Leading change

South Norfolk CCG Nurses (Care Home Practitioners) are working with residential and nursing homes across central Norfolk and Waveney to reduce avoidable hospital admission and misdiagnosis of urinary tract infections (UTIs). They developed and implemented a new checklist, to support nursing and care staff within the residential facilities to improve diagnosis and management for their residents.

Where to look

Within the central Norfolk and Waveney areas, the nurses identified unwarranted variation in the significant use of out of hours GP services, to manage urinary tract infection (UTI). This was leading to unplanned admission to hospital and unnecessary administration of antibiotics. The CCG nurses identified the opportunity to support the residential facilities’ nursing and care staff in preventing UTIs and managing UTIs more effectively. The aim of the project was to prevent over-treatment, use of out of hours GP services, unnecessary hospital admissions and unnecessary antibiotic administration.

What to change

The nurses identified through their work with staff in the care homes that across the range of residential facilities, nurses and care staff had not always routinely been taught how to manage or prevent UTIs. The use of urine dipsticks to diagnose UTIs leads to misdiagnosis and unnecessary referrals to healthcare professionals for the administration of antibiotics. NICE guidance recommends a full, more holistic clinical patient assessment, which advocates an effective UTI diagnosis. The guidance also states that diagnosis should not be based on a urinalysis or Urine Microscopy and Culture (MSU/CSU) alone in people aged over 65 where other symptoms are not present, as up to 50% of older people in residential care have clinically significant bacteriuria.

How to change

The CCG nurses have experience in delivering training in hydration and UTI management and prevention. Utilising evidence-based practice from Bath and North-East Somerset CCG’s quality improvement project To Dip or Not to Dip, they developed a project to support nursing and care staff with training procedures for preventing and managing UTIs. They initially undertook a consultation with:

• Care homes to ask if staff felt a new approach to identifying and managing UTIs would benefit them;
• Other clinicians, including a GP with a special interest in UTI and care homes, to see what they felt needed to be included on a checklist for suspected UTI;
• Medicine management and infection control teams, to ensure prescribing compliance was included and appropriate;
• The CCG Quality Premium 2017-19 – Reducing Gram Negative Bloodstream Infections (GNBSIs), and inappropriate antibiotic prescribing in at-risk groups.

Informed by the consultation, the nurses developed a simple A4 checklist for care home staff to complete when they suspected a resident may have a UTI. Endorsed by five Norfolk CCGs and prescribing leads, the checklist was designed to:

• Support a clinician to make a diagnosis based on clinical symptoms (rather than a carer’s judgement), if they cannot do a full physical assessment;
• Reduce inappropriate diagnosis of UTI and antibiotic use;
• Act as a record to identify risk where individuals are treated for repeated UTI;
• Provide useful tips on how to treat and prevent UTI;
• Standardise information, in line with the local formulary;
• Support learning for both care home staff and relatives.

Through the Medicines Management Team, the nurses identified five care homes with the highest antibiotics prescription rates – one for each CCG. They trained staff at those homes in UTI management and prevention, and how to complete the checklist. This has expanded into a continuing education programme, through which 700 staff from 104 care homes have been trained so far. Sessions have been observed by clinicians from CCGs and the community care provider to monitor quality.

Adding value

Better outcomes – Overall, unplanned admissions due to UTIs have fallen by 22% in South Norfolk CCG and in two other CCGs at a slightly lesser rate. It must be recognised that other admission avoidance work may also be a contributing factor. Care homes are also requesting fewer antibiotics and ongoing support from the nurse leaders suggesting colleagues are implementing the checklist appropriately.

Better experience – Staff report increased confidence in the management and prevention of UTI.

Better use of resources – Care homes engaged in this project have identified that they no longer need to buy urine dipsticks. Staff now complete the UTI checklist and wait for diagnosis based on CSU/MSU, supported by clinical symptoms.

An unexpected benefit has been the discovery through checklist data that many UTIs were catheter related, without any clear reason why a catheter had been used. As a result, the Care Home Practitioners are working with senior CCG and provider nursing colleagues to develop a quality improvement plan to reduce unnecessary catheterisation.

Challenges and lessons learnt for implementation

• Early buy-in from all involved is crucial, but persistence is needed. It helps to be able to show a business or financial benefit.
• General practice support is also needed if care homes are to feel empowered to use the checklist. This is harder if a practice does not have a Nurse Practitioner to do the acute work within a care home
• It is important to agree achievable metrics at the outset.

Find out more

For more information contact:

• Irene Karrouze or Kate Wyatt, Care Home Practitioners, i.karrouze@nhs.net, kate.wyatt2@nhs.net