PrescQIPP

Winner (Silver) - Using technology for diagnosis and treatment of UTIs in the over 65 years in primary care across 3 CCGs in Leicester, Leicestershire and Rutland (LLR) (2018)

Leicester City CCG ,, East Leicestershire and Rutland CCG, West Leicestershire CCG, Leicestershire Health Informatics Service

Introduction

The project focused on using technology for sustained education and good practice in line with evidence based updated local LLR primary care guidance for diagnosis and appropriate use of antibiotics in the treatment of UTI ( in the elderly >65 years ) without variation across LLR.

  1. Implementation of evidence based diagnosis of UTI in line with evidence based National Guidance ( SIGN 88) in all 3 CCG via use of a specific diagnosis protocol /template ( in both systmOne and EMIS ) by collaborative work between the 3 CCG and with Leicestershire Health Informatics Service .
  2. Reduce variation in diagnosing UTI for all elderly patients across the 3 CCG by promoting the use of the template/protocol.
  3. Improving read coding by linking symptoms to read codes when this is ticked while using the diagnosis template by the prescriber
  4. Have a Care home template designed for use by care home staff, instead of using a urine dip stick to feed into the GP template for appropriate diagnosis
  5. Incorporation into the template all resources designed, including patient information leaflets and hydration leaflet to prevent UTI providing easy access to prescribers for patient education.
  6. Promote use of Nitrofurantoin as first line agent and Trimethoprim as second line agent in line with the antimicrobial stewardship agenda for primary care and ensure the 3 NHSE QP targets across the 3 CCGs in LLR are met :
    • Reduction in the number of gram negative blood stream infections
    • Reduction in Trimethoprim Items Prescribed to Patients aged 70 years or greater
    • Reduction in Trimethoprim: Nitrofurantoin Item Ratio
  7. Use OPTIMISE RX message to prompt the use of the diagnosis template when antibiotics for UTI is prescribed in the elderly
  8. Promote across the local health-economy a uniform work stream to diagnose and treatment of UTI in the elderly ( involved Local authority and care home in designing care home template , academia and secondary care for the UTI diagnosis and management protocol)

How was the project established? / How is it currently being established?

  • NHSE published new antimicrobial QP targets related to antibiotics in UTI and specifically reducing inappropriate prescribing of antibiotics for UTI in the elderly( 70+) for 2017-2019
  • Variation in diagnosis of UTI in the elderly was identified in national and local audits and hence the diagnostic element of UTI in the elderly (65+ years) was added to LLR local primary care antimicrobial guidance. Evidence for this was based on SIGN 88 national guidance/algorithm.
  • It was observed that READ coding of the consultation for UTI was poor and varied widely .A clear record of consultation is important if the patient presents out of hours with the same or worsening symptoms.
  • It was also observed care home residents frequently had urine dips with staff also requesting antibiotics for a UTI. The frequency to yield to the requests following a urine dip was high amongst prescribers .
  • Prescriber feedback in primary care indicated the SIGN diagnostic algorithm is complex (dipstick not recommended in this group of patients). The project's aim was to simplify the use of the algorithm and provide prescribers with a support template/protocol integrated into the GP clinical systems (SystmOne and EMIS Web).
  • All UTI resources available nationally and from other CCG's were reviewed by the team by collaborating with care home pharmacist team and local authority. Care home assessment tools were designed after collaboration with care home staff , infection prevention team and local authority to support care home staff to capture relevant details about the residents symptoms and feed into the GP diagnosis template and avoid a urine dipstick and potential inappropriate request for antibiotics to treat a UTI.
  • The 3 primary care CCG antimicrobial pharmacist in LLR designed a protocol and template in collaboration with LHIS ( including care home assessment tool) to adress the issues highlighted above.
    The template supports: 
    • Correct diagnosis in line with evidence based guidance
    • Reduced variation in diagnosis of UTI in the elderly across LLR
    • Correct read coding of symptoms on patient record
    • When diagnosed with UTI direct prescribers to correct first line choice of antibiotic in line with antimicrobial guidance ( including latest renal function results )
    • Provide easy access to all educational and patient information leaflets to prevent and treat UTI
  • The template was promoted to prescribers through: 
    • locality prescribing meetings
    • locality update newsletters to GP practices
    • email to all relevant stakeholders e.g Practice managers ,primary care prescribers, - the care home assessment tool ,hydration leaflets and posters were promoted via local authority and care home pharmacy team ,care home newsletter and care home staff training events local authority
    • OPTIMIS RX prompt messages
      A crib sheet for use of the template for both prescribing systems (SystmOne and EMIS) was designed and provided to all prescribers ( see attached documents) . The template and protocol would trigger in the following instance:
      • patients over 65 years at the point where clinician types UTI or symptoms linked to UTI
      • Optimise RX triggers to prompt GP's to use protocol at the point of prescribing Trimethoprim or Nitrofurantoin
      • On manual launch

Who are the main beneficiaries of the project? How would they benefit?

