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Let’s get STARTed: Managing Urinary Tract Infections in the Residential Aged Care Unit

Grenfell Multi-Purpose Service
Project Added:
8 October 2015
Last updated:
23 October 2015

Let’s get STARTed: Managing Urinary Tract Infections in the Residential Aged Care Unit

Summary

This project created a new model of care to educate staff on how to manage the symptoms of urinary tract infections (UTIs) with alternative therapies, rather than multiple antibiotics. 

View a presentation of this project from the 2015 Western NSW Local Health District (WNSWLHD) Health Awards.

S – Symptoms, T – Testing, A – Assessment, R – Resistance, T - Treatment

Aim

To reduce the number of healthcare-associated infections in the Residential Aged Care Unit (RACU) at Grenfell Multi Purpose Service (MPS), by addressing best practice management of UTIs.

Benefits

  • Improves patient outcomes through preventative measures.
  • Reduces length of stay.
  • Reduces cost of treating healthcare-associated infections.
  • Empowers residents to take control of their health and wellbeing, by encouraging alternative therapies prior to an antibiotic prescription.

Project status

Dates

  • Start: January 2013.
  • Finish: July 2015.

Status

Implementation - The initiative has currently been implemented.

Background

UTIs are one of the most common causes of harm to older Australians, particularly those in Residential Aged Care Facilities (RACFs). Residents of RACFs may be at increased risk of antibiotic resistance from contact with residents who have multidrug-resistant Escherichia coli (E coli), as well as injudicious use of antibiotics used for asymptomatic bacteriuria.

An Australian study screened 119 patients across three RACFs. Overall, 14 residents (12%) had multidrug-resistant E coli, with 27% of these in one of two wings of a single RACF. Eight of 13 (62%) residents had persistent colonisation when re-tested three months later.

Inappropriate use of antibiotics may be a contributing factor to the high level of E coli seen in this group. In one study, 50% of patients who were prescribed antibiotics for a suspected UTI did not meet the clinical criteria for infection. Of these, 20% were prescribed antibiotics for asymptomatic bacteriuria.

Prior to the project, staff reported UTIs based only on the outcome of the urinalysis dip stick test. As a result, treatment usually commenced even when the resident showed no symptoms and before pathology results were available. Pathology results were often not reviewed within an adequate timeframe due to limited availability of medical officers, which also led to inappropriate antibiotic use.

The RACU at Grenfell MPS previously relied on the Rural Remote Consultation phone service to access medical treatment when there was no doctor available. Every time the service was used, a different doctor prescribed treatments, often before any pathology specimens were sent and results received.

To overcome these challenges, Grenfell MPS was invited to participate in a pilot of the Aged Care National Antimicrobial Prescribing Survey (acNAPS). The survey enabled facilities to undertake standardised data collection and reporting on infections and antimicrobial use, in order to identify opportunities for improvement.

Implementation 

  • A ‘START’ pneumonic was developed to help staff understand each stage of the new model of care: symptom, testing, assessment, resistant and treatment.
  • Electronic resources were developed to provide the assistants in nursing, enrolled nurses and registered nurses with a better understanding of the anatomy and physiology of the genitourinary system and factors which predisposed patients to UTIs.
  • Education sessions on the management of UTIs were provided to all nursing staff over a period of six weeks. Sessions were held with all nursing staff at Grenfell MPS and were both formal and informal in nature. All new staff attended the UTI training during their induction and orientation to the RACU.
  • Clear escalation and feedback systems were established to ensure each member of the team was aware of their roles and responsibilities with regard to patient safety and clinical quality. 

Lead organisation

  • Western New South Wales Local Health District 

Implementation site

  • Grenfell Multi Purpose Service

Partnerships 

  • Grenfell Health Council
  • Grenfell MPS Medication Advisory Committee
  • Residential Medication Management Review Accredited Community Pharmacist 

Results

  • Through best practice management of symptomatic and asymptomatic UTIs, there has been a dramatic reduction of UTIs in the RACU at Grenfell MPS and the use of antibiotics to treat UTIs at Grenfell MPS was reduced.
  • Data showed a reduction in UTIs over a two and a half year period, as follows:
    • 27 in 2013
    • 11 in 2014
    • 3 between January and June, 2015
    • 0 between July and September, 2015
  • There was a reduction in delirium caused by UTIs, which were previously attributed by staff to dementia. This was captured in nursing progress notes, with only one resident over the course of the project experiencing delirium.
  • The educational resource was shared electronically within all RACUs in WNSWLHD and has become part of the workforce induction and orientation at Grenfell MPS. It can be accessed by all staff at any time, to refresh their knowledge of best practice guidelines in relation to the management of UTIs.
  • Staff now consider alternative therapies to treat UTI symptoms and collaborate with medical officers before prescribing treatment.
  • The use of antibiotic therapy is now monitored through an infection control antimicrobial stewardship program. Data is reported through the National Standards Evaluation Program Audits bi-annually, as well as unit monitoring and reporting to patient safety and quality meetings. The infection prevention and control registered nurse collected the following data each week:
    • antibiotic usage
    • types of infections
    • microbiology results.
  • ‘Standard 3: Preventing & Controlling Healthcare Associated Infections’ surveillance is ongoing as is antibiotic stewardship.

UTIs at Grenfell MPS 2013-15. Decreases each year 

The above graph illustrates the reduction of UTIs in the RACU of Grenfell MPS over the course of the project.

Lessons learnt

  • The project raised the level of awareness of the incorrect usage of antibiotic within the RACU and could easily be applied to any other RACF.
  • It was helpful to know how to have the correct conversation with residents, to encourage them to provide the sensitive information required.

Resources

Further reading

  • Cardiovascular Expert Group. Therapeutic guidelines: Cardiovascular. Version 6. Melbourne: Therapeutic Guidelines Limited; 2012.
  • Nicolle LE. Urinary tract infection in long-term care facilities. Healthcare Infection 2014; 19: 4-12.

Contacts

Francine Pirie
Clinical Network Services (CNS) Quality, Grenfell MPS
Western NSW Local Health District
Phone: 02 6349 1700
Francine.Pirie@health.nsw.gov.au 

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