How our practice got better at UTI management

The TARGET Antibiotics Toolkit includes a dedicated UTI Resource Suite of materials. The suite is designed to support GPs in managing urinary tract infections (UTIs) and preventing a rise in antimicrobial resistance.

Dr Linda Strettle used resources and recommendations from the toolkit to successfully change policies and processes surrounding diagnosis and management of UTIs at her practice in Rotherham.

The problem

The practice had a problem with ‘drop off’ urine samples. In 2020, patients were dropping off around 20-30 urine samples per day at our receptions. Patients would hand in their sample and complete a short form about their symptoms, which was often incomplete. All further treatment was then prompted by urine dipstick result. Upon discussion with the nursing team we realised that this process was inefficient, time consuming and risky for patient safety. We knew something had to change.

I attended TARGET training to help tackle this issue. I identified three key elements to addressing this problem: a champion; whole practice approach; and patient engagement.

Championing change

I needed to have evidence and guidance behind me to support and engage the practice team in change. I became a TARGET approved trainer by attending antimicrobial stewardship (AMS) workshops. Using what I’d learnt from the workshops, the TARGET UTI Resource Suite documents and prescribing information from Fingertips and Open Prescribing, I assessed the problem.

I carried out TARGET UTI over-65 non-catheterised patient audits to assess our practices’ diagnosis and management of UTI against NICE / PHE guidance. The audit gave proof that urine dipstick results were driving diagnosis and treatment of UTIs in the over 65 age group. However, the guidance recommends that clinical assessment rather than urine dipstick results should drive prescribing in this age group. We were above national average on trimethoprim prescribing compared to nitrofurantoin, and were issuing longer course lengths of antibiotics than NICE guidance recommended.

Whole practice approach

To engage the whole practice, I presented the evidence to our receptionists, nurses, GPs and management. I tailored the level of information depending on their role. Having all the practice staff on board at every stage was key.

I delivered a focused adapted TARGET AMS workshop to all practice clinicians to provide evidence of how our practice was performing compared with national guidance. I drafted protocols for reception staff, and created some simple process flowcharts to shift patients towards a ‘consultation first’ rather than ‘dipstick first’ model.

Our receptionists were enthusiastic and keen to help make a change. Their support was crucial, as they act as the first port of call for patients, some of whom had expressed concerns when we tried to change this policy in the past. For clinicians, I developed flowcharts for UTI diagnosis and had laminated copies of the TARGET UTI flowcharts in all consulting rooms. Throughout the process I continued to gather feedback from staff and make adaptations accordingly.

Patients

When receptionists received challenges from patients about our change of policy, I reached out to the patient directly and personally via letter explaining the reasons behind the change. I asked them to engage with the practice to discuss the changes, encouraging feedback and input from the individual patient. We suspected that often patients wanted reassurance that their symptoms had been noticed and felt dropping a urine sample off achieved this. Instead our process provided this reassurance through a consultation.

UTI management outcomes

Urine sample ‘drop-offs’ have significantly decreased, from 20-30 unsolicited urine samples pre-policy change to five clinician-requested urine samples per day.

This has had a positive effect on the whole practice team. Reception staff feel empowered to refuse to accept unsolicited urine samples, and have the support of the whole team to do so. Nursing staff spend much less time processing these samples and linking patient to sample.

There has been a shift in clinician workload, from managing urine sample results to consultations where patient assessment is in line with national guidance. I felt empowered to question and discuss prescribing practice with hospital consultants, for example when they were prescribing antibiotics in recurrent UTI contexts. I shared some of my materials with around 20 GPs across the UK who seemed to be experiencing similar challenges in management of urine samples and dipsticks.

The guidance and resources from TARGET empowered myself and my colleagues at the practice to have the discussions about UTIs with patients.

Comparing results

Comparing the outcomes in 2020 vs 2021 (following the practice’s policy change) using the TARGET UTI audit:

1. Reduced number of patients over 65 with UTIs who had urine dipstick tests as part of the assessment and diagnosis of UTIs (in line with national guidance).
2. There were less total prescriptions of antibiotics for UTIs in 2021 vs 2020 for a similar time period.
3. Clinicians were documenting more clearly when a patient had delirium and a UTI was considered. The rationale for considering UTI as the diagnosis rather than attributing the delirium automatically to a UTI was more clearly documented.
4. Safety netting and its documentation in the record improved.
5. There were more documented discussions regarding risks of antibiotics and antimicrobial resistance.

Areas for ongoing improvement

1. The TARGET UTI diagnostic criteria were still not always being used (as per the TARGET flow charts).
2. Antibiotic choice, dose and course length was similar to the initial audit and around one third of prescriptions were not in line with national guidance (although we reduced total antibiotics numbers for a similar time period.)

Conclusion

Thanks to our collective efforts, we implemented a practice-wide policy change. I hope that we can continue to sustain this long-term.