Continence Care and Bowel Management
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The best practice guideline (BPG) A Proactive Approach to Bladder and Bowel Management in Adults, Fourth Edition replaces the RNAO BPGs Promoting Continence Using Prompted Voiding and Prevention of Constipation in the Older Adult Population, both of which were last updated in 2011. This BPG provides evidence-based recommendations for effective strategies to support adults (aged 18 years and older) who live with urinary incontinence, fecal incontinence and/or constipation that will improve quality of care and lead to positive health outcomes.
The BPG includes good practice statements on conducing a focused initial assessment and recommendation areas that address the following: toileting strategies, physical activity, adequate intake of fibre and/or fluids, interprofessional approach and bowel protocol.
This BPG can be used by nurses, members of the interprofessional team and caregivers across the continuum of care and in all domains of practice such as administration, clinical, education, policy and research. The evidence-based recommendations in this BPG are applicable to all practice settings where persons who live with urinary incontinence, fecal incontinence and/or constipation are accessing services (e.g., acute care, long-term care, primary and community care, and rehabilitation settings).
Registered Nurses’ Association of Ontario (RNAO). A proactive approach to bladder and bowel management in adults. 4th ed. Toronto (ON): RNAO; 2020. -
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A tool to assist with comparing your organization’s current practice with evidence-based RNAO best practice recommendations.
Registered Nurses Association of Ontario (2022). Gap Analysis- A Proactive Approach to Bladder and Bowel Management. Toronto. ON
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On April 11, 2023, changes to Ontario Regulation 246/22 (the "Regulation") under the Fixing Long-Term Care Act, 2021 (the "Act") came into effect.
Informed by engagement with key partners and stakeholders, as well as feedback from the public, the Ministry of Long-Term Care (the "Ministry") has refined the regulatory framework with consideration of the lived experience of residents and long-term care homes and emerging needs in the sector.Retrieved from: https://www.ontario.ca/laws/regulation/220246
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This presentation reviews strategies of sizing and distribution for improving continence product usage. Developed by Deb Jenkins, APN, Improving Continence Care Collaborative Co-lead, SHRTN Community of Practice. December 2011.
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A presentation on improving continence care developed in 2004 by the IC-5 project with Ontario Women’s Health Council.
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This fact sheet from The Canadian Continence Foundation provides an overview of fecal incontinence, lifestyle changes and treatments. Available in a print out version.
Retrieved from: https://www.canadiancontinence.ca/fecal-incontinence
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Appendix H from the RNAO A Proactive Approach to Bladder and Bowel Management in Adults — Fourth Edition is a systematic approach to dealing with constipation and fecal incontinence.
Registered Nurses’ Association of Ontario (RNAO). A proactive approach to bladder and bowel management in adults. 4th ed. Toronto (ON): RNAO; 2020. (p. 132).
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Appendix G from the RNAO A Proactive Approach to Bladder and Bowel Management in Adults — Fourth Edition shows how the best practice guideline recommendations can be applied in the clinical setting.
Registered Nurses’ Association of Ontario (RNAO). A proactive approach to bladder and bowel management in adults. 4th ed. Toronto (ON): RNAO; 2020. (p.131).
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This bladder and bowel care plan, developed by CorHealth is aimed at people with strokes, but is applicable to residents of long term care. It is one of a series of stroke care plans.
Cor Health (2020) Bladder and Bowel Stroke Care Plans retrieved from Community Reengagement - CorHealth Ontario
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A comprehensive assessment of bladder and bowel function for LTC residents developed by the LTC BPC Project with Toronto Best Practice Steering Committee and Northwest Continence Collaborative (2005). Includes list of medications that affect continence and treatment options.
Reference: Toronto Best Practice Committee and Northwest Continence Collaborative (2006). Bladder & Bowel Continence Assessment.. Toronto.
