Assessment Over Action: Shifting the UTI Culture in Ontario Long-Term Care

The key issue is this: testing and treatment can easily move ahead of assessment.

Urinary tract infection management in long-term care has changed significantly in Ontario. The Ontario UTI Program has helped shift the focus away from treating positive urine results and toward making better clinical decisions based on resident symptoms, assessment findings, and antimicrobial stewardship principles. The goal is simple: reduce unnecessary antibiotic use, improve resident safety, and support more consistent care. But in practice, implementing the program is not always simple.

At IPAC Consulting, through our work with long-term care homes across Ontario, we often see that the challenge is not whether staff are aware of the UTI Program; in many cases, they are. The challenge is how the program is interpreted and applied in real time, especially when a resident has a sudden change in condition, a family member is concerned, or a urine result comes back positive. The key issue is this: testing and treatment can easily move ahead of assessment.

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A Positive Urine Culture Is Not a Diagnosis

One of the most important lessons in UTI management is that bacteria in the urine does not automatically mean infection. Many older adults, especially those living in long-term care, may have bacteria in their urine without any signs or symptoms of a urinary tract infection. This is called asymptomatic bacteriuria, and it should not be treated with antibiotics. This is exactly where practice can become complicated.

Once a urine test is collected and the result comes back positive, the team may feel intense pressure to act. Families may expect treatment, staff may worry about missing an underlying health change, and prescribers may feel more comfortable ordering antibiotics “just in case.” However, a positive urine culture should support clinical decision-making—it should never replace it. The better question to ask is not, “Is the urine positive?” but rather, “Does the resident have symptoms that support a UTI diagnosis?”

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Assessment Should Come Before Testing

A helpful way to think about the Ontario UTI Program is this: assessment should drive testing, and testing should not drive treatment. When a resident has a change in condition, the first step should always be a broader assessment. In long-term care, symptoms such as confusion, falls, changes in behaviour, cloudy urine, foul-smelling urine, or a general decline can understandably raise concern. Staff know their residents well, and they often notice these subtle changes before anyone else does. However, these signs alone are not enough to diagnose a UTI.

Before jumping directly to a urine test, clinical teams should ask an array of comprehensive questions:

• What specific symptoms are present? 

• Are there localized urinary symptoms, such as acute dysuria, new or worsening urgency, new or worsening frequency, or suprapubic pain?
• Is there a fever or other systemic sign that supports an active infection?
• Could there be another clinical explanation, such as dehydration, constipation, pain, medication changes, poor sleep, a respiratory infection, or recent environmental changes?
• Does this specific resident meet the established criteria for urine testing?

This foundational screening step matters immensely because once urine is tested, the raw result can heavily bias the rest of the decision-making process—even when the resident did not meet the criteria for testing in the first place.

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The Most Common Misinterpretation: “Something Changed, So It Must Be a UTI”

Doing less urine testing does not mean delivering less care; it means delivering more appropriate, targeted care.

In long-term care environments, one of the most common patterns is reflexively connecting any baseline change in condition to a possible UTI. Whether a resident becomes more confused, experiences a sudden fall, is eating less, or is simply described as “not themselves,” these changes should absolutely be taken seriously. But taking them seriously does not always mean ordering a urine test. Instead, it means completing a thoughtful, comprehensive assessment to understand what may truly be causing the clinical shift.

This is where the Ontario UTI Program is frequently misunderstood. The program is not saying to do nothing; it is saying to assess first, test only when clinically indicated, and treat only when full diagnostic criteria are met. That distinction is profoundly important. Doing less urine testing does not mean delivering less care; it means delivering more appropriate, targeted care.

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Why Dipsticks Are a Problem in LTC

Another important teaching point is the role of urine dipsticks. In long-term care settings, dipsticks are not reliable for diagnosing UTIs. They regularly detect findings that are highly common in older adults, including baseline asymptomatic bacteria or white blood cells in the urine, but those findings do not necessarily mean the resident has an infection that requires antibiotics. The fundamental problem with dipsticks is that they create false confidence.

A positive dipstick may make the care team feel that a UTI has been verified, when in reality, the resident may completely lack clinical symptoms of an active infection. Removing dipsticks from daily workflow is an important step, but it is not enough on its own. Homes also need to shift the thinking behind dipstick use. If the team removes the dipstick but still maintains the same “check the urine first” approach, actual practice has not changed. The goal is not simply to remove a tool; the goal is to shift the entire clinical decision-making process.

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How to Support Better Practice

For long-term care homes, successful implementation of the Ontario UTI Program requires much more than posting the algorithm on a wall or providing a one-time education session. Staff need repeated, practical opportunities to apply the guidance to real clinical situations. A robust approach includes:

• Training staff on the clear clinical differences between asymptomatic bacteriuria and a symptomatic UTI
• Reinforcing exactly which localized symptoms do and do not support ordering a urine test
• Using structured case studies to walk through common, ambiguous scenarios
• Reviewing recent urine culture and antibiotic prescribing patterns at a facility level
• Creating consistent language across the entire care circle—including nurses, physicians, nurse practitioners, pharmacists, PSWs, and families
• Actively supporting staff when they feel internal or external pressure to “just test” or “just treat”

This multi-disciplinary alignment is especially important because UTI management involves many different roles. PSWs may be the first to notice a change, nurses complete the objective assessment, prescribers make final treatment decisions, and pharmacists support antimicrobial stewardship. If each person interprets the program differently, day-to-day practice becomes fragmented and inconsistent.

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Family Communication Matters

Families often request urine testing or immediate antibiotics simply because they are worried. They may have experienced a past situation where a resident was treated for a UTI and improved, so they understandably associate any behavioral or physical change with a urinary tract infection. Because of this, staff need clear, reassuring language to explain the clinical approach.

Example Conversation Framework:

“We are taking this change in condition very seriously. Right now, we are completing a full, comprehensive assessment to understand exactly what may be causing it. Antibiotics are only helpful when there is evidence of a true, symptomatic infection, and using them when they are not needed can cause real clinical harm. We will continue monitoring closely and will proceed with testing if their symptoms match the required medical criteria.”

This type of explanation helps families understand that the team is not ignoring their concern. Instead, they are responding carefully, safely, and clinically.

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The Practical Takeaway

The Ontario UTI Program works best when healthcare teams follow a structured, sequential order:

1. Start with the resident.
2. Assess the symptoms.
3. Consider other underlying causes.
4. Test only when criteria are met.
5. Treat only when clinically indicated.
6. Reassess antibiotics when more data (like culture timelines) becomes available.

This sequential order matters immensely. When testing happens too early, the raw result driving treatment becomes an inevitability. Conversely, when assessment happens first, the team is empowered to make the safest and most accurate decision for the resident.