Search

Background: Catheter-associated urinary tract infection (CAUTI) is a noted complication among geriatric hip fracture patients. This complication results in negative outcomes for both the patients and the institution providing care. Screening measures to identify predisposing factors, with early diagnosis and treatment of urinary tract infection (UTI) present on admission, may lead to reduced rates of CAUTI. Objective: The goals of this study were to determine the prevalence of UTI on admission among geriatric hip fracture patients and whether routine screening for UTI or predisposing factors at presentation resulted in reduced rates of CAUTI. Methods: A retrospective observational study of geriatric hip fracture patients from January 2017 to December 2018 at a Level I trauma center was performed. Rates of UTI on admission and CAUTI were calculated using routine admission urinalysis. Results: Of the 183 patients in the sample, 36.1% had UTI on admission and 4.4% of patients developed CAUTI. There were no significant differences in patient demographics, comorbidities, and complications between those with UTI on admission and those without. Conclusions: Urinary tract infection on admission may be present among a large portion of geriatric hip fracture patients, leading to increased rates of CAUTI. Routine screening for UTI and its predisposing factors at admission can identify these patients earlier and lead to earlier treatments and prevention of CAUTI. JTRAN Journal of Trauma Nursing 1078-7496 Wolters Kluwer Health, Inc. 10.1097/JTN.0000000000000603 00003 3 RESEARCH Reducing Catheter-Associated Urinary Tract Infection: The Impact of Routine Screening in the Geriatric Hip Fracture Population Singh Shridevi MD ssingh5@numc.edu Angus L. D. George MD langus@numc.edu Munnangi Swapna PhD smunnang@numc.edu Shaikh Dooniya MD dshaikh@numc.edu Digiacomo Jody C. MD jdigiac1@numc.edu Angara Vivek C. DO vangara@numc.edu Brown Aaron MD Aaron.brown.nyee@gmail.com Akadiri Tayo MD tayoakadiri234@gmail.com Department of Surgery, Nassau University Medical Center, East Meadow, New York. Correspondence: L. D. George Angus, MD, Department of Surgery, Nassau University Medical Center, East Meadow, NY 11554 (langus@numc.edu). The content of this article does not substantially overlap with previously published or submitted work, to the best of the authors' knowledge. Authors Shridevi Singh, MD, and Swapna Munnangi, PhD, had full access to all the data in this study and take responsibility for the integrity of the data and the accuracy of the data analysis. The data that support the findings of this study are available from the corresponding author L.D. George Angus, MD, upon reasonable request. The authors declare no conflicts of interest. September/October 2021 28 5 290 297 © 2021 Society of Trauma Nurses 2021 Background: Catheter-associated urinary tract infection (CAUTI) is a noted complication among geriatric hip fracture patients. This complication results in negative outcomes for both the patients and the institution providing care. Screening measures to identify predisposing factors, with early diagnosis and treatment of urinary tract infection (UTI) present on admission, may lead to reduced rates of CAUTI. Objective: The goals of this study were to determine the prevalence of UTI on admission among geriatric hip fracture patients and whether routine screening for UTI or predisposing factors at presentation resulted in reduced rates of CAUTI. Methods: A retrospective observational study of geriatric hip fracture patients from January 2017 to December 2018 at a Level I trauma center was performed. Rates of UTI on admission and CAUTI were calculated using routine admission urinalysis. Results: Of the 183 patients in the sample, 36.1% had UTI on admission and 4.4% of patients developed CAUTI. There were no significant differences in patient demographics, comorbidities, and complications between those with UTI on admission and those without. Conclusions: Urinary tract infection on admission may be present among a large portion of geriatric hip fracture patients, leading to increased rates of CAUTI. Routine screening for UTI and its predisposing factors at admission can identify these patients earlier and lead to earlier treatments and prevention of CAUTI. Catheter-associated urinary tract infections CAUTI