Sources: AHCPR. 2006. Urinary Incontinence. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.10079. ; Brigham & Women’s Hospital. 2004, Urinary incontinence http://www.brighamandwomens.org/medical/HandbookArticles/Urinaryincontinence.pdf. ; The Hartford Institute for Geriatric Nursing. 2001. Urinary incontinence. http://www.hartfordign.org/publications/trythis/issue11.pdf. ; IC-5 Continence Project, 2005, http://www.hospitalreport.ca/projects/QI_projects/IC5.html. Rehabilitation Nursing Foundation. 2002. Constipation. www.rehabnurse.org. ; RNAO. 2005, Preventing Constipation; Prompting Continence. http://www.rnao.org/bestpractices. ; Royal Women’s Hospital. 2005. Urinary incontinence, http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3661. ; Singapore Ministry of Health. 2003, http://www.moh.gov.sg/cmaweb/attachments/publication/Nursing_Management_of_Patients_with_Urinary_Incontinence_1-2003.pdf. U.S. National Library of Medicine and U.S. National Institute of Health. 2006. Drugs, supplements. < http://www.nlm.nih.gov/medlineplus/druginformation.html
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Appendix Q from the RNAO A Proactive Approach to Bladder and Bowel Management in Adults — Fourth Edition shows pictures of stools to help improve assessment of constipation.
Registered Nurses’ Association of Ontario (RNAO). A proactive approach to bladder and bowel management in adults. 4th ed. Toronto (ON): RNAO; 2020. (p. 147).
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This guideline has illustrations and procedures on how to do intermittent catheterizations in adult.
Reference: Vahr, S. Cobussen-Boekhorst, H, Eikenboom, J, Geng, V, Holroyd, S, Lester, M, Pearce, I and Vandewinke, C. 2013. Evidence-based Guidelines for Best Practice in Urological Health Care Catheterisation Dilatation, urethral intermittent in adults. European Association of Urology Nurses. http://nurses.uroweb.org/wp-content/uploads/2013_EAUN_Guideline_Milan_2013-Lr_DEF.pdf.
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Appendix O from the RNAO A Proactive Approach to Bladder and Bowel Management in Adults — Fourth Edition is a comprehensive list of physical, emotional and other factors that contribute to constipation.
Registered Nurses’ Association of Ontario (RNAO). A proactive approach to bladder and bowel management in adults. 4th ed. Toronto (ON): RNAO; 2020. (p.144-145)
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A comprehensive list of physical, emotional and other factors that contribute to urinary continence. Registered Nurses’ Association of Ontario (RNAO). A proactive approach to bladder and bowel management in adults. 4th ed. Toronto (ON): RNAO; 2020.
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A fact sheet on preventing constipation for patients and families with recommendations for action based on the RNAO Constipation BPG. Available in French.
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A one time, single resident risk assessment for dehydration based of the University of Iowa Dehydration BPG.
References:
Mentes, J. C. & The Iowa Veterans Affairs Nursing Research Consortium. (2004). Evidence-Based Practice Guideline: Hydration management. Iowa City, IA: The University of Iowa Gerontological Nursing Interventions Research Center Research Translation and Dissemination Core.
Mentes, J. C. & Iowa-Veterans Affairs Research Consortium. (2000). Hydration management. Journal of Gerontological Nursing, 6-15.
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This comprehensive factsheet provides information to assist with the prevention and management of bladder and bowel problems in people with dementia.
Reference: Australian Government (2016). Dementia and bladder and Bowel Control, retrieved Aug. 4, 2022 from https://www.health.gov.au/resources/publications/dementia-and-bladder-and-bowel-control.© Commonwealth of Australia I Department of Health and Aged Care -
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An illustration of the structure of the lower male and female urinary tracts.
Registered Nurses' Association of Ontario. (2006). Self-Learning Package Continence Care Education. Toronto, ON: Retrieved from: http://rnao.ca/bpg/guidelines/resources/continence-care-education-selflearning-package
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This resource from the CDC (Center for Disease Control and Prevention) National Healthcare Safety Network, is a fact sheet suitable for health care providers which provides a concise overview of urinary tract infections.
Available at: https://www.cdc.gov/nhsn/faqs/faq-uti.html Last Reviewed: March 19, 2024
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A best practice guideline on preventing Catheter-associated Urinary Tract Infections. For use by infection prevention staff, administrators, nurses, and other healthcare providers across the continuum of care. Developed by the Centre for Disease Control and Prevention.
Reference: Healthcare Infection Control Practices Advisory Committee (HICPAC) and Centre for Disease Control and Prevention. (CDC). 2009. Guideline for Prevention of Catheter-associated Urinary Tract Infections. http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf.
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This IADIT tool is an excellent resource on skin care for incontinent people. It has clear pictures, definitions and short descriptions of skin changes and rashes.
