This example describes how the Clinical Commissioning Group (CCG) reduced the incidence of Urinary Tract Infections by promoting hydration in local care homes. As background, NHS England reported in 2014 UTIs were the condition with the highest emergency admissions rate in 2012/13. UTIs in the elderly are often over-diagnosed and over-treated.
A higher than average number of admissions to hospital for UTIs in specific care homes was noted in the Windsor Ascot and Maidenhead CCG area. Upon further investigation care homes were relying on non-clinical signs (smell and colour of urine and dipstick testing) to diagnose UTIs. The project emphasised the importance of a full clinical review in the over 65 year olds and that dipstick testing is not diagnostic of a UTI (NICE QS90).
The project aims were to reduce the incidence of urinary tract infections requiring antibiotics in care homes or UTI related hospital admissions by promoting hydration and to optimise UTI management. This was done primarily through care staff hydration training (NICE NG22) and development of evidence-based resources.
This example won the 2018 NICE Shared Learning Award.
Aims and objectives
The project primary aims were to improve the correct diagnosis of UTIs, reduce UTIs through improving hydration in nursing and residential homes and optimise UTI management. Other objectives included raising awareness of acute kidney injury (AKI) (including signs and symptoms) amongst care staff and signs. The project also raised awareness of increased risk of antimicrobial resistance with over-diagnosis and over-treating UTIs.
The multi-disciplinary project involved a patient safety manager, prescribing and care homes support pharmacist and care homes managers to design tests of change to improve outcomes for the residents (150 in total) in 4 care homes. The care home staff helped to propose and design the tests of change and so had full ownership with support provided by the patient safety manager and prescribing and care home support pharmacist (project leads) and had input from a dietitian.
The six tests of change were:
- UTI Poster
- Staff hydration training – education about dehydration, AKI, UTIs, Diuretics, ACE inhibitors/ARBs, Metformin and NSAIDs (DAMN medicines, antimicrobial resistance and promoting hydration
- Introduction of a ‘7 structured drinks’ round
- Residents’ hydration training
- Food and fluids chart – designed by the care homes
- Good practice guidance for GPs and care home staff, ‘Form U1’.
Related NICE guidance:
- Improve correct diagnosis of UTIs (NICE QS90 - Quality statement 1: Diagnosing urinary tract infections in adults aged 65 years and over)
- Reduce UTIs through improving hydration in nursing and residential homes (NICE NG22 –recommendations 1.5.13 - 1.5.14)
- Optimising UTI prescribing and management by ensuring patients are prescribed antibiotics in accordance with local antibiotic formularies as part of antimicrobial stewardship (NICE QS61 - Quality statement 1: Antimicrobial stewardship)
- Raising awareness of antimicrobial resistance by providing education and training to health and social care practitioners about antimicrobial stewardship and antimicrobial resistance and integrating audit into existing quality improvement programmes (NICE NG15 – recommendation 1.1.3].Raising awareness of antimicrobial resistance through improved communication with health and social care practitioners across all care settings to work together to support antimicrobial stewardship NICE NG15 – recommendation 1.1.16-1.1.18; 1.1.24).
• Raising awareness of AKI and signs or symptoms of AKI [NICE QS76 - Quality statement 1: Raising awareness in people at risk; NICE CG169 recommendation 1.1.1].
Reasons for implementing your project
Dehydration is a common cause of hospital admission for nursing home residents. One in four nursing home patients admitted to hospital are dehydrated. Dehydration increases the risk of UTIs which can lead to multiple complications including confusion, falls, AKI and hospital admission. UTIs in the elderly are often over-diagnosed and over-treated.
There is also national focus on antimicrobial prescribing with an aim to reduce inappropriate prescribing for UTIs in primary care being led by PHE and NHS England. This has led to the introduction of a national quality premium indicator of 10% reduction (or greater) in the number of trimethoprim items prescribed to patients aged 70 years or greater. Windsor Ascot and Maidenhead Clinical Commissioning Group (WAM CCG) prescribing data (April 2016) indicated a higher than England average for total antibiotic items per STAR-PU of 1.055 versus 1.053 respectively. In addition, WAM CCG prescribing data (April 2016) for Trimethoprim to Nitrofurantoin ratio was also higher than the England average, 2.050 versus 1.501 respectively.
Quarterly hospital episode statistics (HES) data for WAM CCG indicated a higher than average number of unplanned hospital admissions with a primary diagnosis of urinary tract infections in specific care homes. These top 4 care homes [3 residential and 1 nursing, total 150 beds] were approached and agreed to take part in the quality improvement project. It was agreed that if improvement was observed it would be spread to other care homes in the East Berkshire region. The care home population of WAM CCG is approximately 1100 residents. UTI baseline data was collected at source by each care home in the format of a safety cross for 2 months. They collected the number of UTIs requiring antibiotics and the number of UTIs resulting in an unplanned hospital admission.
The project involved a patient safety manager, prescribing and care homes support pharmacist and care homes managers to design tests of change to improve outcomes for the residents. The project also provided an opportunity to raise awareness of the risks of dehydration in the elderly and how this can lead to serious conditions such as AKI, UTIs, falls and risks of anti-microbial resistance. GPs were also involved in the development of evidence-based Good Practice Guidance (GPG) for GPs to optimise UTI management and prescribing.