Complications Elderly Geriatric Hip fracture Hospital costs Trauma Urinary tract infections INTRODUCTION: Geriatric hip fracture patients are susceptible to a higher rate of complications, with rates ranging from 7% to 40% (Bliemel et al., 2017; Różańska, Wałaszek, Wolak, & Bulanda, 2016; Thakker et al., 2018). One such complication is catheter-associated urinary tract infection (CAUTI). Risk factors inherent to this population include surgical procedures, immobility, age, and the routine utilization of indwelling urinary catheters in the perioperative period (Detweiler, Mayers, & Fletcher, 2015; Hälleberg Nyman et al., 2013; Zielinski et al., 2015). This complication negatively impacts both the patient and the institution providing care. It is reported that 15.5% of hospitalized patients older than 65 years have urinary tract infections (UTIs) (Centers for Disease Control and Prevention [CDC], 2019; Foxman, 2010). Moreover, 6.2% of infectious disease-related deaths are due to UTIs (Alpay, Aykin, Korkmaz, Gulduren, & Caglan, 2018). Implementation of various measures has led to a reduction in the incidence of UTIs; however, UTIs are still prevalent, placing an enormous financial burden on institutions (Polites et al., 2014; Rebmann & Greene, 2010). The Centers for Medicare & Medicaid has deemed that CAUTI is a "reasonably preventable" inhospital complication and has terminated reimbursements for these events since 2008 (CDC, 2019). The mean cost of UTI is $862 to $1007 per UTI (Bail et al., 2015; CDC, 2019; Scott, 2010), whereas a systematic review found that the mean cost of CAUTI can exceed $10,000 per CAUTI based on the clinical status of the patient (Hollenbeak & Schilling, 2018). A vast majority of patients who suffer hip fractures undergo a surgical repair after admission (Bliemel et al., 2017; Johnstone, Morgan, Wilkinson, & Chissell, 1995; Wallace et al., 2019). These repairs have an elevated risk of causing postoperative urinary retention due to the use of anesthesia, patient immobility, and long duration of surgery (Johnstone et al., 1995; Polites et al., 2014; Rowe & Juthani-Mehta, 2013). It is also common practice at some institutions, including our own, to routinely place an indwelling urinary catheter for bladder drainage during the perioperative period (Bliemel et al., 2017; Hälleberg Nyman et al., 2013). Geriatric trauma patients are a unique patient population with numerous intrinsic risk factors for UTI (Bohl et al., 2017; Magill et al., 2014; Monaghan et al., 2011). Some of these risk factors include female sex, falls, head injury, and altered mental status (Aubron et al., 2012; Bliemel et al., 2017; Zielinski et al., 2015). Elderly patients tend to be institutionalized with lower mobility or have medical comorbidities such as hypertension, diabetes, stroke, or dementia that predispose these patients to bladder or bowel incontinence and UTI (Foxman, 2014; Mody & Juthani-Mehta, 2014; Woodford & George, 2009). In addition, less attention to sanitary precautions further predisposes this specific patient population to high rates of UTIs (Alpay et al., 2018). Although current guidelines do not recommend treating asymptomatic bacteriuria (Zalmanovici Trestioreanu, Lador, Sauerbrun-Cutler, & Leibovici, 2015), this specific population subset may not be able to vocalize or validate symptoms due to altered mental status and communication incapability as a result of dementia, stroke, etc. (Tsuda et al., 2015). Hence, we presume that in this specific patient population, UTI is a missed diagnosis because of the missed clinical correlation needed as per current UTI diagnostic criteria guidelines (CDC, 2019; Rowe & Juthani-Mehta, 2014). Failure in early diagnosis and treatment in this specific elderly patient population results in morbid outcomes for patients and significant financial penalties for institutions (Detweiler et al., 2015; Thakker et al., 2018; Zielinski et al., 2014). However, the question arises whether a CAUTI diagnosis is truly the progression of asymptomatic bacteriuria due to the indwelling catheter or is rather a result of comorbid UTI at admission. Therefore, we propose that by screening geriatric hip fracture patients with a urinalysis (UA) within 24 hr of an indwelling urinary catheter that is placed at admission, we will find there is a significant frequency of