Copyright © 2008 Joan Junkin. All rights reserved. Please send request for permissions to IADIT@medbiopub.com.
1. Bliss DZ, Zehrer C, Savik K, et al. Incontinence-associated skin damage in nursing home residents: a secondary analysis of a prospective, multicenter study. Ostomy Wound Manage. 2006;52:46–55.
2. Institute for Healthcare Improvement. Prevent Pressure Ulcers: How-To Guide. May 2007. Available at: http://www.ihi.org/nr/rdonlyres/5ababb51-93b3-4d88-ae19- be88b7d96858/0/pressureulcerhowtoguide.doc
3. Gray M, Bliss DB, Ermer-Seltun J, et al. Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2007;34:45-54.
4. Junkin J, Selekof JL. Prevalence of incontinence and associated skin injury in the acute care inpatient. J Wound Ostomy Continence Nurs. 2007;34:260-269.
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A fact sheet on urinary continence for patients and families with recommendations for action based on the RNAO Continence BPG. Available in French.
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This algorithm looks at a multidisciplinary approach related the management of urinary incontinence in the community or long term care homes. It addresses: presenting symptoms, clinical assessments, presumed etiology, treatment/management and evaluation. This one page tool can be laminated and posted for reference.
Retrieved from: https://static1.squarespace.com/static/65a5be5a40b6451450a341e1/t/662baacdd6ace53530f7fdfd/1714137805738/chart-initial-managemen
© 2001 The Canadian Continence Foundation
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An illustration showing how the urinary tract nerves come from the brain and spinal cord.
Registered Nurses' Association of Ontario. (2006). Self-Learning Package Continence Care Education. Toronto, ON: Retrieved from: http://rnao.ca/bpg/guidelines/resources/continence-care-education-selflearning-package
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This powerpoint presentation for health care providers, shows how to distinguish between the types of urinary incontinence and interventions to treat urinary incontinence. A poster and patient handout are also part of this module which is also available in french.
Spencer, Martha ( 2019) Introduction to Urinary Incontinence- Clinician Learning Series.Ontario. Retrieved from https://www.rgptoronto.ca/resource/introduction-to-urinary-incontinence-clinician-learning-series/
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Appendix P from the RNAO A Proactive Approach to Bladder and Bowel Management in Adults — Fourth Edition is a list of the major drug groups that can contribute to constipation.
Registered Nurses’ Association of Ontario (RNAO). A proactive approach to bladder and bowel management in adults. 4th ed. Toronto (ON): RNAO; 2020 (p. 146).
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A list of the major drug groups that can contribute to urinary incontinence. Registered Nurses’ Association of Ontario (RNAO). A proactive approach to bladder and bowel management in adults. 4th ed. Toronto (ON): RNAO; 2020.
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This resource from the Canadian Continence Foundation provides a list of some medications used for overactive bladder treatment.
Retrieved from: https://static1.squarespace.com/static/65a5be5a40b6451450a341e1/t/66576f2b08d96963095e44db/1717006123689/OABEn-2016.pdf
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This resource from the Canadian Continence Foundation explains pelvic muscle exercises, how they may help with incontinence and how to properly perform them.
Retrieved from: https://static1.squarespace.com/static/65a5be5a40b6451450a341e1/t/662badc92a66f708cd6df4cf/1714138569848/pelvicmuscleexercises.p
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A detailed policy and procedure for preventing dehydration in LTC residents. It was developed by the Toronto Best Practice Implementation Steering Committee.
Reference: Toronto Best Practice in LTC initiative working group , (December 2006), Policy and Procedure: Hydration Management Toronto Best Practice in LTC Initiative, date retrieved, June 8 2015,
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A presentation on causes, risk factors and interventions for dehydration developed by the Committee for the Enhancement of Elder Friendly Environments (CEEFE) Central South Geriatric Program (Ontario).
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This poster defines dehydration and explains the shows the risk factors related to dehydration and strategies to prevent dehydration.
Reference: Developed by the Elder friendly environments Coalition (2008).
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A systematic approach to encouraging incontinent people to become continent. Registered Nurses’ Association of Ontario (RNAO). A proactive approach to bladder and bowel management in adults. 4th ed. Toronto (ON): RNAO; 2020.
