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Urinary Tract Infections in Care Home Residents
“To Dip or Not To Dip?”
Improving the quality of UTI care by working together across Healthcare
3 Boroughs Infection Prevention and Control Team
• To understand the background to the project • What is “To dip or not to dip”? • Define what is a urinary tract infection. • Know the signs and symptoms of urinary tract infection • Understand the importance of the appropriate use of
antibiotics. • Look at ways to improve the hydration and hygiene of
residents. • Know how to complete the assessment form and the process
for contacting the GP. • Know how to check vital signs and monitor patient. • Next steps for your care home.
Objectives
The Background to the project
Ecoli is on the Increase
Target…..
How can we help achieve this reduction?
Improve UTI management
Training and Education Guidelines
and Procedures
Surveillance of infections
Optimise antimicrobial
use
Introduce projects that look at improving
management of UTI.
Increase use of symptoms for diagnosis
The “To dip or not to dip” project
This is an evidence based systematic approach to improve the diagnosis and management of UTIs in care home residents over 65 years.
Success Elsewhere
Your help and feedback is vital!
The first ‘To Dip Or Not To Dip’ project was in South-West England:
• Reduced antibiotic use in care home residents
• Reduced emergency admissions for UTI and dehydration
Across the UK, ‘To Dip Or Not
To Dip’ is taking off!
A different way – ‘To Dip Or Not To Dip’
Care Homes, GPs, Community Matrons, District Nurses,
Practice & Care Home Pharmacists, Community Therapists, Advanced Nurse Practitioners, Microbiologists,
Infection Control Team…
Integrated Team
Working together to improve care for residents
What is happening in this region?
Variability between homes and GP practices
Widespread use of dipsticks in UTI diagnosis NOT evidence based practice.
Poor 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.
NHS BANES have shown positive results from a community project based on ensuring accurate diagnosis of UTIs in NH residents and reducing inappropriate prescribing.
Let’s watch the training video.
Risk Factors that increase risk of Urinary Tract Infection.
Incomplete emptying of the bladder
Constipation
Prostate enlargement
Uterine Prolapse
Certain medications
Impaired Immune systems
Poor hygiene
Dehydration
Urinary catheter in situ
Bacteria in the urine of older people Bacteria harmlessly live in the bladder of an older person:
100%
What effect does
this have on the
urine dipstick? 50%
40%
Urine dip stick shows ….
Urine dipstick will be
positive for nitrites and
leucocytes...
But doesn’t tell us if it
is an infection or not!
Often antibiotics are
then prescribed
inappropriately
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 only in the diagnosis of older people with possible UTI” (SIGN)
“Do not use dipstick testing to diagnose UTI in adults with urinary catheters” (NICE)
How is antibiotic use related to resistance?
Antimicrobial resistance is a Global Problem Antimicrobial resistance is a global problem that leads to antibiotics no longer being effective in treating even simple infections.
There are serious consequences for everyone, but particularly those undergoing major surgery, chemotherapy, organ or stem cell transplants.
Every year, 25,000 people across Europe, and 700,000 worldwide, die from antibiotic-resistant infections, and the UK government predicts the annual global toll could be 10 million by 2050.
Group Work
What causes dehydration in your residents?
Prevention is better than cure!
The Urine Colour Chart
Importance of Hydration Water makes up approximately 60 percent to 65 percent of your total body weight and plays a key role in many body functions.
Water helps regulate body temperature, lubricate joints and tissues, transport nutrients and carry out various metabolic reactions.
Some people drink only when they feel thirsty, but thirst is actually a sign of dehydration. You can tell when you are well hydrated because you will only feel thirsty on rare occasions, if at all, and your urine will be clear or pale yellow.
Improving Hydration. Staying hydrated is one of the most basic requirements
for living and being healthy.
Everyone’s body needs water for every system in your body, including the digestive system function, respiratory system function and circulation of nutrients and oxygen.
Learning how to improve and maintain hydration will help keep your residents healthy and free from complications of dehydration.
Group work
Work in pairs to think of ways to improve hydration in your residents.
The importance of Personal hygiene
Look at all aspects of hygiene and cleanliness that you can control in your Care Home and consider how you can raise standards.
The Complete
‘To Dip or Not to Dip’
Process
What do you do if you think a resident has a UTI??
Check . . . . . . . Temperature
Pulse
Respiration
Fluid intake – how much in past 4 – 6 hours
Fluid output – how much?
Any difficulty/burning/frequency when passing urine
Pain anywhere – back/abdominal/supra pubic
Orientated to time date or increased confusion
Then complete the assessment tool!
Monitoring vital signs. The assessment form requests the recording of :-
Temperature – Is the residents temperature above 38ºc or below 36ºc
Pulse – Is the pulse above 90?
