To Dip or Not To Dip. March Zoe Mason Care Home Pharmacist HCCG

Transcription

1 To Dip or Not To Dip March 2017 Zoe Mason Care Home Pharmacist HCCG

2 TDONTD A patient centred approach to improve the management of UTIs in Care Homes Overarching Priorities: Patient Safety, Improved Quality of Care & Amicrobial Stewardship

3 Protect patients Prevent harm

4 Ecoli is on the increase

5 Target..

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7 How can we help achieve this reduction? Optimise antimicrobial use Training and Education Improve UTI management Guidelines and Procedures Increase use of symptoms for diagnosis Reduce use of dispticks Surveillance of infections

8 Why avoid dipsticks?? SIGN Guidance advises not to use dipstick tests in elderly in the diagnosis of UTI

9 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

10 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

11 Number needed to Benefit Number needed to benefit from treating asymptomatic bacteriuria = 7

12 Numbers needed to Harm Number needed to harm from treating asymptomatic bacteriuria = 3

13 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

14 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.

15 Surveillance Data First Quarter 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

16 Surveillance Data Oct-Dec 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

17 Admission Data Unplanned admissions from Halton Care homes Residents >65 years AKI, UTI or Urosepsis Year Total Admissions Approx. Care Home Population % Population 2014/ / / /18 (Ap-Jul)

18 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

19 Halton Care Home Patient Px Trimethoprim

20 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

21 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

22 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

23 Referral Pathway GP practice 1 2 Receive Assessment tool via fax from care home Care Home will ring to confirm receipt 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 GP reviews and makes a clinical decision regarding need for antibiotics, face-to-face review or watchful waiting GP contacts care home with outcome and records intervention on EMIS Please ensure practice scans signed and completed form onto EMIS Record for Audit. Read Code R08zz

24 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.

25 UTI Assessment Form: Mrs Anne Smith 01/01/1930 Halton Care Home 08/08/2017 John Mann C 88 Nitrofurantoin MR 100mg BD 3/7 A Doctor 27/9/2017

26 Mrs Anne Smith 01/01/1930 Halton Care Home C N/A N/A N/A N/A JOHN SMITH 07/03/ :30

27 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

28 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

29 Wider Roll Out St Helens CCG March Warrington CCG Summer Liverpool CCG TBC

30 Take Home Messages Nitrofurantoin Or Pivmecillinam if egfr<30/45ml/min Trimethoprim (unless known sensitivity) ***For LOWER UTI only *** Do NOT dip urine in over 65 years Diagnosis based on clinical signs and symptoms Nitrofurantoin does NOT penetrate the kidney HYDRATION = Prevention

31 Full information can be found on the NHS Halton CCG member s site at:

32 Thank You Any Questions