To Dip or Not To Dip March 2017 Zoe Mason Care Home Pharmacist - - PowerPoint PPT Presentation

‘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?

Improve UTI management

Training and Education

Guidelines and Procedures

Surveillance

• f infections

Optimise antimicrobial use Reduce use of dispticks

Increase use

• f

symptoms for diagnosis

Why avoid dipsticks??

SIGN Guidance advises not to use dipstick tests in elderly in the diagnosis of UTI

• 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

Halton’s Goal

• 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

How will we do this ?

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

• f 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 Admissions Approx. Care Home Population % 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 >38oC or > 1.5oC 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

1

• Receive Assessment tool via fax from care home
• Care Home will ring to confirm receipt

2

• GP Receptionist scans Assessment tool on to EMIS using

read code R08zz or passes paper copy to Duty GP

3

• Receptionist tasks the duty or on-call GP with details

4

• GP reviews and makes a clinical decision regarding need

for antibiotics, face-to-face review or watchful waiting

5

• GP contacts care home with outcome and records

intervention on EMIS –

6

• Please ensure practice scans signed and completed form
• nto 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 .50C 88 88 Nitro rofu fura ranto toin in MR 100mg BD 3/7

A Doctor

• r 27/9/2

7/9/2017

Mrs Anne

e Smith 01/01 01/1 /1930 930

Halto ton n Care e Hom

• me

38.5 .50C

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
• n 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

Trimethoprim (unless known sensitivity)

Nitrofurantoin

Or Pivmecillinam if eGFR<30/45ml/min ***For LOWER UTI only ***

Nitrofurantoin does NOT penetrate the kidney Do NOT dip urine in over 65 years Diagnosis based on clinical signs and symptoms

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