Quality Measure Coding Deep Dive: UTI & Indwelling Catheters

Use of an indwelling catheter can place a resident at a higher risk for conditions such as Urinary Tract Infections (UTIs), sepsis, trauma, and hospitalization. Indwelling catheters should only be used when medically necessary and periodically re-evaluated for the appropriateness of continued use.

Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder-Long Stay

This quality measure reports the percentage of residents who have had an indwelling catheter in the last 7 days. This includes indwelling and suprapubic catheters as well as nephrostomy tubes. The Indwelling Catheter QM is a long stay measure which means that residents are included in the long-stay sample when their cumulative days in facility (CDIF) are greater than or equal to 101.  Be aware that days out of the facility are not calculated in the cumulative day count.

There are covariates associated with this measure. Covariates are found to increase the risk of an outcome and are adjusted at the resident level.  The impact of the covariate is reflected in the facility adjusted percent.  If covariates are not coded accurately in H0400 & M0300B1-D1, the quality measures will be misrepresented.

Catheter Management Strategies

• • Audit MDS coding for accuracy in applicable items in Sections I, H, and M
  • A diagnosis of Neurogenic bladder or Obstructive uropathy will exclude the resident from this measure. Be familiar with what neurogenic bladder and obstructive uropathy are as well as causes & symptoms so that the physician can be queried when necessary. These diagnoses may be caused by the following conditions:
    • Neurogenic bladder: CVA, MS, neurologic trauma (i.e. brain and spinal cord injuries), Parkinson’s Disease, Alzheimer’s Disease, and DM
    • Obstructive Uropathy: cancer, BPH, urethral stricture, diabetic neuropathy, renal failure, or trauma
  • Evaluate new admissions/readmissions for indwelling catheter use and determine if it is medically necessary. Assure diagnoses are appropriate and query the physician if necessary.
  • With the physician, re-evaluate the use of indwelling catheters for urinary retention. Consider utilizing bladder scanners to assess urinary retention and consider intermittent catheterization as appropriate.
  • Consider alternatives: Can condom catheters be utilized for male patients without obstruction or urinary retention?
  • If catheters are placed to promote wound healing, monitor wound progress and discontinue the catheter as soon as possible.
  • Perform bladder evaluation assessments per policy & implement interventions accordingly (i.e. toileting program).
  • Consider completing another MDS assessment if/when the indwelling catheter is discontinued.

Percent of Residents With a Urinary Tract Infection – Long Stay

UTIs are one of the top infections in nursing facilities. Evaluating cause(s) and providing timely treatment can prevent further complications (e.g., delirium, sepsis). Furthermore, improper diagnosis of UTI can lead to inappropriate antibiotic use resulting in antibiotic-resistant organisms and adverse effects.

This measure reports the percentage of long-stay residents who have had a urinary tract infection (UTI) within the last 30 days.

I2300 Urinary tract infection (UTI):

Code only if both of the following are met in the last 30 days:

1. It was determined that the resident had a UTI using evidence-based criteria (i.e., McGeer, NHSN, or Loeb) in the last 30 days, AND
2. A physician documented UTI diagnosis in the last 30 days.

If the diagnosis of UTI was made before the resident’s admission, entry, or re-entry into the facility, it is not necessary to obtain or evaluate the evidence-based criteria used to make the diagnosis in the prior setting.

UTI Management Strategies

• • Audit MDS coding for accuracy of Item I2300.
    • Note: Item I2300 UTI, has specific coding criteria. Please refer to RAI Manual, Page I-12 for specific coding instructions for this item.
  • Review facility policies regarding UTIs (e.g., McGeer criteria, screening for asymptomatic bacteriuria), and ensure nurses, providers, and responsible parties are aware of the policies and infection criteria.
  • Evaluate and promote efforts to minimize risks of developing UTIs:
    • Consider hydration programs with fluids easily accessible or offered at regular intervals those who are cognitively impaired
    • Ensure chronic conditions are effectively managed, including things like regular monitoring of blood glucose for diabetics.
    • Regularly perform competency reviews for handwashing, perineal, and catheter care.
  • Utilize QM and internal data to implement performance improvement activities as warranted:
    • Discuss new diagnosis of UTI or new orders for ATB for UTI in the clinical meeting and review/revise care plans and promote antibiotic stewardship.
    • Assess residents that trigger for UTIs repeatedly for further intervention or need of urology referral.

References

• • Center for Medicare and Medicaid Services. (2019). MDS 3.0 RAI Manual. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html
  • Centers for Medicare & Medicaid Services. (2020, October 19). Quality Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures
  • Quality Improvement Organizations. Quality Measure Tip Sheet. https://www.hqi.solutions/wp-content/uploads/2017/07/Catheters_71719_508-1.pdf

Blog by Kristen Walden, MSN, RN, RAC-CT, Proactive Medical Review

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