Urinary Tract Infection (UTI) was identified as the main reason to call a GP out-of-hours or to result in an unplanned admission to hospital from residential and nursing homes. Care home staff were using a urine dipstick to diagnose a urinary tract infection then calling a health care professional (HCP) for antibiotics, resulting in inappropriate use of antibiotics and over-treating what is perceived as a UTI in the absence of clinical symptoms.
In response, an UTI prevention and management approach was designed and shared with staff, along with training, to improve not only the prevention but also the proactive appropriate management of patients at risk of developing UTIs.
Eastern AHSN provided Quality Improvement (QI) coaching to the nurses employed by South Norfolk Clinical Commissioning Group (CCG) to work with residential and nursing homes across central Norfolk and Waveney to support the implementation of the checklist approach.
The overarching aim was to reduce avoidable admissions to hospital from care homes. The Eastern AHSN believes this successful project is an easily replicable approach to the improved management or prevention of UTI and can directly impact by not only improving patient care with the added benefit of admission avoidance and reducing unnecessary clinical call outs.
Successful results and benefits:
- At the time of writing, 700 staff from 104 care homes across Norfolk have been trained in the management and prevention of UTI and how to complete the UTI checklist. Unplanned emergency admissions have reduced by 22% and a reduction in antibiotic prescribing has been seen within this cohort of care homes.
- Staff reported increased confidence in the management and prevention of UTI.
- Data from the checklists highlighted that a lot of UTIs were related to catheter management and obtaining samples from the bag, which became increasingly preventable from the change in treatment.
- Care workers were assuming residents had an UTI, but after the teaching sessions they realised it may be dehydration that could present the same symptoms and commenced re-hydration.
- If an UTI is suspected then the staff were taught to initially think dehydration and to increase fluid intake then to reassess the patient prior to making call outs.
- Care homes are not now doing routine urine dipsticks or using urine dipsticks as a diagnostic test to diagnose UTI’s which has improved our diagnosis of UTI.
- Feedback from care homes and primary care has been very positive with one care home manager emailing to say: “The UTI checklist is definitely used at our nursing home and we have noticed a positive difference since we started. Thank you for your support.”
The UTI checklist aims to:
- Support a clinician to make a diagnosis based on clinical symptoms
- Reduce inappropriate antibiotic use
- Reduce inappropriate diagnosis of UTI
- Act as way of recording trends if a resident is repeatedly treated for UTI
- Provide top tips on essential guidance on how to treat and prevent UTI
- Standardised information on diagnosis and treatment for HCP in line with local formulary
- To work in line with NICE QS90 in treatment and management of UTI.
We consulted with:
- Care homes to ask staff if they felt that this approach would benefit them if they suspected a resident had a UTI
- Healthcare professionals including GP with a special interest in UTI and care homes to see what information they felt should be on the suspected UTI checklist
- Medicine management and infection control teams to ensure we followed NICE and local guidance for improved antibiotic prescribing in primary care.
A simple A4 checklist was designed for care home staff to complete if they suspected that their resident had a UTI. This was endorsed by 5 Norfolk CCGs and by the prescribing leads.
We included top tips on how to manage and prevent a UTI to be used as part of learning and training within a care home for carers and relatives.
We identified the five care homes with the highest number of prescriptions for antibiotics as our initial PDSA test cohort. The five care homes were trained in the management and prevention of UTI and how to complete the checklist. The training sessions were conducted for groups of five to 15 staff per session.
The programme has expanded and we have now trained 700 staff so far from 104 care homes.
We are currently using primary diagnosis of UTI and unplanned admission to A&E, and inappropriate antibiotic prescribing for UTI.
Staff report increased confidence in the management and prevention of UTI, and data from the checklists highlighted that many UTIs were related to catheter management and obtaining samples from the bag.
Care workers were assuming residents had a UTI but after the teaching sessions they realised it may be dehydration as may present the same symptoms. Therefore, if a UTI is suspected think dehydration push fluids and reassess which reduced the call out to primary care.
At the time of writing this case study, 700 staff from 104 care homes across Norfolk have been trained in the management and prevention of UTI and how to complete the UTI checklist. Unplanned emergency admissions have reduced by 22% and a reduction in antibiotic prescribing has been seen within this cohort of care homes.
Care homes are not doing routine urine dipsticks or using urine dipsticks as a diagnostic test to diagnose UTI’s which has improved our diagnosis of UTI.
Feedback from care homes and primary care has been very positive with one care home manager emailing to say: “The UTI checklist is definitely used at our nursing home and noticed a lot of positive difference since we have started. Thank you for your support.”
- Working in collaboration with primary care is key; if they are on board they will drive the use of the UTI checklist, and make more informed decisions based on clinical symptoms rather than a carer’s opinion.
- Don’t assume that all carers know how to collect a sterile sample to prevent contamination – based on this project we are working with infection control to set standards around collecting mid-stream specimen of urine, catheter specimen of urine and having a process around how to obtain sterile pots, syringes and the Newcastle kit.
- UTI prevention in isolation will not improve standards but incorporating teaching sessions around hydration (setting daily fluid target levels) and constipation is key.
- Training alone did not change practice around management and prevention of UTI however with the use of the UTI checklist and improved training, which is more evidence based on NICE QS90, it was easier to implement as we had a standard to work towards. However, we did realise that any change in practice takes time to embed.
The plan is to have all GP practices that are aligned to a care home to use this checklist and we are introducing this alongside the training packages to share with all relevant staff to share the learning and to increase the spread of the improved practice and management of UTIs.
At present we are trying to replicate this project at a GP practice with 6 care homes attached to the practice with a total of 250 care home beds. We have collected initial data around antibiotic prescriptions for UTI’s. With this data we can see if NICE QS90 was followed; if the antibiotic was issued from a urine dipstick; antibiotics prescribed on basis of a phone call to GP surgery by a care worker and if repeated antibiotics were prescribed empirically.
UTI teaching will be embedded including teaching around constipation and dehydration, once all care workers are trained to use the UTI check list we will repeat the data collection to see if the use of inappropriate antibiotics have reduced alongside the inappropriate diagnosis of UTI.