patients who present with either UTI on admission or with UA findings that could predispose patients to a UTI with an indwelling urinary catheter. METHODS: A retrospective observational study of patients at an urban Level I trauma center, as verified by the American College of Surgeons, was performed. The trauma center is a 500-bed public safety-net hospital that serves 1.4 million people, with approximately 75,000 emergency department visits and approximately 1,700 trauma admissions each year. After obtaining approval from the Institutional Review Board (19-205), the trauma registry was queried by using ICD-10 codes S72.001-S72.26 for hip fracture for all patients 65 years and older from January 1, 2017, through December 31, 2018, which were the first 2 years that routine screening UA was included as a component of the multidisciplinary geriatric hip fracture comanagement protocol at this institution (Wallace et al., 2019). Routine screening UAs were obtained within 24 hr of admission. Demographic information, comorbid conditions, preinjury medications, mechanism of injury, vital signs, Abbreviated Injury Score, Injury Severity Score, Revised Trauma Score, Glasgow Coma Scale, admission disposition, hospital course, intensive care unit (ICU) length of stay, hospital length of stay, complications, disposition, and outcome were extracted from the trauma registry supplemented by direct review of the electronic medical record. Initially, 193 patient records were identified. However, 10 of these patient records were deemed incomplete and were excluded, as they either did not have at least one of the above data points available or the screening UA performed, leaving 183 patients for the final sample. There was no historical control group, as the frequency of UTI and asymptomatic bacteriuria at the time of admission were the variables of interest. All patients were admitted to the ICU as part of our institution's protocol for geriatric hip fracture patients. Urinary tract infection is a clinical diagnosis with symptoms of dysuria, urinary frequency, urinary urgency, or suprapubic pain. Catheter-associated urinary tract infection is defined as a UTI in the setting of an indwelling urinary catheter that has been in place for more than 2 consecutive days in an inpatient location, with the catheter being present either the day of UTI diagnosis or removed the day before (CDC, 2021). Urinalysis can be used as a diagnostic tool to reinforce the clinical diagnosis of a UTI with positive results for leukocyte esterase or nitrites in a midstream-void specimen (Schulz, Hoffman, Pothof, & Fox, 2016; Simati, Kriegsman, & Safranek, 2013; Stovall et al., 2013). Leukocyte esterase is specific (94%–98%) and sensitive (75%–96%) for detecting uropathogens equivalent to 100,000 colony-forming units (CFU) per ml of urine (Devillé et al., 2004; Nicolle et al., 2005; Simati et al., 2013). Negative nitrite tests do not rule out a UTI because the causative organism can also be non-nitrate-reducing (e.g., Enterococci species, Staphylococcus saprophyticus, and Acinetobacter species). Therefore, the sensitivity of nitrite tests ranges from 35% to 85%, but with a specificity of 95% (Devillé et al., 2004; Nicolle et al., 2005; Simati et al., 2013). Nitrite tests can also be falsely negative if the urine specimen is too diluted (Devillé et al., 2004; Nicolle et al., 2005; Simati et al., 2013). In addition, microscopic hematuria may be present in 40%–60% of patients with UTI (Devillé et al., 2004). The diagnosis of UTI in this study was made based on the following UA results regardless of clinical symptoms: white blood cells >10/high-power field (hpf), +nitrites, +bacteria. Comparisons of outcomes were then compared to subgroups within the data collected. Patients diagnosed with UTI were treated with antibiotics. Statistical Analysis: Descriptive statistics were used to summarize the demographic and clinical variables in the study sample. Continuous variables were summarized by presenting mean and standard deviation. Categorical variables were summarized using frequency and percentages. The study sample was stratified into two groups based on whether or not the patient had a UTI upon admission. Continuous variables were compared using unpaired Student's t-test. The Fisher exact test or Pearson χ2 test was used to examine the association