Project overview
BACKGROUND
Urinary tract infection (UTI) is the most commonly diagnosed infection in older people living in care homes. It accounts for more than 50% of antibiotic prescriptions in this population. Several factors increase the risk of UTI in older people, such as underlying urological conditions, chronic bacterial colonisation of the urine and cognitive impairment. Having a urinary catheter can also increase the risk of infection. UTI can be difficult to recognise in older people, who don’t always have the typical signs and symptoms of a UTI. This means it can be difficult for care home staff to tell the difference between early signs and symptoms of a UTI and other conditions. Strategies that support accurate recognition of UTI are important to enable the effect of UTI prevention strategies to be monitored and to reduce unnecessary antibiotic prescribing.
A range of strategies to prevent UTI have been proposed, including staying well hydrated, incontinence management, personal hygiene measures and the care and management of urinary catheters. Understanding which strategies are effective and how they can be successfully implemented in care homes, where many residents are cognitively impaired and most care is delivered by non-clinical staff, is critical to tackling UTI and assuring residents’ health and well-being.
WHAT WE DID
We wanted to understand how UTI can be prevented in older people living in care homes and what support care home staff need to help prevent and recognise UTI. To find out, we used a research method called ‘realist synthesis’. This draws on multiple types of information, including evidence from research, improvement initiatives and experiences of people involved in social care. We asked care home staff, people living in care homes and family carers about their experiences. We also spoke to healthcare professionals and others who work with care homes. We combined these experiences and ideas with the evidence we found from research studies and improvement projects.
Using this approach, we have developed an understanding of what interventions work, for whom, in what circumstances and why. Our findings have been grouped into three theory areas:
1. supporting accurate recognition of UTI
2. preventing UTI and catheter-associated UTI
3. the infrastructure and systems required to make best practice happen
WHAT WE FOUND
The evidence we found shows that care staff have a key role in preventing and recognising a UTI given how closely they work with residents. They are often best placed to notice subtle changes in a resident’s behaviour or wellbeing that might indicate infection. There are several things care staff can do proactively to help residents from developing a UTI, such as prioritising hydration needs and addressing poor fluid intake. Putting in place infection prevention measures such as caring for, or where possible, removing a urinary catheter can also help. Actively monitoring residents to determine reasons for changes in behaviour can increase the focus on preventative activities and help avoid inappropriate antibiotic treatment.
The detection and prevention of UTI in older people could be improved in several ways, including:
• education tailored to the roles and work of care home staff;
• leaders of care homes providing a culture of safety and improvement where UTI is recognised as something preventable rather than unavoidable;
• having a safe and supportive environment where staff are confident to communicate their concerns;
• all care team members, residents and their families and other professionals linked with the care home having a common language and shared goals in the recognition, prevention and diagnosis of UTI.
CONCLUSIONS
Findings from this review suggest actionable recommendations at both an organisational and system level to support the prevention and recognition of UTI in the care of older people living in care homes. These recommendations centre on the need to align UTI prevention and recognition with person-centred care by embedding them in daily routines.
Care home providers need to incorporate evidence-informed actions to prevent UTI into routine daily care so that the risk of acquiring an infection is minimised. They also need to support the accurate recognition of UTI to ensure residents receive the most appropriate care and unnecessary antibiotic prescribing is reduced. The whole care team, including individual residents, their family carers, care home staff and visiting health professionals need to be involved in developing and implementing these strategies.
A system-wide approach with regulatory and inspection frameworks aligned to evidence on prevention and recognition of UTI is also vital to ensure that resources and infrastructure are available to enable care home managers and their staff to prioritise this as part of person-centred care. Key recommendations for system-wide actions include:
• Commissioners/regulators of care identify prevention and accurate recognition of UTI as a priority area of care for care homes and facilitate access to relevant expertise to support improvement activity
• Action is taken to facilitate access to relevant expertise to support multi-disciplinary assessment and treatment plans for residents with recurrent UTI who have the greatest potential to benefit from effective treatment
• Work is undertaken to harmonise decision and communication tools for the recognition and prevention of UTI with those focused on recognising deterioration to facilitate their adoption and integration in care homes
