Download To Dip or Not To Dip

To Dip or Not To Dip – a patient centred
approach to improve the management of
UTIs in the Care Home environment
Elizabeth Beech
February 2016
Pharmacist - NHS Bath and North East Somerset CCG
National Project Lead Healthcare Acquired Infection and Antimicrobial Resistance - NHS England
[email protected]
@elizbeech
To Dip or Not To Dip – a patient centred
approach to improve the management of
UTIs in the Care Home environment
Elizabeth Beech
February 2016
Pharmacist - NHS Bath and North East Somerset CCG
National Project Lead Healthcare Acquired Infection and Antimicrobial Resistance - NHS England
[email protected]
@elizbeech
Mandy Slatter
Pharmacist - NHS Bath and North East Somerset CCG / RUH Trust
[email protected]
AIMS for Community Project
• Ensure accurate diagnosis of UTI in NH residents
• Decrease inappropriate antibiotic prescribing for UTI’s
• Decrease inappropriate use of urinary dipsticks in NH residents >65yrs
• Increase use of first line antibiotics for treatment of UTI’s
• Review use of antibiotic prophylaxis for UTI’s
No dipstick for UTI – really???
• Up to 50% nursing home population and 90% of patients with long term catheters
have a positive dipstick with NO UTI present due to asymptomatic bacteriuria.
• Treatment of asymptomatic bacteriuria:
NO BENEFIT and POSSIBLE HARM NNH = 3
For example:
Increased risk of difficult to treat infections – C diff
Increased risk of resistant urine infections – ESBL E.coli
Side effects of antibiotic medications
Negative effects on other medication the patient takes
• A positive dipstick is more likely to lead to treatment
WHICH MAY NOT BE APPROPRIATE
Process
• Suspicious of a UTI?
Step 1 • Reach for the UTI diagnosis form
• Fill in details for 1 - 4
Step 2 • Fax to GP/ring to discuss/?MSU
• Record action (5)– file in pt notes
Step 3 • Review patient as needed
A WORD OF CAUTION
There is some concern that there may be some mismanagement of
cases of UTI infection in the community. By 2011 E. coli
accounted for almost one third (32.2%) of all bacteraemia reports
in England, with a 35% increase between 2007 and 2011. Half of
E.coli bacteraeimias were from a urogenital source, half had a
healthcare interaction in the prior four weeks and 10% have a
urinary catheter. This suggests that a proportion of community
onset bacteriuria is being missed by clinicians in the community
or inappropriate antibiotics are being given
…….Continue monitoring the patient even if not initially
conclusive for UTI
Background and key findings
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This is an evidence based systematic approach to improve the diagnosis and
management of UTIs in residents in all Nursing Homes in BaNES. Delivered by the
CCG care home pharmacist service, in all 23 homes in 2015, it has led to the more
appropriate use of antibiotics and a reduction in the potential for health acquired
infections and antimicrobial resistance
Before: 101/234 (43%) of residents had been prescribed a total of 223 antibiotic
prescriptions for UTIs in 6 months
After: 50/265 (19%) of residents had been prescribed a total of 70 antibiotic
prescriptions for UTIs in 6 months
The number of residents prescribed antibiotic prophylaxis reduced from 28 residents
to 5 residents
No reports of unintended harm were reported, and hospital admissions for UTI,
urosepsis and AKI reduced in the nursing home population (not RH population)
This CCG will consider the use of this model to implement improvements in Acute
Kidney Injury in 2016-17, which accounts for 1 in 5 unplanned admissions. Pathfinder
sites also suggest 50% of primary care AKI is due to UTIs. Hydration messages were
included in this programme and may account for the unexpected observed reduction
in admissions due to AKI
Reduction in antibiotic prescribing for UTI in 8
Nursing Homes over two 6 month periods
before
intervention
after intervention
Change
Number of
residents
prescribed one or
more antibiotics
101/234
43%
50/265
19%
