UTIs in older people: the tool reducing unnecessary prescribing

Pioneering nurses like Jo McEwen are leading the way in antimicrobial stewardship, using a watch and wait approach to cut inappropriate antibiotic prescribing and improve care

Pioneering nurses like Jo McEwen are leading the way in antimicrobial stewardship, using a watch and wait approach to cut inappropriate antibiotic prescribing and improve care

Picture: Alan Richardson

When older patients have a suspected urinary tract infection (UTI), a prescription for antibiotics is the most common treatment – but what if the tests that indicate an infection are misleading and there is nothing wrong?

For advanced nurse practitioner in antimicrobial stewardship Jo McEwen, of NHS Tayside in Scotland, this issue is at the heart of her award-winning educational programme, which challenged nursing staff in eight local community hospitals to think differently about the care they provide.

‘There was a great belief that urinalysis was a reliable diagnostic tool to identify UTIs in older adults,’ says Ms McEwen, who qualified in 2001 at the University of Dundee. But in practice it can be a blunt instrument, detecting asymptomatic bacteria that are a natural consequence of ageing and live harmlessly in the bladder, she says.

Decision aid

To improve nursing practice and patient care, she created and led a 12-month programme, beginning in April 2015. Four hour-long educational sessions were delivered during handover periods, when the most staff were available on the wards.

Alongside information about the importance of nursing’s role in antimicrobial stewardship, clinical scenario-based workshops helped staff implement their learning, exploring any challenges in a safe and controlled way.

‘We should be relying on what someone is telling us rather than a clinical test’

Jo McEwen, nurse practitioner in antimicrobial stewardship

Nurses were encouraged to look at the whole person, using a decision aid developed by the Scottish Antimicrobial Prescribing Group to diagnose and manage suspected UTIs in older people.

‘We applied it to clinical practice, really trying to promote person-centred assessment,’ explains Ms McEwen, whose work was publicly recognised with an Antibiotic Guardian staff engagement award from Public Health England in 2017.

An eye-opener

Rather than testing routinely, staff considered whether the individual patient had signs of an infection, such as a raised temperature, as well as any pain, their frequency or urge of urination, and any new or worsening confusion.

‘We should be relying on what someone is telling us rather than a clinical test,’ says Ms McEwen.

For many nursing staff it proved to be an eye-opener. ‘Once the rationale was provided the change in practice was almost palpable,’ she says.

Following the programme, a survey of staff who took part showed that urinalysis was no longer being used as a diagnostic tool for UTIs in this group of patients, with nurses saying they felt more confident about their role in managing infections, including questioning inappropriate sample requests.

This increased confidence was borne out statistically too, with a 29% reduction in the number of inappropriate urine samples being sent to laboratories for testing.

Optimising care

‘I was ecstatic. I wasn’t sure how the nursing workforce would react to antimicrobial stewardship,’ says Ms McEwen.

‘I just set them on the path and gave them the tool. They completed the journey and it’s their work that has led to the change, optimising care for patients. Now if there is just one sign of a potential UTI, they don’t automatically contact the GP. They watch, wait, promote hydration and look at personal and toilet hygiene.’

‘We’ve reduced unnecessary exposure to antibiotics, decreasing the likelihood of developing resistant organisms’

Jo McEwen

She cites a wide range of benefits, including saving health professionals’ time and a small amount of money. But perhaps most importantly the initiative has led to significant improvements in the care patients receive. ‘Nursing staff have a greater understanding of how to manage a UTI in older people, including the signs and symptoms to look out for,’ says Ms McEwen. ‘We’ve also reduced unnecessary exposure to antibiotics, decreasing the likelihood of developing resistant organisms.’

How can I improve care?

  • Boost your knowledge. ‘There are lots of free educational tools to improve your learning on antimicrobial stewardship,’ says Ms McEwen (see ‘Useful resources’ below)
  • Look at where you can influence antimicrobial stewardship within your own practice. ‘If you’re administering antibiotics, read the prescribing and administration guidelines,’ says Ms McEwen. ‘Most will include the optimal dose and a defined duration, so you know your patient is receiving the correct prescription’
  • Remember that the issue can’t be seen in isolation from infection prevention and control. ‘It needs to go hand in hand,’ says Ms McEwen
  • Make sure that clinical assessments are always person-centred. ‘It’s about really focusing on the signs and symptoms an individual is displaying’

Ms McEwen has worked in infection-related areas since qualifying, including both clinical and academic posts in infection control and health protection.