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A comprehensive list of physical, environmental, functional and other factors that contribute to fecal incontinence. Registered Nurses’ Association of Ontario (RNAO). A proactive approach to bladder and bowel management in adults. 4th ed. Toronto (ON): RNAO; 2020.
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La ligne directrice sur les pratiques exemplaires (LDPE) Une approche proactive de la gestion de la vessie et des intestins chez les adultes Quatrième édition, remplace les LDPE de la RNAO Favoriser la continence par le déclenchement de la miction et Prévention de la constipation chez les personnes âgées - Lignes directrices sur les pratiques, toutes deux mises à jour pour la dernière fois en 2011. Cette LDPE fournit des recommandations fondées sur des preuves pour des stratégies efficaces pour soutenir les adultes (âgés de 18 ans et plus) qui vivent avec l'incontinence urinaire, l'incontinence fécale et/ou la constipation qui amélioreront la qualité des soins et mèneront à des résultats de santé positifs.
Le LDPE comprend des énoncés de bonnes pratiques sur la réalisation d'une évaluation initiale ciblée et des domaines de recommandation qui traitent des éléments suivants : stratégies d'élimination des toilettes, activité physique, apport adéquat de fibres et/ou de liquides, approche interprofessionnelle et protocole intestinal.
Ces LDPE peuvent être utilisées par les infirmières, les membres de l'équipe interprofessionnelle et les soignants dans tout le continuum de soins et dans tous les domaines de pratique tels que l'administration, la clinique, l'éducation, les politiques et la recherche. Les recommandations fondées sur des données probantes de ce LDPE s'appliquent à tous les milieux de pratique où les personnes qui vivent avec une incontinence urinaire, une incontinence fécale et/ou une constipation accèdent à des services.
Registered Nurses' Association of Ontario (2020) Une approche proactive de la gestion de la vessie et des intestins chez les adultes retrieved from Bladder_and_Bowel_Management_FINAL_WEB_FR_LR_0.pdf (rnao.ca)
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Appendix S from the RNAO A Proactive Approach to Bladder and Bowel Management in Adults — Fourth Edition provides systematic approaches to decreasing constipation.
Registered Nurses’ Association of Ontario (RNAO). A proactive approach to bladder and bowel management in adults. 4th ed. Toronto (ON): RNAO; 2020. (p. 150-151).
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A one-time, single resident assessment for 30 signs and symptoms of dehydration.
Author and Date unknown
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This comprehensive website from the Canadian Continence Foundation has resources on both urinary and fecal incontinence. Including information about bladder health, causes of urinary incontinence, diagnosis and treatment of urinary incontinence, pamphlets and videos.
Reference: The Canadian Continence Foundation. Retrieved at: https://www.canadiancontinence.ca/
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This information sheet from the Canadian Continence Foundation- describes what bladder training is, provides tips to decide whether bladder training is feasible and how to get started.
Retrieved from: https://static1.squarespace.com/static/65a5be5a40b6451450a341e1/t/662badf174edb437138841a2/1714138610191/TrainingYourBladder.pdf
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A detailed, 8 page assessment of urinary and bowel continence issues that can be completed by a staff. Treatment options are suggested and a client record sheet is included.
Reference: Registered Nurses’ Association of Ontario (2006). Transdisciplinary Patient/Client Continence Assessment Tool. Toronto, Canada: Registered Nurses’ Association of Ontario. Retrieved from: http://ltctoolkit.rnao.ca/sites/default/files/resources/continence/Continence_AssessmentTools/RNAO_TransdisciplinaryPatientClient_Continence.pdf
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This powerpoint presentation aimed at health care providers, describes bladder physiology, classifies and identifies medications that contribute to incontinence and pharmacological treatments used for urinary incontinence. It is also available in french
Alston, Jillian ( 2020) Urinary Incontinence & Medications- Clinician Learning Series. Ontario. Retrieved from https://www.rgptoronto.ca/resource/urinary-incontinence-medications-clinician-learning-series/
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This presentation gives a summary of the research evidence on UTI’s in Long Term Care. It discusses challenges in diagnosis, treatment and prevention of UTI’s. Developed by Barbara Grace Cowie, RN MN, Nurse Continence Advisor, Advanced Practice Nurse, West Park Healthcare Centre.