56% reduction in
the proportion of
residents
prescribed an
antibiotic
Number of
antibiotic
prescriptions
223
70
153 fewer
antibiotic
prescriptions - a
67% reduction
Number of
residents
prescribed
prophylactic
antibiotics
28
5
82% reduction in
the number of
residents
prescribed an
antibiotic for UTI
prophylaxis
Antibiotic choices – reduction in prescribing in 8
Nursing Homes over two 6 month periods
Number of
prescriptions
before
intervention
Number of
prescriptions
after intervention
Change
Trimethoprim
112
29
83
74%
Nitrofurantoin
51
21
30
59%
Cefalexin
46
2
44
96%
Co-amoxiclav
13
18
-5
12 were inappropriate
7 were appropriate
1
3
Other antibiotic
-2
2 were culture driven
choices
All antibiotics
223
73
150
67%
Reduction in use of urinalysis dip sticks to
diagnose UTI in 8 Nursing Homes over two 6
month periods
• The recorded use of urinalysis dip sticks
associated with antibiotic prescribing reduced by
81% from 135 to 25
• 3 nursing homes reduced recorded use to 0
• 1 nursing home with very high use of dip sticks
reduced recorded use by 79% from 53 to 11
Antibiotic prescribing for UTI in all Nursing
Homes over 6 month period post implementation
Antibiotic choice as a proportion of 156 antibiotic prescriptions for
UTI in 21 nursing homes after implementing use of Sign 88 diagnostic
criteria 2014-2015
Amoxicillin N=1
Co-amoxiclav N=23
Ciprofloxacin N= 6
Nitrofurantoin N=45
Cefalexin N=15
Trimethoprim N=65
Antibiotic prescribing for UTI in all Nursing
Homes over 6 month period post implementation
Number of antibiotic prescriptions for UTI in 21 nursing homes after implementing use of
Sign 88 diagnostic criteria 2014-2015
Culverhay
The Orangery
Bloomfield
Rosewell
Cholwell
The Laurels
Cedar Park
Larkhall Springs
Cranhill
Oakfield
Shockerwick
Heather House
St Theresas
Kingfisher Lodge
Bybrook
Combe Lea
Clare Hall
Sunnymeade
Fosse House
Bridgemead
Treetops
Nitrofurantoin
Trimethoprim
Cefalexin
Ciprofloxacin
Co-amoxiclav
Amoxicillin
0
5
10
15
20
25
Number of antibiotic prescriptions in 6 month period
30
35
What next?
Feedback…
Your experiences?
Problem areas?
Dipsticking – not doing or just not recording?
Forms???
How to sustain?
Future education?
To all nursing home staff…
Well done
and a great big
THANK YOU!
References
• Nina, S et al (2014). Investigation of suspected urinary tract
infection in older people. BMJ 349.
• SIGN 88. Management of suspected bacterial urinary infection
in adults. July 2006 (Updated July 2012).
http://www.sign.ac.uk/guidelines/fulltext/88/index.html
• RUH Information for Clinicians. Ref OPU-001. Urinary Tract
Infection in the Non Catheterised Older Adult. Issue date:
1/8/13. Available via RUH Intranet.
• Health Protection Agency Nov 2014. Managing Common
infections: Guidance for Primary Care and Urinary Tract
Infection: Diagnosis Guide for Primary Care
https://www.gov.uk/government/collections/primary-careguidance-diagnosing-and-managing-infections
• RUH guidelines - Urinary Tract Infection in the Non
Catheterised Older Adult, July 13. Available via RUH intranet.
Useful Links
PHE primary care antimicrobial guidance Nov 14
https://www.gov.uk/government/publications/managing-common-infections-guidance-for-primarycare
BCAP primary care antimicrobial information 2013-2015 – update soon
http://www.bcapformulary.nhs.uk/primary-care-antimicrobial-guidelines
TARGET toolkit for training on UTI’s from RCGP Autumn 2014 http://www.rcgp.org.uk/courses-andevents/online-learning/ole/urinary-tract-infections.aspx
SIGN 88 guidance for diagnosis of UTI 2012 http://www.sign.ac.uk/guidelines/fulltext/88/index.html
PHE guidance for diagnosis of UTI 2011 https://www.gov.uk/government/collections/primary-careguidance-diagnosing-and-managing-infections
KTT9 Medicines optimisation topic on antimicrobial use Jan 15
https://www.gov.uk/government/collections/primary-care-guidance-diagnosing-and-managinginfections
NICE draft quality standard on UTI in adults Nov 15. Final guidance due May 15
https://www.nice.org.uk/guidance/indevelopment/GID-QSD89