysis, the clinical significance
demonstrates the magnitude of the quantitative effect. As reported by Carpenter et al. (2021),
clinical significance means the difference is important enough to the patient and the healthcare
team for improving quality patient outcomes. For this EBQI project, time from acute UTI
symptoms to treatment time was significantly reduced using POCT, therefore enhancing quality
of life and wellness of those affected within the elderly population at this LTC. Furthermore,
antibiotic stewardship was augmented with a reduction of unnecessary or blind antibiotic
prescribing. This is because not all subjects demonstrating acute changes in cognitive or
functional status had a positive UA with use of POCT. This also supports healthcare provider
treatment decisions and subsequent differential diagnoses. The clinical significance in this
project supports evidence-based care where the focus was placed on translating and
implementing evidence into practice.
4.1048
0.1286 0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
TI M
E (D
AY S)
S YM
PT O
M O
N SE
T TO
TR
EA TM
EN T
LAB TESTING POCT
LAB TESTING vs. POCT
44
Strengths and Limitations
Strengths for this EBQI project included cost effectiveness and data abstraction, which
was collected solely by the project manager ensuring consistency in results comparing
laboratory testing to POCT results. Data was directly entered on the data collection form (pre)
and Urinalysis Data Reporting Form (post). The support of nursing staff and physicians
contributed to the strengths by utilizing POCT in lieu of laboratory testing. The availability of
specific antibiotics in the facility emergency supply enhanced the efficacy of faster treatment.
Additionally, this project was not expensive, the total expense was $711.67 for all POCT
supplies. This EBQI project demonstrated confirmation that the innovation of this project within
LTCF or remote clinics is easy to use, cost-effective, and will enhance the outcomes of those
greater than 65 years old with symptoms of a Urinary Tract Infection.
Limitations to this project analysis included a small study size. According to data
analysis using G-power, a sample size of at least 30 was warranted to secure validity. Sample
selection was dependent on patient symptoms of illness of which the project manager had no
control over. Another limitation was access to medical records. This facility used paper medical
records and there were many healthcare personnel within the facility that required concurrent
access to the paper medical record. Further limitations of this EBQI project included the nurses
not reading the policy and procedure, and nurses were not taking the time to use the POCT for
symptomatic patients. Instead, when a healthcare provider was not on site, nurses were
requesting orders for laboratory urinalysis and cultures. Additional limitations included some of
the physician-ordered antibiotics were not in the on-site emergency box which led to delayed
treatment. Additionally, limitations included the inability to readily obtain an aseptic urine
specimen on incontinent patients and inability of physicians readily responding to treatment
orders which delayed response in treatment time. There was a conflict in assessment of
patients using the McGeers Criteria (Appendix H) and the evidence-based literature that was
acquired to support delirium (mental status changes and behavior) as symptoms of a UTI in the
45
elderly. According to Rashid et al. (2021), delirium complicates Urinary tract infection (UTI)
recovery in approximately one-third of patients with UTI and is characterized by a constellation
of symptoms that reflect dysfunction of the frontal cortex and hippocampus, including
psychomotor agitation, inattentiveness, and short-term memory impairment.
This analysis required patients to have differences in their baseline status based on the
inclusion criteria, therefore awaiting patient change in condition to meet the inclusion criteria
posed a limitation. Treatment times using POCT were longer when the HCP was not onsite or
available by direct text. The Urinalysis Reporting Form did not include time stamped information
regarding shift of onset of symptoms, and time of physician order written. This was
subsequently determined by observation of order entry into the physician order page of the
medical record. Treatment time initiation was obtained by reviewing the Medication
Administration Records.
Discussions and Recommendations
Implementation of evidence-based practice (EBP) is essential for ensuring high-quality
health care at minimum cost. Although all nurses have a responsibility to implement EBP at an
individual patient level, nurse practitioners (NPs) as clinical leaders have additional
responsibilities in leading and collaborating with transdisciplinary teams to implement EBP
across patient groups and embed practice change into routine care according to Clarke et al.
