1. Management of suspected bacterial urinary tract infections A team Approach
Jane Lawson
Senior Infection Prevention and Control Nurse
Durham dales Easington Sedgefield , North Durham and Darlington CCGs

2. IPCT team and the wider Health Economy
CQC
Local mental health trust
CCG meds Optimisation team
Local Authority
CDDFT Acute Trust
Neighbouring acute trusts
NHSE
PHE
NECS
CCG commissioning team
• County Durham and Darlington Health and Social Care HCAI group
• Infection Control Liaison Group
• County Durham and Darlington Foundation Trust (CDDFT) Infection Control Committee
• Primary care new build/refurbishment of premises meetings.
• CDDFT Monthly HCAI meeting
• County Durham and Darlington CCGs quality meetings
• Care home manager forums
• Provider Quality Review Group
• Care Quality Commission (CQC) information sharing meetings
• Safeguarding information sharing meeting
• Urinary Catheter Group with CDDFT
• Care Home Executive Strategy meetings
• Sunderland CCG and South Tyneside CCG HCAI improvement group
• County Durham and Darlington Area Health Protection Group
• Post 72 hour Clostridium difficile appeals meeting
• Pre 72 hour Clostridium difficile RCA meeting GP practice
• Post 72 Clostridium difficile RCA meeting CDDFT
• Pre and post 48 hour MRSA Bacteraemia meeting CDDFT
• TB Strategy group meetings.
• Cluster Investigation Team meeting
• Health Research Methodologist Study, Durham University

3. Summer 2014 increased ESBL’s, GP surgeries states care homes handing lots of urine samples for no reason. SIGN guidelines
Evidence based guidelines tend to focus on issues of antibiotic treatment with less emphasis on clinical diagnosis
Plan of action visited 3 care homes within a practice population. Evidence based SIGN
Training and working with GP surgery
ESBl follow up patients and realised

4. Further investigation
Increased incidence of ESBL – extended spectrum beta lactamase in urine samples in care homes
Care home staff not always aware why sample sent
Lack of understanding of signs and symptoms of UTI’s
Lack of understanding of catheter care
Not maintaining personal hygiene when changing incontinence pads
Practice of using diagnostic sticks to confirm UTI.
Professionals prescribing antibiotics on the result of dipstick
Main reason staff send samples is for confusion and dark urine,
Practice of dipsticking is all the healthcare workers
Prevalence study on catheters faecal incontinence

5. Approach to change : Pilot proposal
Discussed problem with lead PN in GP surgery
Reviewed existing urine sample submission forms
Developed new form for care home staff to complete
Introduced diagnostic flow chart for care home staff base on SIGN
Discussed planned approach with GP’s, community matrons, microbiologist and care home managers
Resource pack developed and launched within the three targeted care homes.
To reduce esbl – appropriate prescribing
Clinical presentation of uti
In conjunction wit lab results.Barnard Castle one surgery 3 care homes

6. After 3 months After 3 months:
care home staff no longer dipsticking urine samples
care home staff documenting why sample has been sent
verbal feedback from all involved indicate that less samples have been sent
GP’s still requesting staff to dipstick urines
HCA’s working in surgery continue to dipstick urine

8. DON Prospective
“As Executive Director of Nursing and Director of Infection Prevention and Control and on behalf of the Foundation Trust board;  I can say we are very supportive of the collaboration between the Foundation Trust and CCG teams, in their aims of reducing HCAI infections specifically GNBSIs. We cannot achieve this reduction by working in isolation. The team demonstrate strong leadership and vision to drive this agenda forward, to achieve improved health outcomes and better experience for all our patients across the whole health and social care sector. We look forward to widening this collaborative working across the region”
Noel Scanlon, Executive Director of Nursing, County Durham and Darlington NHS Foundation Trust
“As a health economy we are working very closely together on this agenda to make sure that the changes we make are agreed, understood and implemented across primary, community and secondary care. Our Boards and Governing Bodies have been involved from the start and receive regular updates. They are very supportive of the staff engaged in this important work”
Gill Findley, Director of Nursing, Durham Dales, Easington and Sedgefield CCG and North Durham CCG
              