She was appointed to her current role in 2014, and her specialist nursing post is believed to be the first of its kind in the world. ‘It’s been both exciting and terrifying at the same time,’ she says.

Sounding board

‘It’s only comparatively recently that the role of the nurse in antimicrobial stewardship has come to the fore and been acknowledged, with the first paper written about it only around ten years ago. Identifying, developing and leading what we can contribute as a profession is exciting ­– but at the beginning it felt quite lonely.’

Now more nurses are taking on similar roles, and she is one of five in Scotland, with at least half a dozen believed to be working in England. A network has been formed, with a group in Scotland that met for the first time last October.

‘It’s reassuring to have a sounding board and know that we’re going in the right direction,’ says Ms McEwen. ‘It’s good to know that we’re of similar mindsets in terms of nursing practice.’

Picture: Alan Richardson

When not to prescribe

Nurses can play a major role in reducing inappropriate antibiotic prescribing, she believes. ‘We’re a constant in the patient’s journey of healthcare,’ says Ms McEwen. ‘Whether they’re admitted to hospital or seen in outpatients or primary care, it’s generally a nurse who will see them through.

‘Identifying, developing and leading what we can contribute as a profession is exciting ­– but at the beginning it felt quite lonely’

Jo McEwen

‘We’re also responsible for clinical assessment, which can influence prescribing behaviour, alongside making sure medicines are administered safely, including the correct dosage, how long the course should last and the patient’s response.’

Among her project’s main challenges was tackling an agenda that focused heavily on prescribing. ‘We looked at where nurses could influence prescribing decisions, including when not to prescribe,’ explains Ms McEwen.

‘We wanted to empower nurses, saying to them it was okay to do this – and that actually it’s part of good nursing care. But giving them licence to do it was challenging.’

At the start of the sessions she recalls being asked whether it was okay for nurses to ask questions about whether patients needed a test or an antibiotic. ‘My answer was yes, absolutely. You’re advocating for your patient,’ says Ms McEwen. ‘It’s clear from the results we had afterwards that nurses were implementing this into their clinical practice.’

Anecdotally, GPs say the programme has helped to improve communication. ‘It hones in on what they need to know and helps them decide whether they need to see a patient or not,’ she says.

Health promotion and raising awareness are also key. ‘There’s a long-standing cultural belief that antibiotics are the answer to everything when you’re unwell.’

Reassuring rationale

Improving nurses’ knowledge of antimicrobial stewardship puts them in a better position to explain to patients and their loved ones why a prescription for antibiotics may not be the best option.

‘The greater our understanding, the better we can provide a reassuring rationale,’ says Ms McEwen.
Looking ahead, she plans to continue her educational initiatives with nursing staff, developing similar programmes for healthcare assistants and care home staff.

‘Nurses’ awareness is getting better and we’ve come a long way, but as a profession there’s a lot more we need to address,’ she says. ‘Antimicrobial stewardship is good nursing care. The term might be foreign to us, but how we deliver this is embedded within our nursing practice. It’s really about promoting high-quality care.’

Useful resources

Antimicrobial Stewardship: Managing Antibiotic Resistance

A free online six-week course, provided by Future Learn, to help healthcare professionals ensure safe, high-quality antibiotic use. It covers topics such as the global impact of antibiotic resistance, implementing antimicrobial stewardship in hospitals, and successful global examples. For more information click here

Antimicrobial Stewardship: A competency-based approach

Developed by the World Health Organization (WHO), this free online course takes about eight hours to complete. It is designed to equip clinicians who frequently prescribe antimicrobials with knowledge and tools to improve their use in clinical practice. It includes modules on allergies, UTIs, community-acquired respiratory tract infections, and infections of blood and skin. Click here

TARGET antibiotic toolkit

Developed by the Royal College of General Practitioners (RCGP), the toolkit is designed to be used by the whole primary care team in GP practices. It includes a range of resources to support responsible use of antibiotics by prescribers and patients. Click here

Scottish Antimicrobial Prescribing Group (SAPG)

The SAPG provides a range of resources on antimicrobial stewardship for both undergraduate and postgraduate healthcare professionals. These include an interactive workbook for nurses and midwives. Click here

Lynne Pearce is a freelance health journalist

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