‘To Dip or Not To Dip’ March 2017 Zoe Mason Care Home Pharmacist HCCG
TDONTD A patient centred approach to improve the management of UTIs in Care Homes Overarching Priorities : Patient Safety, Improved Quality of Care & Amicrobial Stewardship
Protect patients Prevent harm
Ecoli is on the increase
Target…..
How can we help achieve this reduction? Training and Guidelines Education and Optimise Procedures antimicrobial use Improve UTI management Increase use Surveillance of of infections symptoms Reduce for diagnosis use of dispticks
Why avoid dipsticks?? SIGN Guidance advises not to use dipstick tests in elderly in the diagnosis of UTI
Halton’s Goal 1. To reduce inappropriate antibiotic prescribing for UTI’s. 2. Improve awareness on preventing and diagnosing UTIs in care home staff 3. Reduce unnecessary dipstick testing 4. Improve communication between care homes and GPs 5. Appropriate sending of urine samples for C&S
How will we do this ? • Education & Evidence based advice • UTI Prevention Hydration • Provide a practical UTI assessment tool • FAX FORM to aid diagnosis • NOT DIPSTICKS! • Encourage appropriate antibiotic choices • GP guidance document
Number needed to Benefit Number needed to benefit from treating asymptomatic bacteriuria = 7
Numbers needed to Harm Number needed to harm from treating asymptomatic bacteriuria = 3
Why not to treat? • Abx treatment has no role in treating the majority of cases of ASB. • Withholding treatment has no effect on mortality or renal function. • Treatment of ASB may eliminate low virulence strains that suppress the development of uropathogens, promoting the development of symptomatic UTI’s
What is happening in Halton? • Variability between homes and GP practices. • Anecdotal reports suggest diagnosis of UTIs is based primarily on dipstick results. • Limited recording of clinical signs & symptoms. • Low number of samples sent for culture. • Higher than UK average prescribing of trimethoprim in patients aged 70 yrs or older. • Higher than UK average trimethoprim:nitrofurantoin. • High prescribing of resistant antibiotics .
Surveillance Data First Quarter 2017 • 8 of 26 homes completed surveillance forms • April-July 125 residents Px an Abx for UTI • Could be up to 375 prescriptions for UTI in Halton • 30% (38) of residents had MSSU • Trimethoprim : Nitrofurantoin Ratio April – Jun 31:24 July 3 :13
Surveillance Data Oct-Dec 2017 • 8 of 26 homes completed surveillance forms – Limited Data • Oct- Dec 77 residents Px an Abx for UTI • 50 Women & 16 Men • 24% (19) of residents had MSSU • Trimethoprim : Nitrofurantoin : Fosfomycin 17 : 35 : 2
Admission Data Unplanned admissions from Halton Care homes – Residents >65 years – AKI, UTI or Urosepsis Year Total Approx. % Population Admissions Care Home Population 2014/15 219 860 25.5 2015/16 214 860 24.8 2016/17 181 770 24.1 2017/18 (Ap-Jul) 52 750 7
Practice Data 1 Runcorn Practice – 54 care home patients – 27 (50%) prescribed at least 1 Abx for UTI (Ave 3.3) – 6 (11%) coded for UTI – 6 (11%) had dipstick – No MSU recorded for any patients 1 Widnes Practice – 83 care home patients – 36 (43%) prescribed at least 1 Abx for UTI (Ave 1.8) – 12 (14%) Coded for UTI – 19 (23%) had dipstick – 5 (6%) Had an MSU reported
Halton Care Home Patient Px Trimethoprim
What are the issues..? 1. Dipstick on all three occasions – CH 2. Limited clinical information to aid diagnosis 3. Patient not seen on all 3 occasions 4. Fails to meet initial treatment criteria in each case Temp >38 o C or > 1.5 o C above base line twice in 12h And >1 other symptom 5. Abx prescribed NOT first line – PAN Mersey
Cultures and Sensitivities • ESBL Producer • Resident RESISTANT to trimethoprim • High levels of resistance in the >70’s population • Quality premium to prescribing Sensitive to first line antibiotic
To Dip or Not To Dip : Developed by BaNES CCG Pre intervention data: • 43% residents prescribed >1 for UTI in 6/12 • 12% of residents were on L/T antibiotics for UTI prophylaxis 6 months post intervention: – 56% RR in prescribed antibiotics for UTI – 67% RR in the number of antibiotic prescriptions – 82% RR in the number prescribed prophylactic antibiotics for UTI – Improved appropriate management of UTI according to SIGN – Reduction in unplanned admissions for UTI, urosepsis and AKI – Reduced calls to GP practices for inappropriately diagnosed UTI
Referral Pathway GP practice • Receive Assessment tool via fax from care home 1 • Care Home will ring to confirm receipt • GP Receptionist scans Assessment tool on to EMIS using 2 read code R08zz or passes paper copy to Duty GP • Receptionist tasks the duty or on-call GP with details 3 • GP reviews and makes a clinical decision regarding need 4 for antibiotics, face-to-face review or watchful waiting • GP contacts care home with outcome and records 5 intervention on EMIS – • Please ensure practice scans signed and completed form 6 onto EMIS Record for Audit. Read Code – R08zz
Thinking UTI? • Mrs Anne Smith, DOB 01/01/30 • She is currently in a Halton Residential Care Home • Background of mild dementia • Does not have a urinary catheter • More confused than yesterday • Frequent visits to toilet overnight • Usually continent, but has had several accidents today • Temperature 38.5 ̊c • Thinking UTI… Use the Assessment Tool .
UTI Assessment Form: Mrs Anne Smith th 01 01/01 01/19 1930 Halto ton Care Home 08 08/08 08/20 2017 17 John Mann 38.5 .5 0 C 88 88 Nitro rofu fura ranto toin in MR 100mg BD 3/7 A Doctor or 27/9/2 7/9/2017
Mrs Anne e Smith 01/01 01/1 /1930 930 Halto ton n Care e Hom ome 38.5 .5 0 C N/A N/A N/A N/A JOHN SMIT ITH 07/03/ 3/2018 18 08:30 :30
Challenges • Non - engagement of Care Home Managers • High Turnover of Care Home staff • Capacity of pharmacists to collect baseline and post intervention data • Uploading and read coding of Assessment tool on to clinical systems by GP practice • Changing practice of external healthcare providers – STHK are planning to implement on DMOP wards
Issues so far….. • Care homes are still dip sticking urine samples and not completing the Assessment Form correctly • DN’s still dip sticking urine samples • Practices are not always read coding the Assessment Forms - We would appreciate it if any UTI Assessment Forms which are faxed to the practice could be Read Coded R08ZZ • Not all practices and prescribers are aware of the TDONTD protocol • There has been confusion regarding completion of the Assessment Form
Wider Roll Out • St Helens CCG – March • Warrington CCG – Summer • Liverpool CCG – TBC
Take Home Messages Nitrofurantoin Or Pivmecillinam if eGFR<30/45ml/min Do NOT dip urine in over 65 years Trimethoprim (unless known sensitivity) Diagnosis based on clinical signs and symptoms ***For LOWER UTI only *** Nitrofurantoin does NOT penetrate the kidney HYDRATION = Prevention
Full information can be found on the NHS Halton CCG member’s site at: http://www.haltonccg.nhs.uk/members- practices/medicines-management/care-homes
Thank You Any Questions
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