Patients:

  • Better diagnosis of UTIs and reduction in inappropriate use of antibiotics and more appropriate treatment leading to improved patient outcomes
  • Potential reduction in recurrence of UTIs due to resistant organisms (and reduction in C. diificile etc due to excessive antibiotic use in vulnerable patients)
  • Decrease in antimicrobial resistance due to reduced prescribing of inappropriate antibiotics resulting in higher initial treatment success.
  • Reduction in Ecoli bacteraemia
  • All of which support patient safety and patient care

GPs:

Technological support at the point of prescribing to guide GPs to use latest antimicrobial guidelines for the diagnosis and treatment of UTIs in over 65 years, via GP clinical systems during the patient consultation. Supports evidence based clinical practice

Care homes:

Providing care home staff with a tool to capture resident's symptoms therefore giving GPs a better clinical picture. Encouraging care home staff to follow latest antimicrobial guidance by using the Care Home Assessment Tool rather than using a urine dip. Provides a written record of the resident's assessment to support future patient care and potential treatment decisions.

CCGs:

Helps CCGs achieve NHSE antimicrobial quality premium targets and support the DOH Antimicrobial resistance strategy 2013-2018. Help CCG with improving prescribing indicators and patient outcomes

What were the main outcomes and / or achievements of the project?

  • The project succeeded in establishing a protocol /template for appropriate diagnosis of UTI in the elderly ( >65 year old) based on evidence ( SIGN 88 guidance ) in 3 CCG and OOH hubs in 108 SystmOne practices and 30 EMIS practices .
  • This includes easy access to all resources around prevention leaflets and patient education leaflets being present in one place.
  • All of the above improved patient care by utilising existing NHS resources with no additional investment.
  • The 3 CCG's have also achieved the NHSE QP target for UTI antimicrobial prescribing indicators for 2017-2018 ( visual graphs and statistics from NHSE dash board attached).
  • Reduced antimicrobial resistance and Ecoli due to appropriate use of antibiotics in line with promoting antimicrobial stewardship.
  • This is present at both SystmOne and EMIS practices across LLR and helps to implement evidence based practices uniformly across a large area
  • Positive GP feedback from all 3 CCG including comments on how this was helping them train new GP registrars

This project in our area has no additional costs other than time spent by meds management team in development.

The project retained the quality elements of the NHS Banes CCG "TO dip or not to dip" project and the Nottingham CCG resources idea and took it a notch further to use technology in a sustained way to diagnose UTI and reduce antibiotic prescribing in a complex group of patients over a large area
There is the potential for the protocol and template to be widely shared through out primary care in other CCG to replicate this. 

Use the prescribing support system OPTIMISE electronic system to prompt the use of UTI template before prescribing antibiotics for UTI in the following instances to ensure the use of protocol for appropriate diagnosis:

  • Trigger: Patients aged 65 years and over, without an uncomplicated urinary tract infection recorded within 1 day, prescribed either trimethoprim without another valid indication (acute pyelonephritis within 22 days or acute prostatitis within 35 days) or nitrofurantoin.

    Message Nitrofurantoin or trimethoprim: prescribed without a recorded lower urinary tract infection in patients aged 65 years or overReview use of nitrofurantoin or trimethoprim without a recorded indication; complete the "LLR suspected UTI template in over 65yrs" before prescribing an antibiotic.

  • Trigger : Patients prescribed with a urinary tract infection within 1 month, without a recorded midstream urine sample within 1 month, previously prescribed nitrofurantoin or trimethoprim within 1 month, prescribed either trimethoprim without another valid indication (acute pyelonephritis within 22 days or acute prostatitis within 35 days) or nitrofurantoin.

    Message: Nitrofurantoin and trimethoprim: second course for a urinary tract infection prescribed without a midstream urine sample Review repeated use of trimethoprim or nitrofurantoin without a recorded midstream urine sample for a urinary tract infection.