of categorical variables with UTI on admission. A p value <.05 was considered statistically significant. Statistical analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC). RESULTS: The study sample consisted of 183 hip fracture patients who met the inclusion criteria. Of these 183 patients, 36.07% had a UTI on admission, and 63.93% did not. Table 1 depicts the baseline clinical and demographic characteristics of the study sample stratified by the UTI status upon admission. The average age of the patients was 84.9 years (M = 84.9, SD = 8). The majority (76.5%) were female. Fall from the same level was the most common mechanism of injury (77%). The mortality rate was 4.4%. Advance directives were in place for 8.2% of the patients. The median ICU length of stay was 3 days (interquartile range [IQR] = 1), and median hospital length of stay was 4 days (IQR = 4). Overall, eight patients, or 4.4% of the study sample, had CAUTI, six of whom were female. A Foley catheter was in place for a median of 2 days (IQR = 1). Acute rehabilitation was the most common discharge disposition (49.7%). There was a statistically significant increase in median ICU length of stay in those with UTI on admission compared with those without. All other demographic and clinical characteristics did not demonstrate any statistically significant difference between the two groups. TABLE 1 Demographic and Clinical Characteristics: Variable Total Sample (n = 183) n (%) UTI on Admission (n = 66; 36.07%) n (%) No UTI on Admission (n = 117; 63.93%) n (%) p Value Age, M (SD), year 84.9 (8.0) 86.2 (7.5) 84.2 (8.3).108 Sex Female 140 (76.5) 53 (80.3) 87 (74.4).363 Male 43 (23.5) 13 (19.7) 30 (25.6) Mechanism of injury .715 Fall from bed 5 (2.7) 1 (1.5) 4 (3.4) Fall from chair 10 (5.5) 3 (4.5) 7 (6.0) Fall from stairs 19 (10.4) 7 (10.6) 12 (10.3) Fall from toilet 2 (1.1) 2 (1.1) 1 (0.8) Fall same level 141 (77.0) 50 (75.8) 91 (77.8) Fall unspecified 2 (1.0) 1 (1.5) 1 (0.8) Other 4 (2.2) 3 (4.5) 1 (0.8) Mortality 8 (4.4) 4 (6.1) 4 (3.4).401 ICU length of Stay, Mdn (IQR), day 3 (1.0) 3 (3.0) 2 (1.0).004 Hospital length of stay, Mdn (IQR), day 4 (4.0) 5 (5.0) 4 (3.0).118 CAUTI 8 (4.4) 0 (0.0) 8 (6.8) Foley days, Mdn (IQR), day 2 (1.0) 2 (1.0) 2 (1.0).593 Injury Severity Score, M (SD) 9.9 (2.9) 10.2 (3.1) 9.7 (2.8).307 Glasgow Coma Scale, M (SD) 14.7 (1.2) 14.5 (1.6) 14.8 (.88).219 Hospital disposition .806 Acute rehabilitation 91 (49.7) 29 (43.9) 62 (53.0) Died full code/withdrawal of care 8 (4.4) 4 (6.1) 4 (3.4) Home 4 (2.2) 2 (3.0) 2 (1.7) Skilled nursing facility 15 (8.2) 6 (9.1) 9 (7.7) Subacute rehabilitation 61 (33.3) 24 (36.4) 37 (31.6) Other nursing facility 4 (2.2) 1 (1.5) 3 (2.6) Note. CAUTI = catheter-associated urinary tract infection; ICU = intensive care unit; IQR = interquartile range; UTI = urinary tract infection. Comorbidities in the study sample were summarized in Table 2. Hypertension was the most common comorbid condition in the overall study sample and the groups stratified by UTI status on admission. There were no significant differences in the comorbid conditions between those who had a UTI on admission and those who did not. The inhospital complications in the study sample were summarized in Table 3. Unplanned returns to the operating room (2.2%) and ICU (2.3%) were the most common inhospital complications observed in the study sample. The inhospital complications were not significantly different between those who had a UTI on admission and those who did not. TABLE 2 Comorbidities: Comorbidity Total Sample (n = 183) n (%) UTI on Admission (n = 66; 36.07%) n (%) No UTI on Admission (n = 117; 63.93%) n (%) p Value Anticoagulation 48 (26.2) 20 (30.3) 28 (23.9).347 Bleeding disorder 3 (1.6) 1 (1.5) 2 (1.7).920 CHF 37 (20.2) 14 (21.2) 23 (19.7).802 Chronic renal failure 15 (8.2) 5 (7.6) 10 (8.5).217 Cirrhosis 2 (1.1) 0 (0.0) 2 (1.7).536 Congenital anomaly 1 (0.5) 0 (0.0) 1 (0.8).639 COPD 12 (6.6) 7 (10.6) 5 (4.3).064 Dementia 43 (23.5) 18 (27.3) 25 (21.4).366 DOH status 28 (15.3) 9 (13.6) 19 (16.2).639 Cancer 10 (5.5) 2 (3.0) 8 (6.8).277 Hypertension 131 (71.6) 45 (68.1) 86 (73.5).443 Major psychiatric illness 3 (1.6) 1 (1.5) 2 (1.7).921 Mental personal disorder 8 (4.4) 2 (3.0) 6 (5.1).505 Myocardial infarction 1 (0.5) 0 (0.0) 1 (0.8).639 Respiratory disease 6 (3.3) 4 (6.0) 2 (1.7).113 PAD 9 (4.9) 5 (7.6) 4 (3.4).128 SP CVA 9 (4.9) 4 (6.0) 5 (4.3).233 Smoker 13 (7.1) 6 (9.0) 7 (6.0).168 Steroid use 1 (0.5) 0 (0.0) 1 (0.8).639 PNA 1 (0.5) 0 (0.0) 1 (0.8).639 ARDS 1 (0.5) 0 (0.0) 1 (0.8).639 Note. ARDS = acute respiratory distress syndrome; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; DOH = Department of Health; PAD = peripheral arterial disease; PNA = pneumonia; SP CVA = status post cerebrovascular accident; UTI = urinary tract infection. TABLE 3 Inhospital Complications: Complication Total Sample (n = 183) n (%) UTI on Admission (n = 66; 36.07%) n (%) No UTI on Admission (n = 117; 63.93%) n (%) p Value Cardiac arrest with CPR 2 (1.0) 1 (1.5) 1 (0.8).464 Myocardial infarction 1 (0.5) 0 (0.0) 1 (0.8).639 Unplanned intubation 4 (2.2) 2 (3.0) 2 (1.7).322 Unplanned return to OR 4 (2.2) 0 (0.0) 4 (3.4).164 Unplanned return to ICU 1 (0.5) 1 (1.5) 0 (0.0).361 Acute renal failure 3 (1.6) 1 (1.5) 2 (1.7).446 Severe sepsis 3 (1.6) 0 (0.0) 3 (2.6).259 Coagulopathy 1 (0.5) 0 (0.0) 1 (0.8).639 Acute renal injury 1 (0.5) 1 (1.5) 0 (0.0).361 Other 1 (0.5) 0 (0.0) 1 (0.8).639 Note. CPR = cardiopulmonary resuscitation; ICU = intensive care unit; OR = operating room; UTI = urinary tract infection. DISCUSSION: The elimination of all CAUTI is not attainable; however, it is necessary to take "reasonable preventive" measures to mitigate this inhospital complication that also has a significant financial burden on institutions. By ceasing reimbursements for hospital-acquired UTI, there has been a reduction in UTI rates (CDC, 2019). Yet, there is still a significant prevalence of hospital-acquired UTIs that is burdensome to the host institution (Chenoweth, Gould, & Saint, 2014; Gould et al., 2010; Hassan, Tuckman, Patrick, Kountz, & Kohn, 2010). This study looked at a specific patient population with two important characteristics that deem them at high risk for UTI at admission or postadmission: age and fractured hip. This study aimed to assess the frequency of a positive UA at admission in elderly hip fracture patients, which was found to be 36%. Bliemel et al. (2017) found that 24% of their elderly hip fracture patients sustained an inhospital UTI. The patients in Bliemel et al.'s study were assessed with a UA and urine culture after indwelling catheter removal in those who had clinical symptoms specific for UTI or diffuse symptoms of fatigue, fever, or weakness (Bliemel et al., 2017). In our study, we screened and treated patients based on UA results at admission as per our inhospital protocol for elderly hip fractures. By doing so, rates of CAUTI may have been reduced. In our study period, eight of 183 (4.4%, Table 4) patients developed CAUTI during their hospital course, and 66 of 183 (36%, Table 1) patients had UTI on admission. The increased incidence of CAUTI seen in previous studies compared to our data supports the theory that the colonization of urine with bacteria might have already been present and untreated. It is generally recommended that patients with asymptomatic bacteriuria should not be treated, and for the nonelderly hip fracture patient, we agree. The limitation in obtaining symptomatology history in this specific patient population due to their comorbidities (e.g., dementia) and the significant incidence of positive UA at admission in this study supports the theory that the clinical diagnosis of UTI should be assessed objectively and thus treated appropriately in elderly hip fracture patients. TABLE 4 Comorbidities With CAUTI But No UTI on Admission: Comorbidity CAUTI (n =8; 4.4%) n (%) No UTI on Admission Excluding CAUTI (n = 109) n (%) Anticoagulation 4 (50) 24 (22.0) Bleeding disorder 0 (0.0) 2 (1.83) CHF 3 (37.5) 20 (18.3) Chronic renal failure 0 (0.0) 10 (9.2) Cirrhosis 1 (12.5) 1 (0.9) Congenital anomaly 0 (0.0) 1 (0.9) COPD 0 (0.0) 5 (4.6) Dementia 3 (37.5) 22 (20.2) DOH status 5 (62.5) 14 (12.8) Cancer 2 (25.0) 6 (5.5) Hypertension 6 (75.0) 80 (73.4) Major psychiatric illness 0 (0.0) 2 (1.8) Mental personal disorder 0 (0.0) 6 (5.5) Myocardial infarction 1 (12.5) 0 (0.0) Respiratory disease 0 (0.0) 2 (1.8) PAD 0 (0.0) 4 (3.7) SP CVA 0 (0.0) 5 (4.6) Smoker 0 (0.0) 7 (6.4) Steroid use 0 (0.0) 1 (0.9) PNA 0 (0.0) 1 (0.9) ARDS 0 (0.0) 1 (0.9) Note. ARDS = acute respiratory distress syndrome; CAUTI = catheter-associated urinary tract infection; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; DOH = Department of Health; PAD = peripheral arterial disease; PNA = pneumonia; SP CVA = status post cerebrovascular accident; UTI = urinary tract infection. Study Limitations: The retrospective design of the study is a limitation in itself. Our data were collected by analyzing medical records, which intrinsically lends itself to systematic bias. The validity of data relating to such things as laboratory values and interpretation can therefore not be fully guaranteed. Our sample size was also small, and we hope to elaborate with future studies. However, as a pilot study, we believe that publishing our findings will engage the academic community and help determine future study parameters. Furthermore, as a descriptive, observational study, there are limitations as there are no control groups, and interpretation of results is therefore theoretical. CONCLUSIONS: Based on our findings, we strongly believe that if an admission UA was conducted for elderly hip fracture patients and positive results were treated accordingly, there would be a significant reduction in the diagnosis of CAUTI. An indwelling urinary catheter is commonly placed in elderly hip fracture patients, increasing their inherent risk for a UTI based on catheter placement alone. This study has also demonstrated the increased incidence of positive UA as an additional theoretical risk factor for CAUTI in these patients. Because of potential for serious complications, mortality, and financial burden on institutions, early identification of urinary tract infection or asymptomatic bacteriuria should be identified and treated in a protocolized manner in elderly hip fracture patients. These protocols can lower the incidence of CAUTI and improve outcomes in this susceptible and high-risk population. Although routine screening for urinary tract infection is a common measure adopted in geriatric wards, it has not been common practice among elderly trauma patients. This article brings forward the need to adopt this common practice to reduce the likelihood of a CAUTI being attributed to institutions, given the high risk of infection/colonization in the geriatric population. Therefore, we recommend that all elderly hip fracture patients be screened at admission with a UA and be treated appropriately. KEY POINTS: Catheter-associated urinary tract infections (CAUTIs) are a well-known complication among the geriatric hip fracture population. CAUTI has negative consequences for both the patient and the institution and may be due to urinary tract infection (UTI) present on admission. This study observed outcomes in geriatric hip fracture patients who underwent routine UTI screening on admission. The results of this study suggest reduced rates of CAUTI compared to previously published literature. The results suggest there may be a role in routine UTI screening for geriatric hip fracture patients. Acknowledgments: We thank the patients at Nassau University Medical Center for trusting us with their care. We also thank the staff of the trauma department at Nassau University Medical Center for their continued commitment to patient care. REFERENCES: Alpay Y. Aykin N. Korkmaz P. Gulduren H. M. Caglan F. C. (2018). Urinary tract infections in the geriatric patients. Pakistan Journal of Medical Sciences , 34 (1), 67 – 72. doi:10.12669/pjms.341.14013 Aubron C. Huet O. Ricome S. Borderie D. Pussard E. Leblanc P.-E. Duranteau J. (2012). Changes in urine composition after trauma facilitate bacterial growth. BMC Infectious Diseases , 12 , 330. doi:10.1186/1471-2334-12-330 Bail K. Goss J. Draper B. Berry H. Karmel R. Gibson D. (2015). The cost of hospital-acquired complications for older people with and without dementia: A retrospective cohort study. BMC Health Services Research , 15 , 91. doi:10.1186/s12913-015-0743-1 Bliemel C. Buecking B. Hack J. Aigner R. Eschbach D.-A. Ruchholtz S. Oberkircher L. (2017). Urinary tract infection in patients with hip fracture: An underestimated event ? Geriatrics & Gerontology International , 17 (12), 2369 – 2375. doi:10.1111/ggi.13077 Bohl D. D. Iantorno S. E. Saltzman B. M. Tetreault M. W. Darrith B. Della Valle C. J. (2017). Sepsis within 30 days of geriatric hip fracture surgery. The Journal of Arthroplasty , 32 (10), 3114 – 3119. doi:10.1016/j.arth.2017.05.024 Centers for Disease Control and Prevention. (2019). Guideline for prevention of catheter-associated urinary tract infections 2009. Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/cauti/ Centers for Disease Control and Prevention. (2021). Urinary tract infections (UTI) events. Retrieved from https://www.cdc.gov/nhsn/psc/uti/ Chenoweth C. E. Gould C. V. Saint S. (2014). Diagnosis, management, and prevention of catheter-associated urinary tract infections. Infectious Disease Clinics of North America , 28 (1), 105 – 119. doi:10.1016/j.idc.2013.09.002 Detweiler K. Mayers D. Fletcher S. G. (2015). Bacteruria and urinary tract infections in the elderly. The Urologic Clinics of North America , 42 (4), 561 – 568. doi:10.1016/j.ucl.2015.07.002 Devillé W. L. J. M. Yzermans J. C. van Duijn N. P. Bezemer P. D. van der Windt D. A. W. M. Bouter L. M. (2004). The urine dipstick test useful to rule out infections. A meta-analysis of the accuracy. BMC Urology , 4 , 4. doi:10.1186/1471-2490-4-4 Foxman B. (2010). The epidemiology of urinary tract infection. Nature Reviews Urology , 7 (12), 653 – 660. doi:10.1038/nrurol.2010.190 Foxman B. (2014). Urinary tract infection syndromes: Occurrence, recurrence, bacteriology, risk factors, and disease burden. Infectious Disease Clinics of North America , 28 (1), 1 – 13. doi:10.1016/j.idc.2013.09.003 Gould C. V. Umscheid C. A. Agarwal R. K. Kuntz G. Pegues D. A. , & Healthcare Infection Control Practices Advisory Committee. (2010). Guideline for prevention of catheter-associated urinary tract infections 2009. Infection Control and Hospital Epidemiology , 31 (4), 319 – 326. doi:10.1086/651091 Hälleberg Nyman M. Gustafsson M. Langius-Eklöf A. Johansson J.-E. Norlin R. Hagberg L. (2013). Intermittent versus indwelling urinary catheterisation in hip surgery patients: A randomised controlled trial with cost-effectiveness analysis. International Journal of Nursing Studies , 50 (12), 1589 – 1598. doi:10.1016/j.ijnurstu.2013.05.007 Hassan M. Tuckman H. P. Patrick R. H. Kountz D. S. Kohn J. L. (2010). Cost of hospital-acquired infection. Hospital Topics , 88 (3), 82 – 89. doi:10.1080/00185868.2010.507124 Hollenbeak C. S. Schilling A. L. (2018). The attributable cost of catheter-associated urinary tract infections in the United States: A systematic review. American Journal of Infection Control , 46 (7), 751 – 757. doi:10.1016/j.ajic.2018.01.01 Johnstone D. J. Morgan N. H. Wilkinson M. C. Chissell H. R. (1995). Urinary tract infection and hip fracture. Injury , 26 (2), 89 – 91. doi:10.1016/0020-1383(95)92183-b Magill S. S. Edwards J. R. Bamberg W. Beldavs Z. G. Dumyati G. Kainer M. A. ,... Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. (2014). Multistate point-prevalence survey of health care-associated infections. The New England Journal of Medicine , 370 (13), 1198 – 1208. doi:10.1056/NEJMoa1306801 Mody L. Juthani-Mehta M. (2014). Urinary tract infections in older women: A clinical review. JAMA , 311 (8), 844 – 854. doi:10.1001/jama.2014.303 Monaghan S. F. Heffernan D. S. Thakkar R. K. Reinert S. E. Machan J. T. Connolly M. D. Cioffi W. G. (2011). The development of a urinary tract infection is associated with increased mortality in trauma patients. The Journal of Trauma , 71 (6), 1569 – 1574. doi:10.1097/TA.0b013e31821e2b8f Nicolle L. E. Bradley S. Colgan R. Rice J. C. Schaeffer A. Hooton T. M. ,... American Geriatric Society. (2005). Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clinical Infectious Diseases , 40 (5), 643 – 654. doi:10.1086/427507 Polites S. F. Habermann E. B. Thomsen K. M. Amr M. A. Jenkins D. H. Zietlow S. P. Zielinski M. D. (2014). Urinary tract infection in elderly trauma patients: Review of the trauma quality improvement program identifies the population at risk. The Journal of Trauma and Acute Care Surgery , 77 (6), 952 – 959. doi:10.1097/TA.0000000000000351 Rebmann T. Greene L. R. (2010). Preventing catheter-associated urinary tract infections: An executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide. American Journal of Infection Control , 38 (8), 644 – 646. doi:10.1016/j.ajic.2010.08.003 Rowe T. A. Juthani-Mehta M. (2013). Urinary tract infection in older adults. Aging Health , 9 (5). doi:10.2217/ahe.13.38 Rowe T. A. Juthani-Mehta M. (2014). Diagnosis and management of urinary tract infection in older adults. Infectious Disease Clinics of North America , 28 (1), 75 – 