How did you implement the project
The project commenced with a multidisciplinary meeting involving a patient safety manager, care homes support pharmacist and 4 care homes managers to design tests of change to improve outcomes for the residents. The care home staff proposed and designed the tests of change and so had full ownership with support provided by the patient safety manager and care home support pharmacist and had input from a dietitian.
The SIX tests of change were:
- UTI poster [NICEQS90]
- Staff training on hydration and the importance of correctly identifying signs and symptoms of UTIs [NICE QS90]
- Introduction of ‘7 structured drinks round’ [NICE NG22]
- Residents hydration training [NICE NG22, QS90, QS121, NG15, NG22, CG169, QS76]
- Food and fluids chart [NICE NG22]
- Good Practice Guidance (GPG) for GPs and carers and use of FORM U1.
Carers, nurses, activity co-ordinators, chefs and care home managers all participated in the training which was evaluated by carers at the end of each training session. It captured the care staff’s thoughts on the project and how it would run/improve. The food and fluids chart was designed with a senior carer in the nursing home who tested the chart in their unit and shared it with staff. Changes were made from feedback after a month’s trial and it continued to be used effectively. Staff engagement was excellent as they designed something that works for them and is easy to use. In the nursing home, ‘huddles’ were used to communicate hydration information and receive feedback from staff.
Some residents were involved in designing drinks rounds trolleys and helped to choose which drinks to add to the trolleys based on activities to taste different drinks. Residents said they liked trying different things and sometimes even had 2 cups! The drinks rounds became a highlight for residents and a socialising point. The project has minimal cost implications including decorations for drinks trolleys but sometimes these are supplied by families wishing to take part.
GPs were involved in the development of evidence-based GPG for UTI management and prescribing. To promote implementation, a form (Form U1) was designed and introduced for use by care homes to communicate signs and symptoms of UTI with GPs and better manage residents’ UTIs. This form can also be used as a treatment care plan for carers and stored in resident’s records. Local infection control managers, CCG quality leads and the CCG effective prescribing committee ratified these resources locally.
The project surpassed expected aims by reducing unexpected admission to hospital with a primary diagnosis of UTI and reducing the number of UTIs requiring antibiotics. PHE and NHS England targets for reducing the use of antibiotics whilst improving the quality of life for residents has also been achieved.
UTI Admission to hospital [data Jul 2016-Nov 2017]
- 2015/2016: 18
- 2016/2017: 12
- 2017/2018: 4 to date of submission
UTI requiring antibiotics:
The incidence of UTIs has reduced from 1 every 13 days at baseline to 1 every 47 days since the project commenced.
One residential home has been UTI free for 243 days!
- WAM CCG total antibiotic items per STAR-PU = 1.055 (Apr 2016) reduced to 1.038 (Nov 2017) and better than England average.
- England average total antibiotic items per STAR-PU = 1.053 (Apr 2016), 1.044 (Nov 2017).
- Trim: Nitro ratio data WAM CCG ratio= 2.05 (Apr 2016) reduced to 0.51 (Nov 2017) and better than England average.
- Trim: Nitro ratio data England average ratio = 1.501 (Apr 2016), 0.866 (Nov 2017).
For further analysis of results please see the supporting material.
One resident with a history of a UTI every 6 weeks used a food and fluid chart to help him increase his fluids. He went UTI free for 8 months and is socialising more and more mobile. Residents are generally enjoying the wider choice of drinks, cups and the focus that drinks rounds bring into their day with the brightness, colour and theme of the trolley.
Through improving hydration, residents’ health improved, and they were more able to participate in activities and social gatherings. Most importantly the project has improved residents’ quality of life.
The average cost of a UTI hospital admission is £1331 (NHS National Tariff Payment System). There has been a reduction of 10 admissions to hospital to date a saving of £13,310.00. Other savings included reduced GP call outs, reduced falls as highlighted by care home managers as well as reduced use of antibiotics.
Care staff were extremely grateful for the training on how to identify UTIs correctly as per NICE QS90. This also raised awareness of risks of dehydration in the elderly and how this can lead to serious conditions such as AKI, UTIs, falls and anti-microbial resistance. One carer stated that he knew that he was to give out drinks but now recognised the importance of hydration in the urinary system and how it can affect residents’ physical and psychological well-being. The training sessions received excellent feedback.
Key learning points
A key success to this project was the care home prescribing and support pharmacist who had an existing good relationship with the care home staff, therefore had their trust in commencing a new project. She also supported throughout the project with any challenges/questions they had.
The data analysis was supported by the patient safety manager which was helpful but not essential as the data is gathered in a simple format. Data gathering was key, and the care home staff could see the importance of this and felt proud at their achievements with demonstrated improvements. This was shared with all staff within the care homes to encourage continued good practice.
Structured drinks rounds are designed by care home staff, easy to follow and low cost to implement. The simplicity and minimal cost of this project has spread by word of mouth. It has already been rolled out to a further 9 care homes in East Berkshire and Oxfordshire (611 beds in total). Presentations/teleconferences have been held at the request of CCGs wishing to undertake something similar (Bedford, Luton, Milton Keynes, Chiltern, Swindon, Vale of York), AQuA and East Anglia University. There has also been interest from secondary care providers.
Integrated working is key and so involvement with as many stakeholders including the patients and their family is crucial from the outset. In hind sight, it may have been also been beneficial to include our local Healthwatch organisations to spread the message of the importance of hydration to other populations who are also vulnerable from the outset.
Oxford AHSN funded the project. Health Education England has awarded a grant to assist with the further development of training materials that are easily accessible for care home staff.