9. Themes identified from the RCA’s
Incorrect labelling of urine samples and labelling of specimens not consistent as CSU or MSU
<65 years of age patient, diagnosis of UTI made on admission on a positive dipstick and no MSU sent to confirm diagnosis or to establish sensitivities for antibiotics prescribing.
History of UTI’s stated on admission but no MSU’s been sent in last 5 months
Diagnosis of uro-sepsis but MSU NAD
Urology OPD letter requested GP to prescribe antibiotics on the strength of a positive dip test, no symptoms documented.
Problems with catheter management in care home by community nursing team, antibiotics prescribed because of a positive dipstick, catheter changed to size 18 for bypassing,
HCA in the surgery dip tested urine and requested antibiotics from GP- duly prescribed , no symptoms documented, no MSU sent.
Joint working party with Acute trust to look at the 14 cases for CDDFT and then we then piloted a RCA for 8 cases in DDES using a new RCA visited GP surgeries

10. Care Home management of UTIs
Resource packs distributed to all care homes
Educational sessions delivered
Patient symptoms form for referral for GP

11. Prevent UTI’s

12. Prevention is very important

14. Bacteria in the urine of older people
Bacteria harmlessly live in the bladder of an older person:
100%
40%
What effect does this have on the urine dipstick?
50%

15. What is best practice for UTI?
National Guidelines:
“People >65 years should have a clinical assessment before being diagnosed with UTI” (NICE)
“Do not use urine dipstick testing in the diagnosis of older people with possible UTI” (SIGN)
“Do not use dipstick testing to diagnose UTI in adults with urinary catheters” (NICE)

16. Often antibiotics are then prescribed inappropriately
No dipstick – really??
50%
40%
100%
Urine dipstick will be positive for nitrites and leucocytes... But doesn’t tell us if it is an infection or not!
Does this happen locally?
Answer: It happens everywhere – worldwide research showing this sequence of events is very common in hospitals, primary care, care homes.
Often antibiotics are then prescribed inappropriately

17. Antibiotics are powerful drugs Antibiotics are precious drugs
More harm than good?
Antibiotics are powerful drugs
Antibiotics are precious drugs
Giving an older person antibiotics when they don’t really need them can lead to:
Side-effects such as rashes & stomach upsets
C.diff diarrhoea which can be life-threatening
Antibiotic resistance so antibiotics won’t work when the person really does need them
1 in 3 older people will suffer side-effects from antibiotics if given them when they don’t need them
Antibiotics are the only drug where the more you give them, the less they work!

18. Remember
• In people aged over 65 years, asymptomatic bacteriuria is common, but is not associated with increased morbidity.
• Elderly institutionalised patients frequently receive unnecessary antibiotic treatment for asymptomatic bacteriuria despite clear evidence of adverse effects with no compensating clinical benefit.

19. Local work – Antibiotic prescribing
Fair Funding Scheme targets to encourage switch to nitrofurantoin in-line with guidance
Fair Funding Scheme targets to encourage reduction in total antibiotic prescribing
Regular reporting of trimethoprim in over 70s and 3C prescribing via monthly prescribing reports
Education sessions in LPGs,
UTI management
National AMR campaign
UTI and AMR campaign resources available on GPTeamNet

20. DDES trimethoprim to nitrofurantoin ratio
Shows CCG switch from trimethoprim to nitrofurantoin, and compared to rest of country

21. Trimethoprim items in over 70s
Shows reduction in trimethoprim items in over 70s

22. DDES total items per STAR-PU
Not seeing significant reductions in items per star-pu, and still above national target, and far above national average.

