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Type and Title of Submission


Title:

Implementation of NICE Clinical Guideline 54 Urinary Tract Infection in Children using a care pathway to improve appropriate investigation, treatment, referral and follow-up.

Description:

Category:

Clinical

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG54 - Urinary tract infection in children

Category(s) that most closely reflects the nature of the submission:

Implementation policy

Is the submission industry-sponsored in any way?

No


Description of submission


Aim

To ensure appropriate management of children attending a Paediatric Emergency Medicine Service with a Urinary Tract Infection, in line with NICE guidelines. To use NICE guidelines as a template for referrals to paediatric out-patient clinics, including those from primary care providers. This is likely to reduce the number of investigations performed on children with a low risk of urinary tract pathology.

Objectives

1. To improve consistency in assessment and management of children with symptoms of urinary tract infection using a care pathway to facilitate care delivery. 2. To audit care delivery against NICE audit criteria using the care pathway proforma. 3. To disseminate NICE recommendations to primary care providers to streamline new referrals in accordance with the NICE guidelines

Context

Previous guidelines for the management of urinary tract infection in children recommended follow-up for children with a confirmed diagnosis of UTI. This follow up included radiological and invasive investigations for a large number of children, including those with a first uncomplicated urinary tract infection. GPs routinely referred children to paediatric out-patient services for follow-up. NICE guidance now recommends that children aged > 3 months with a first urinary tract infection with an E.Coli organism which responds well to antibiotics within 48 hours do not need to be referred for follow-up. A Urinary Tract Infection Interest Group was established to decide on the best approach to implementation of the new NICE guidelines. This group consisted of representatives from Emergency Medicine, General Paediatrics, Nephrology, Urology, Radiology and the Trust Care Pathways Co-ordinator. GP and PCT representation was also added to the group to discuss dissemination into primary care, and direct children who are more likely to have abnormal pathology to secondary care. GPs may also choose to order ultrasound investigations, without the need for an out-patient appointment with a paediatrician, where appropriate. The NICE guidelines are complex, and it was agreed with primary care representatives that education should be provided for local GPs. A referral proforma was also developed to explain the key messages within the guidelines. This proforma is sent to the patient's GP if a referral does not appear to comply with NICE guidelines. GPs are asked to complete additional information about specific risk factors, atypical features or recurrence, if they want to re-refer their patient to be seen by a paediatrician.

Methods

1. To improve consistency in assessment and management of children with symptoms of urinary tract infection using a care pathway to facilitate care delivery. Quick ref guidelines were produced for all clinicians managing patients within the Paediatric Emergency Medicine Department. A pathway was produced to guide and record the care provided through assessment, investigation and out-patient follow-up. This was introduced in July 2008. For patients referred from elsewhere, the care pathway is attached to the referral letter (or Choose & Book referral) as soon as the referral is accepted. It is then added to casenotes for use by General Paediatricians, Nephrology and Urology Teams in out-patient clinics. Prompts are included throughout the care pathway to request appropriate investigations, start appropriate treatment based on results, and organise referral and imaging as set out in the NICE guidelines. Clinic notes are also recorded in the same document. 2. To audit care delivery against NICE audit criteria using the care pathway proforma. Audit of the management of UTI will evaluate the effectiveness of the pathway as a tool for implementing NICE recommendations. Patients are identified prospectively for audit, and the pathway document assists with the audit process, by incorporating NICE audit criteria. 3. To disseminate NICE recommendations to primary care providers in order to streamline new referrals in accordance with the NICE guidelines. Education sessions have been held with local GP groups and quick reference guidelines issued to assist with appropriate investigation and referral. Referrals with insufficient information are returned to the GP with a referral proforma. The proforma explains the NICE referral criteria and requests details of specific risk factors, recurrent or atypical features which may have been missing from the original referral. A record is kept of any referrals which are returned to GPs, to audit the re-referral rate.

Results and evaluation

A system has been introduced with the follow-up pathway to ensure that all patients are notified to the audit department when follow-up is commenced. Notifications can be from Emergency Medicine, General Paediatrics, Paediatric Nephrology or Paediatric Nephrology Teams. Patient data is currently being collected for a trust wide audit of UTI using NICE audit criteria. We aim to have provisional audit data by the end of 2008, with the audit completed by March 2009. The results of the audit will be submitted for poster or oral presentation at the NICE Conference and National Clinical Audit Conferences. The audit will evaluate compliance with NICE guidance, but also attempt to monitor the effectiveness of the guidelines for the treatment and follow-up of children presenting to Alder Hey with a urinary tract infection. Audit of re-referrals will provide information on children who may not meet the NICE criteria for follow-up, but go on to develop urinary tract pathology. This information will be shared with NICE to inform any future review of the guidelines.

Key learning points

Publication of NICE guidelines does not implement change. Opinion leaders within an organisation need to engage with the guidelines, interpret the key messages and disseminate these to their colleagues. Different specialties need to get together to discuss the implications and work together to agree the best way to support change across the organisation. When key clinicians are engaged, a pathway which both guides and records the care provided is an effective tool for consistent implementation of new guidance. It also allows for evaluation of the effectiveness of new guidance, which helps to convert the sceptics (or provide evidence for non-compliance if guidance is found to be less effective than the ‚??old ways‚??). NICE guidelines can support requests for additional equipment. In this case, the purchase of portable USS for demonstrating presence of urine in the bladder prior to supra-pubic aspiration. The training of Emergency Department staff in the use of ultrasound also has implications for service. Engaging with primary care to agree responsibilities and referral criteria has been extremely helpful. GP representatives from Practice Based Commissioning Consortia have been a useful resource, and we have used their structures to deliver appropriate education and receive a range of feedback from the GP community. Primary care links made during this implementation have since been utilised for other projects, and have given hospital based clinicians a better understanding of the challenges faced by General Practitioners. Incorporating audit criteria into the care pathway document which records care delivery makes the audit process easier.

View the supporting material

Contact Details

Name:Julie Doyle
Job Title:NICE Guidance Co-ordinator
Organisation:Alder Hey Children's NHS Foundation Trust
Address:Research & Development Dept, 1st Floor Mulberry House, Eaton Road
Town:Liverpool
Postcode:L12 2AP
Phone:0151 228 4811
Email:Julie.Doyle@alderhey.nhs.uk

 

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This page was last updated: 26 September 2008

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.