Quality statement 2: History and examination – recording of risk factors

Quality statement

Infants, children and young people with a urinary tract infection have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.

Rationale

Presenting symptoms, findings on examination, results of urine testing and knowledge of risk factors are all important when a diagnosis of urinary tract infection is being considered. Recording of risk factors is a cumulative process as part of the history and examination of an infant, child or young person with a urinary tract infection. Recording of risk factors is also important in order to identify whether onward referral and further investigations will be needed.

Quality measures

Structure

Evidence of local arrangements to ensure that infants, children and young people (under 16 years) with a urinary tract infection have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.

Data source: Local data collection.

Process

Proportion of infants, children and young people with a urinary tract infection who have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.

Numerator – the number of people in the denominator who have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.

Denominator – the number of infants, children and young people (under 16 years) with a urinary tract infection.

Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for infants, children and young people with a urinary tract infection to have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.

Healthcare practitioners ensure that infants, children and young people with a urinary tract infection have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.

Commissioners ensure that they commission services for infants, children and young people with a urinary tract infection where risk factors for urinary tract infection and serious underlying pathology are recorded as part of their history and examination.

Infants, children and young people under 16 with a urinary tract infection have any factors that may put them at risk of urinary tract infection and of more serious underlying conditions recorded in their patient notes.

Source guidance

Urinary tract infection in under 16s: diagnosis and management (2018) NICE guideline CG54, recommendation 1.1.7.1 (key priority for implementation)

Definitions of terms used in this quality statement

The NICE guideline on urinary tract infection in under 16s recommends that the following risk factors for a urinary tract infection (UTI) and serious underlying pathology should be recorded as part of history and examination on confirmed UTI:

  • poor urine flow

  • history suggesting previous UTI or confirmed previous UTI

  • recurrent fever of uncertain origin

  • antenatally-diagnosed renal abnormality

  • family history of vesicoureteric reflux (VUR) or renal disease

  • constipation

  • dysfunctional voiding

  • enlarged bladder

  • abdominal mass

  • evidence of spinal lesion

  • poor growth

  • high blood pressure.