23. Local work – catheters
Catheter group and work with Patient Hand held records
Education sessions for GP admin, practice pharmacists and at LPGs about catheters
Developed an information packs about catheters for use in primary care
Ongoing work with Continence Team at CDDFT to develop a catheter formulary

24. Local work streams – secondary care
Analysis of data
Sepsis
Antimicrobial stewardship
Prevention / diagnosis / management UTI
HOUDINI
ISC catheterisation
UTI walk rounds
Urine dipstick audits

26. MSUs >65 years CSUs Clinical details not stated (78/178) = 44%
Abx not stated (163/178) = 92%
CSUs
Clinical details not stated (25/44) = 57%
Abx not stated (39/44) = 87%

27. UTI walk rounds UTI diagnosis, management and prevention
Every ward, all staff
Brief presentation and discussion
Delivered posters and freebies
Designed poster focussing on UTI dx
Patient held record – urinary catheterisation
Feedback
Falls assessment
Nov dec 2017 all wards and comm hospitals
Back of audit government recommendations
Every ward
Target all staff
Brief presentation UTI dx mngx prevention
Feedback staff – good practices – hydration charts, not dipsticking
Picked up some issues – falls ass
Based on audit findings knew which wards main culprits

28. Obstacles
What we realised that individuals and separate teams across the health economy were doing different things
GP surgeries dipstick testing, limiting care homes to white bottles, requested repeat urine samples
Mental health: dipstick urine before mental health assessment
Ambulance service, dipstick urines
OOH not following guidelines
Acute Trust, dipstick all urines and do not send off MSU/CSU
Tried to address each area, NEAS, mental health, acute
Changing in the health teams eg federation, wrap around teams, TAPs.

31. How do we go forward?
Better to prevent infection from occurring in the first place
Strengthen community base IPC
Improve accuracy of diagnosis and treatment of UTI in older people
Prevent UTI in over 65
hydration
reduce catheter use
4. Improving antimicrobial therapy

32. Development of Protocol for the Diagnosis and Management of UTI for over 16 years non pregnant women and men
Standardised document for consideration of adoption within GP practices
Includes information on use of dipsticks, sending samples and treatment algorithms
Developed with CDDFT Microbiologists and Pathology lab
Includes patient referral forms for completion on handing in samples
Also combined with posters for Patient waiting rooms on dehydration and UTI management

35. Key points of guidelines
In people aged over 65 years, asymptomatic bacteriuria is common, but is not associated with increased morbidity.
Elderly institutionalised patients frequently receive unnecessary antibiotic treatment for asymptomatic bacteriuria despite clear evidence of adverse effects with no compensating clinical benefit.
Unnecessary antibiotic treatment of asymptomatic bacteriuria is associated with significantly increased risk of clinical adverse events including the development of antibiotic-resistant UTIs
Awareness of all primary staff regarding urine dipstick testing in catheterised patients and those >65 years to be raised
Dipsticks NOT to be used to diagnose UTIs in elderly or catheterised patients.

36. RightCare GU Project Hydration Catheter Care GNBSI NEAS / 111 Coding
PINCH ME

38. Hydration

43. Reduce catheter usage HOUDINI to empower nurses to remove catheters
Catheter formulary
Centralised catheter prescribing

44. Different work streams AMR, PHE, CCG’s

45. Who is involved in reducing the target?
Reduction in Gram Neg. bacteraemia cases
PHE North , AMR group , health protection leads, PHE
AMT, Trust led, NECS
IPCT
Trust HCAI forum operational
Other CCG – HCAI forum
Collaborative working CCDFT, CCG, PH, LA, GP’s , 3 work streams
NE AB pharmacist group secondary care
HCAI assurance group, LA, CCG, Trusts NHS and Private , PHE
AMR/ HCAI Forum
NECS primary care AB group
NE region , microbiologists, PHE
Catheter, group CCDFT, CCG
Performance within commissioning
Quality meetings
AMR Deepa had a meeting to look at work streams and develop a plan across the health economy

48. For the gram negative target to be achieved we have to work like this…
Health economy wide meeting
NHSE

49. Thanks for listening…..
Any Questions?