(2021). The changes that occurred through this EBQI project can be used to guide other HCPs
and NPs in clinical practice. The impact of the interventions has evidently supported earlier
treatment and wellness of a vulnerable population with the implementation of urine POCT. The
knowledge gained through this process sets the stage for subsequent EBQI projects using
POCT as a practice that can be substantiated and expanded upon for future clinical projects.
This project positively influenced the elderly in a long-term care facility with less illness and
symptom time. In addition, this project substantiated cost and clinical investments to the long-
term care facility in preventing transfer of patients to the emergency room with early
46
identification and treatment of UTIs. The healthcare provider benefits from this project by
gaining rapid clinical information for an appropriate treatment or subsequent plan of care.
Recommendations for leaders in similar settings include a formal educational in-service
for nurses with demonstration and feedback to the basis of the POCT, inclusion criteria, use of
forms, use of the quality control testing, and urinalysis dip sticks. Although this conveniently took
place on the units during working hours, nurses felt rushed with shift assignments therefore
lowering the quality of the educational exchange. This could be mitigated by formally inviting
nurses to explore areas for improvement in shift time management strategies to expand upon
subsequent EBQI projects for enhancement of nursing processes that would assist in overall
enhanced patient care. The developed policy stated that a physician’s order was not necessary
for nurses to perform a urine POCT, however judicious use of POCT is warranted because of
asymptomatic bacteruria that is common in the elderly. To remedy this, closely coordinated
efforts with the infection preventionist could’ve assisted in clarifying misunderstandings of when
to use the POCT vs. a 3-day UTI watch.
Initially there were two vials of control solutions for quality control assessment. A pipette
had to be used to aspirate the test fluid from each test tube-like vial at which time the solution
was placed on the urine dipstick for quality control (QC) measurement. It was discovered that
the QCs were consistently incorrect. Nurses performing the QC tests were using the same
pipette for each QC solution and therefore the control solutions became mixed rendering
incorrect QC checks. This was resolved with the purchase of control solution bottles that require
drops from each bottle for QC testing, therefore the solutions were not able to be mixed.
Further research recommendations are to establish other varieties of POCT for rapid
patient assessment and treatment in the long-term care facility setting. This DNP project has
demonstrated the efficacy of quicker treatment for a common, yet critical infection among the
elderly. A subsequent recommendation for nurse leaders in the long-term care setting is to
explore the impact urine POCT has on the reduction of hospital admissions of the elderly,
47
consistent with Healthy People 2030. Prospective studies should consider the age related
cognitive, physical, and physiological changes that occur throughout the aging process and the
impact these changes can have in the assessment and treatment of this unique population. The
benefits of this DNP project demonstrate how NPs and nurse leaders can improve outcomes for
populations with evidence-based interventions.
Implications for the Discipline of Nursing
It is essential for advanced practice nurses to understand the connection between
science-based evidence and its contribution to improvement in clinical practices. Coupled with
philosophical, ethical, and theoretical foundations, the DNP nurse is prepared to improve
population health, enhance patient care, increase safety, and support transformations in
healthcare. Evidence-based practice quality improvement projects affords the DNP student with
opportunities to develop cognizance and practices to understand a wide array of scientific
comprehensions which are collected from research and used for the development,
implementation, analysis, and sustainability of practices that are scientifically supported.
Consistent with Healthy People 2030 (n.d), one goal is to reduce the rate of hospital
admissions for urinary tract infections among older adults. Additionally, Healthy People 2030
(n.d), reported the most recent data demonstrates 551.3 hospital admissions for urinary tract
infections per 100,000 adults aged 65 and over. Urinary tract infections (UTIs) are common
infections in older adults according to Gharbi et al. (2019), and serious cases require treatment
in the hospital. Teaching older adults about managing bladder and urinary problems can help
prevent UTIs — and early identification and treatment can keep UTIs from getting serious
enough that they require hospitalization.
Project Alignment to the AACN DNP Essentials
Essential I -Scientific Underpinnings for Practice
This guided EBQI DNP project has prepared the DNP student to identify and address
current and future practice issues guided by strong scientific foundations which are based on
48
philosophical, ethical, and elemental concerns that are inherent in the construct of contextual
science applications. This DNP project contributes to the significant body of knowledge by
improving health and wellness of a vulnerable population that guides nursing practice for the
welfare of improved patient care. This was accomplished through actions and advanced
strategies including research, implementation, and evaluation to enhance healthcare delivery
established from nursing and supplementary discipline theories.