89. doi:10.1016/j.idc.2013.10.004 Różańska A. Wałaszek M. Wolak Z. Bulanda M. (2016). Prolonged hospitalization of patients with hospital acquired pneumoniae in the intensive care unit—morbidity, mortality and costs of. Przeglad Epidemiologiczny , 70 (3), 449 – 461. Schulz L. Hoffman R. J. Pothof J. Fox B. (2016). Top ten myths regarding the diagnosis and treatment of urinary tract infections. The Journal of Emergency Medicine , 51 (1), 25 – 30. doi:10.1016/j.jemermed.2016.02.009 Scott B. M. (2010). Clinical and cost effectiveness of urethral catheterisation: A review. Journal of Perioperative Practice , 20 (7), 235 – 240. doi:10.1177/175045891002000701 Simati B. Kriegsman B. Safranek S. (2013). FPIN's clinical inquiries. Dipstick urinalysis for the diagnosis of acute UTI. American Family Physician , 87 (10). Stovall R. T. Haenal J. B. Jenkins T. C. Jurkovich G. J. Pieracci F. M. Biffl W. L. Cothren Burlew C. (2013). A negative urinalysis rules out catheter-associated urinary tract infection in trauma patients in the intensive care unit. Journal of the American College of Surgeons , 217 (1), 162 – 166. doi:10.1016/j.jamcollsurg.2013.02.030 Thakker A. Briggs N. Maeda A. Byrne J. Davey J. R. Jackson T. D. (2018). Reducing the rate of post-surgical urinary tract infections in orthopedic patients. BMJ Open Quality , 7 (2), e000177. doi:10.1136/bmjoq-2017-000177 Tsuda Y. Yasunaga H. Horiguchi H. Ogawa S. Kawano H. Tanaka S. (2015). Association between dementia and postoperative complications after hip fracture surgery in the elderly: Analysis of 87,654 patients using a national administrative database. Archives of Orthopaedic and Trauma Surgery , 135 (11), 1511 – 1517. doi:10.1007/s00402-015-2321-8 Wallace R. Angus L. D. G. Munnangi S. Shukry S. DiGiacomo J. C. Ruotolo C. (2019). Improved outcomes following implementation of a multidisciplinary care pathway for elderly hip fractures. Aging Clinical and Experimental Research , 31 (2), 273 – 278. doi:10.1007/s40520-018-0952-7 Woodford H. J. George J. (2009). Diagnosis and management of urinary tract infection in hospitalized older people. Journal of the American Geriatrics Society , 57 (1), 107 – 114. doi:10.1111/j.1532-5415.2008.02073.x Zalmanovici Trestioreanu A. Lador A. Sauerbrun-Cutler M.-T. Leibovici L. (2015). Antibiotics for asymptomatic bacteriuria. The Cochrane Database of Systematic Reviews , 4 , CD009534. doi:10.1002/14651858.CD009534.pub2 Zielinski M. D. Kuntz M. M. Polites S. F. Boggust A. Nelson H. Khasawneh M. A. Pieper R. (2015). A prospective analysis of urinary tract infections among elderly trauma patients. The Journal of Trauma and Acute Care Surgery , 79 (4), 638 – 642. doi:10.1097/TA.0000000000000796 Zielinski M. D. Thomsen K. M. Polites S. F. Khasawneh M. A. Jenkins D. H. Habermann E. B. (2014). Is the Centers for Medicare and Medicaid Service's lack of reimbursement for postoperative urinary tract infections in elderly emergency surgery patients justified ? Surgery , 156 (4), 1009 – 1015. doi:10.1016/j.surg.2014.06.073 [ABSTRACT FROM AUTHOR]

A surgical post-acute treatment unit (SPA) was developed for acutely injured elderly patients who no longer warranted acute care in an intensive care setting to decrease complications by focusing increased bedside attention to cognition, nutrition, respiration, and mobilization. A retrospective review was performed comparing patients 65 years and older with isolated rib fractures treated before the SPA was opened with patients treated in the SPA. The 2 populations were comparable except the SPA group had a higher mean Injury Severity Score. Nine complications occurred in the pre-SPA group, and no complications occurred in the SPA patient population. Four patients in the pre-SPA group died compared with zero deaths for the SPA group. The rates of complications and mortality between elderly patients with isolated rib fractures were not statistically different between patients treated with a traditional admission to an inpatient ward and patients admitted to the SPA, even though the SPA patients had significantly more severe chest injuries. Establishing a physical environment to support the needs of elderly trauma patients with isolated rib fractures who no longer need the intensive care unit (ICU) is effective in decreasing the complications and unplanned returns to the ICU. [ABSTRACT FROM AUTHOR]