Elizabeth Beech National Project Lead Healthcare Acquired Infection and Antimicrobial Resistance

1. To Dip Or Not To Dip – Improving the management of Urinary Tract Infection in older peopleImproving Patient Safety & Care 6th Feb 2019Continuous Learning, Measurement & Improvement Elizabeth Beech National Project Lead Healthcare Acquired Infection and Antimicrobial Resistance NHS Patient Safety Team, NHS Improvement elizabeth.beech@nhs.net @elizbeech #ToDipOrNotToDip

2. UK ambitions to reduce antimicrobial resistant infections and provide safe and effective care We will reduce inappropriate antibiotic prescribing by 50% We will reduce healthcare associated Gram-negative bloodstream infections in England by 50%

3. There were 42,000 E.coli blood stream infections in the 12 months to November 2018 • 75% of these have a community onset, and half will have a urinary tract origin, with antibiotic resistant E.coli increasing risk of UTI treatment failure ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

4. 33.25 million antibiotic items were prescribed in primary care in England in 2017/18 at a cost of £165.25 million7 million (21%) of were for antibiotics commonly prescribed in primary care to treat lower UTI at a cost of £45 million2.75 million (40%) of these antibiotics were prescribed to people aged 70+ years • ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

5. 13,447 residents in 251 aged care homes in Australia which participated in a single day PPS during June-September 2016 https://www.safetyandquality.gov.au/publications/aged-care-national-antimicrobial-prescribing-survey-2016/ 1,300 (9.7%) residents prescribed at least one antimicrobial (N=1,867) ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

6. 16,000 care homes provide care for 459,000 residents in England https://www.cqc.org.uk/publications/major-report/state-care • ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

7. 545,000 antibiotic prescriptions were dispensed for 341,536 residents in long term care facilities in UK in the 12 months Nov16 – Oct171 in 2 residents had a least one antibiotic, and 40% of these were for UTIhttps://academic.oup.com/jac/advance-article/doi/10.1093/jac/dkz008/5304212 • ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

8. #ToDipOrNotToDipA patient centred approach to improve the management of Urinary Tract Infection UTI in the Care Home environment in Bath and North East Somerset • This is an evidence based systematic approach to improve the diagnosis and management of UTIs in residents in all 23 Nursing Homes in Bath and North East Somerset • It was delivered by the CCG care home pharmacist service working during 2015-16, aligned to the existing GP enhanced nursing home service, and funded by the CCG as a quality improvement project in 2014 - <£10K • And continued as an quality improvement programme due to impact • Why did we do this? Local clinical audit in 2013 identified residents were frequently prescribed antibiotics for UTI; 19% - 48% of residents per care home based on diagnosis by urine dip stick testing - which guidelines do not support • ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

9. #ToDipOrNotToDip – Improving the management of UTI How to achieve? Education sessions and resources for care home staff Aim of the project • Improve awareness on preventing and diagnosing UTIs in care home staff • Reduce unnecessary dipstick testing of urine samples • Improve communication between care homes and GPs about residents with suspected UTI • Reduce unnecessary antibiotic use in residents • Appropriate sending of urine samples for culture and sensitivity test Stop using urine dipsticks to diagnose suspected UTI Introduce a clinical assessment and communication tool for care home and GP use GPs following local guidelinesfor treating UTIs Use of red top bottles which contains boric acid for preserving the urine and increase sampling • ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

10. ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

11. #ToDipOrNotToDipPilot results from 8 Nursing Homes in NHS Bath and North East Somerset 56% reduction in the proportion of residents who had an antibiotic for a UTI • 143 / 690 residents had at least one antibiotic for a UTI in 6 month period Jul-Dec 2015 after implementation 67% reduction in the number of antibiotic prescriptions • 153 fewer in 6 month period in 8 nursing homes with pre and post data 82% reduction in the number of residents prescribed antibiotic prophylaxis • 13 / 690 residents had antibiotic prophylaxis in 6 month period Jul-Dec 2015 after implementation Unplanned hospital admissions for UTI, urosepsis and AKI reduced in the nursing home population following implementation • ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

12. #ToDipOrNotToDip Improving the management of UTI in NHS Bath and North East Somerset Jul-Sep spike in the number of residents treated for UTI in 2016 reduced in 2017 following re-education in Apr-Jun 2017 • ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

13. #ToDipOrNotToDip Improving the management of UTI in NHS Bath and North East Somerset No seasonal change in the number of residents with urinary catheter use but there has been a reduction in number of residents with CAUTI and the number of antibiotics prescribed • ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

14. #ToDipOrNotToDip – Spreading the improvement Community of interest hosted on Slack – 400+ clinicians from multiple countriesSpread – Support – Adopt – Adapt – Improve ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

15. #ToDipOrNotToDipResources free to use https://www.e-lfh.org.uk/programmes/antimicrobial-resistance-and-infections/ • ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

16. Join the #ToDipOrNotToDip community of interest of 400+ people in Slack via elizabeth.beech@nhs.net ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

17. #ToDipOrNotToDip– What Next? • New PHE UTI diagnostic guidance for people aged 65+ years • NICE publish UTI guidance x 4 • NHS Improvement to publish an improvement toolkit • Tackling antimicrobial resistance 2019-2024 - The UK ‘s 5-year national action plan Ambition 4: Provide safe and effective care for patients Ambition 8: Demonstrate appropriate use of antimicrobials • NHS England AMR diagnostic collaborative priority work stream • NHS England CQUIN scheme for providers will focus on hospital improvement • NHS Long Term Plan provides opportunities to implement in community networks • NHS England Medicines Optimisation Care Homes programme ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net

18. To Dip Or Not To Dip – Improving the management of Urinary Tract Infection in older peopleWelcome to contact elizabeth.beech@nhs.net for details Elizabeth Beech National Project Lead Healthcare Acquired Infection and Antimicrobial Resistance NHS Patient Safety Team, NHS Improvement elizabeth.beech@nhs.net @elizbeech #ToDipOrNotToDip ToDipOrNotToDip – Improving the management of UTI in older people elizabeth.beech@nhs.net