Respiratory rate – Is the respiratory rate above 20?
Monitoring vital signs.
Temperature – Do you have facilities for the recording of a residents temperature?
Pulse – The radial pulse is generally used. Place the tips of your index and middle fingers just proximal to the patients wrist on the thumb side, orienting them so that they are both over the length of the vessel.
Respiratory rate - Respirations are recorded as breaths per minute. They should be counted for at least 60 seconds. Try to do this as discretely as possible so as not to affect the respiratory rate. Observe the rise and fall of the chest.
Always consider alternative causes
Constipation
New medication or dose
***Dehydration*** Pain
Urinary retention
Pneumonia
Environmental irritants
Having a bad day!
Referral Pathway
1
• Resident unwell…. You suspect a UTI
• Consider other factors
• Reach for UTI Assessment form
2
• Fill in ALL patient details and complete parts 1-4
3
• Fax Assessment form to GP practice /SPA/ as per local protocol
• Call to confirm receipt/discuss with GP/Nurse
4
• Record GP action (Part 5) – File in resident’s Care Plan
5
• Out of Hours - Care homes to contact as per local protocol
• Use the completed assessment tool to communicate symptoms to out-of-hours providers. 5
When Antibiotics are not prescribed Monitoring your resident.
Monitor temperature, heart rate for several days, discontinue if symptoms resolve
Monitor for progression of symptoms or change in clinical status
Encourage fluid intake
Consider alternate diagnosis for nonspecific symptoms
If symptoms resolve, no further intervention required
Then what…….? Symptoms resolve with nursing
measures, treatment of underlying
conditions or spontaneously.
Specific urinary signs/symptoms or
fever emerge → Complete
assessment form, MSU and Treat
with antibiotic
OR
When NOT to use assessment tool
When you think the resident has a different infection or problem identified in section 2
When the resident is very poorly i.e. when you would normally get urgent help
Outside normal working hours and at weekends:
Observe local arrangements– Non urgent problem
Call 999 – Medical emergency
Urine Sampling
Urine culture in women and men over 65years. Send urine for culture if two or more signs of infection, especially dysuria, fever over 38 c or new incontinence.
Do not treat asymptomatic bacteruria in the elderly as it is very common.
Urine culture in women and men with catheters.
Only send urine for culture if resident is symptomatic.
Ensure correct catheter sampling port is used.
Urine sampling • In women shower/wash before taking sample • Try to catch a mid stream sample in a sterile pot • The pot and form require 3 identifiers. • Name , Date of birth and NHS number • Ensure GP practice and address is included.
Samples that are not correctly labelled will not be processed.
Procedure • Apply non‐traumatic clamp a few centimetres below the sampling
port. • Wash hands with soap and water and put on apron and gloves. • Wipe the sampling port with clean wipe. • Using a needle‐less system: insert syringe firmly into centre
sampling port (according to manufacturer's guidelines), aspirate the required amount of urine and remove syringe.
• Transfer an adequate volume of the urine specimen (approx. 10 mL) into a sterile container immediately.
• Wipe the sampling port with clean wipe.
Post‐procedure • Unclamp catheter tubing
• Dispose of waste, remove apron and gloves and wash hands.
• Label sample and complete microbiological request form
including 3 patient identifiers and relevant clinical information,
such as signs and symptoms of infection, antibiotic therapy.
• Dispatch sample to laboratory.
• Document the procedure in the patient's records.
• REMEMBER TO FOLLOW UP RESULTS
Taking a catheter specimen
What Next…… 1. Key staff in the care home will be expected to cascade information
regarding the project to all care home staff. Ensure ALL members of staff are trained, and consider agency staff
Complete E –Learning package Watch Training Animation -
2. Display posters in clinical areas 3. Ensure leaflets and handbook are displayed in clinical areas for
reference 4. Ensure Assessment tool Form readily available in clinical areas for
use. 5. REMOVE Dipsticks from ALL clinical areas 6. Project starts Warrington - 4th June 2018 7. Halton – 1st October 2017 8. St Helens – 7th May 2018
E Learning package
http://www.nottingham.ac.uk/toolkits/play_16544
Training animation.
https://m.youtube.com/watch?v=rZ5T1Cz7DHQ&feature=youtu.be
Search – To dip or not to dip You tube.
Link to Resources on web pages
https://www.sthelensccg.nhs.uk/your-health/infection-control/to-dip-or-not-to-dip-reducing-urinary-tract-infections/
Any Questions?
Contact details for the Three Boroughs Infection Control team
Tel: 01744 457314 / 01744 457312
Fax: 01744 457327
E mail: [email protected]