Essential II: Organizational and Systems Leadership for Quality Improvement and
Systems Thinking
As a developed leader in organizational and systems leadership critical for the DNP to
improve patient and healthcare outcomes, the Doctoral level knowledge and skills in these
areas are consistent with nursing and health care goals to eliminate health disparities and to
promote patient safety and excellence in practice. Consistent with this DNP essential, the target
population of this project focused on the elderly living in a nursing home. Throughout this DNP
project development, the expanded ability to assess the impact of new practice policies and
procedures was achieved to meet the health needs of this patient population. This quality
improvement strategy was demonstrated by creating and sustaining changes at the
organizational policy level. The project was cost effective to the facility by way of avoiding
additional costs on laboratory testing, curtailing spending on ineffective or unnecessary
antibiotic prescriptions, and reduced expenses on treatments associated with side effects of
antibiotic use, which supports realistic and strategic health care delivery. Throughout this EBQI
process, the ability to assess risk and collaborate with other members of the health care team
were necessary to improve the quality of care and to refine work practices for the efficacy of the
organization, staff, and patients. This collaboration thereby parallels the organizational and
systems leadership component of this DNP essential.
49
Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice
Scholarly nursing practice is characterized by the discovery of new phenomena and the
application of new discoveries in increasingly complex practice situations. The integration of
knowledge from this evidence-based quality improvement project applies to solutions of an
identified practice problem and has demonstrated evidence-based improved health outcomes
consistent with this DNP nursing essential. Analytical methods were demonstrated by critically
appraising existing literature to determine the best substantiation for practice. Processes were
designed and implemented to evaluate the outcomes of the new practice, practice patterns, and
systems of care. This DNP project was designed, directed, and implemented using quality
improvement methodologies to promote safe, timely, effective, efficient, equitable, and patient-
centered care. Relevant findings of this quality improvement project were used to develop
practice guidelines and improve practice.
Essential IV: Information Systems/Technology and Patient Care Technology for the
Improvement and Transformation of Health Care
DNP graduates are distinguished by their abilities to use information systems and
technology to support and improve patient care, healthcare systems, and to provide leadership
within healthcare and/or academic settings. Leadership within this DNP essential was
demonstrated through identification of the problem, research, policy development, and
education of the DNP project and outcomes. The development and design of the data collection
form and urinalysis reporting form demonstrated efficient information exchange between the
nursing staff and healthcare providers. Detailed technical collaboration with the nursing and
medical teams for advantageous outcomes in relation to legal, ethical, and regulatory
compliances has demonstrated the core of this DNP essential. Nursing education using the
POCT for early identification of UTIs is ongoing as is the dissemination of information
demonstrating positive outcomes affected by this EBP QI project.
50
Essential V: Health Care Policy for Advocacy in Health Care
Institutional decision making, using organizational and regulation standards facilitate the
delivery of health care services to engage in practice to address health care needs.
Engagement in the process of policy development was fundamental to supplementing health
care standards that meet the needs of the elderly residing in a nursing home. Opportunities to
gain an understanding about health policies have influenced multiple care deliveries, including
faster access to care, and enhanced quality of care. This DNP program has provided the
capacity to engage proactively in the development and implementation of institutional health
modification to enhance the welfare of a vulnerable population, consistent with this DNP
essential.
Essential VI: Interprofessional Collaboration for Improving Patient and Population Health
Outcomes
Throughout this DNP project there were multiple levels of interprofessional partnership
to improve the health of the target population. Collaboration was essential during the
development and implementation of this project. Examples include correspondences with the
UOP DNP faculty for direction and guidance for the development and completion of this project,
consultation with the UOP IRB for an ethical standard review to implement this project, and
collaboration with peers and colleagues for review and discussions in the development of
reporting tools and a clearly stated policy and procedure. Effective team leadership was
demonstrated in coordinating correspondence with members of the interprofessional teams to
improve population health outcomes to meet this DNP essential.