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This is a one-page algorithm that is part of Public Health Ontario’s Urinary Tract Infection (UTI) Program. It clearly describes signs and symptoms of UTI’s and promotes ‘watchful waiting’ as an acceptable alternative before treating probable UTI’s. Is suitable for posting on a bulletin board.
Reference: Public Health Ontario (PHO). 2019. Assessment algorithm for urinary tract infections (UTIs) in medically stable non-catheterized residents. Accessed Mar. 13, 2019. http://www.publichealthontario.ca/en/BrowseByTopic/IPAC/Documents/UTI_Assessment_Algorithm.pdf
© 2019 Ontario Agency for Health Protection and Promotion
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This PHO resource provides basic facts about asymptomatic bacteriuria
Reference: Public Health Ontario, 2014, Asymptomatic Bacteriuria Fact Sheet. Retrieved from http://www.publichealthontario.ca/en/Pages/default.aspx
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This fact sheet is part of Public Health Ontario’s Urinary Tract Infection (UTI) Program. It succinctly describes the evidence for not using dipsticks to diagnose UTI’s. Is suitable for sharing with staff, residents and families.
Reference: Public Health Ontario (PHO). Revised 2019.Urinary Tract Infection (UTI) Program Evidence to Support Discontinuing the Use of Dipsticks to Diagnose a UTI in Residents of Long-Term Care Homes (LTCHs) https://www.publichealthontario.ca/-/media/Documents/U/2016/uti-dipsticks.pdf?sc_lang=en
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This resource can be used by health care providers at the long-term care homes (LTCHs) when consulting or meeting with friends and families of residents who have questions about a LTCH’s approach to managing suspected UTIs.
Reference: Public Health Ontario (PHO). Revised 2016. Retrieved from https://www.publichealthontario.ca/-/media/Documents/U/2016/uti-faq-residents-families.pdf?sc_lang=en
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This PowerPoint presentation is part of Public Health Ontario’s Urinary Tract Infection (UTI) Program. It provides an overview of how to implement a UTI program.
Reference: Public Health Ontario (PHO). 2017. UTI Program (PHO) Management of UTIs in Non-catheterized Long-Term Care Home Residents. http://www.publichealthontario.ca/en/BrowseByTopic/IPAC/Documents/UTI_Presentation_Orientation_Education_Program.pdf
© 2017 Ontario Agency for Health Protection and Promotion
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This policy and procedure is part of Public Health Ontario’s Urinary Tract Infection (UTI) Program. It is a comprehensive policy that could be adapted by long term care homes and other health care organizations. It is complimented by a guidance document available on the PHO website.
Reference: Public Health Ontario (PHO). Revised 2019. UTI Program: Sample policy and procedure for assessment and management of urinary tract infections (UTIs) in non-catheterized residents. Retrieved from https://www.publichealthontario.ca/-/media/Documents/U/2018/uti-sample-policy-procedure.pdf?sc_lang=en
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This Public Health Ontario resource provides a list of UTI symptoms, contrasts between non-catheterized and catheterized residents and when not to send a specimen.
Reference: Public Health Ontario, 2014, When To Collect A Urine Specimen For Culture And Sensitivity Fact Sheet. Retrieved from https://www.publichealthontario.ca/-/media/Documents/U/2016/uti-urine-collection.pdf?sc_lang=en
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Public Health Ontario (PHO) has developed the Urinary Tract Infection (UTI) Program in response to concerns about the overuse of antibiotics for presumed UTI's in residents in long-term care homes (LTCHs) and the associated antibiotic-related harms. The Program contains a number of tools for assessment, planning, implementation and evaluation of a program to reduce UTI’s in LTC homes.
Reference: Public Health Ontario (PHO), 2019. Urinary Tract Infection (UTI) Program.
Retrieved Aug. 4, 2022 from https://www.publichealthontario.ca/en/Health-Topics/Antimicrobial-Stewardship/UTI-Program
© 2022 Ontario Agency for Health Protection and Promotion
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This is a comprehensive list of reasons for delirium that need to be considered before assuming that a change in mental status is due to a UTI.
Public Health Ontario (2019).UTI Program (PHO)- Causes of Delirium and Mental Status Changes retrieved from https://www.publichealthontario.ca/-/media/Documents/U/2016/uti-delirium-mental-status.pdf?sc_lang=en
© 2022 Ontario Agency for Health Protection and Promotion