Essential VII: Clinical Prevention and Population Health for Improving the Nation’s Health
This EBPQI project was developed as a clinical intervention to reduce the treatment time
of the elderly experiencing UTI symptoms in the skilled nursing facility setting. The outcomes
measured from this DNP project have demonstrated a significant reduction in treatment time
with the introduction of urine POCT. The ability to demonstrate an evidence-based clinical
51
intervention is central to achieving the national goal of improving the health status of a
population. This DNP project enabled the analysis of epidemiological, biostatistical, and
environmental data in the development, implementation, and evaluation of clinical prevention
and population health.
Essential VIII: Advanced Nursing Practice
This DNP program has provided enhanced awareness in identifying and utilizing the
quality improvement processes to enhance the wellness of a vulnerable population. This
program has provided support with resources, and a foundational knowledge to excel in
leadership roles for practice within a specialization. Confidence was established in applying
informed practice decisions based on the knowledge attained from this DNP program. This DNP
program has provided the advanced practice nurse with capabilities to excel in guiding,
mentoring, educating, and supporting nurses to achieve excellence in nursing practice with
evidence-based scientific knowledge in the assessment of and treatment of vulnerable
populations, therefore meeting this DNP essential.
Dissemination
The dissemination of nursing DNP projects often project quality improvement,
implementing evidence-based practice changes, and critically appraising pertinent evidence to
modify or enhance patient or healthcare outcomes according to Ayala et al. (2022). Effective
dissemination and communication of quality improvement processes in nursing are vital to
ensure that the conducted research has an impact on improving and sustaining health
outcomes. Dissemination was an essential component of this EBQI project to achieve the
purpose of fostering policy change based on research findings.
Strategies for dissemination of this EBQI project include a project presentation to the
University of Phoenix DNP leadership team and colleagues, and the administrative, medical,
and nursing teams within the LTCF of which the project was conducted, Submission of the
projects’ abstract to the peer-reviewed Geriatric Nursing Journal is planned as well. This journal
52
was chosen for project submission because it is a comprehensive source for clinical information
and management advice relating to the care of older adults. The journals’ peer-reviewed articles
report the latest developments in the management of acute and chronic disorders and provide
practical advice on care of older adults across the long-term continuum. Dudley-Brown (2019)
has indicated that dissemination proposes the translation of evidence so changes can occur,
and innovations can be created to benefit patients, nurses, populations, and the health care
system. Sharing the project outcome is important because the result of this DNP project
demonstrates both statistical and clinical significance in the improvement of practice for the
betterment of the elderly population living in a long-term care facility.
53
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Appendices
Appendix A
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Appendix B
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Appendix C
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Appendix D
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Appendix E
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Appendix F
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Appendix G
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Appendix H
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- Abstract
- Dedication
- Acknowledgements
- LIST OF TABLES
- LIST OF FIGURES
- Introduction to the Problem
- Problem Statement
- Purpose of the Project
- Practice Question
- Theoretical Framework
- Literature Synthesis
- Introduction
- Point-of-Care Testing
- Benefits of POCT
- An Aging Population
- Age-Related Changes
- Risk Factors for Urinary Tract Infections
- Atypical Presentation of UTIs in the Elderly
- Antimicrobial Resistance
- Urine Point-of-Care Testing in Long-Term Care
- Misuse of Antibiotics for Urinary Tract Infections
- Gap in Practice
- Summary
- Project Stakeholders
- Barriers to Change
- Facilitators to Change
- Ethical Considerations
- Informed Consent/Assent
- Project Methodology
- Project Design
- Population and Sample
- Project Setting
- Description of the Evidence Based Intervention
- Outcomes and Project Objectives
- Instrument Tool
- Data Sources and Collection
- Data Analysis
- Project Implementation
- Description of the Evidence-Based Intervention
- Project Findings
- Results/Outcomes
- Strengths and Limitations
- Discussions and Recommendations
- Implications for the Discipline of Nursing
- Project Alignment to the AACN DNP Essentials
- Dissemination
- References
- Appendices
