Implementing the NICE UTI in Children guideline in a UK Paediatric Emergency Department by devising a new Standard Operating Procedure (SOP). Using prospective audit to monitor change in practice and evolve better care pathways for our patients.
Aims and objectives
To introduce a new Standard Operating Procedure (SOP) for managing systemically well children discharged home with a suspected UTI. To use prospective audit to monitor change in practice and calculate financial savings achieved following the introduction of the new SOP. To use the audit findings to further improve the implementation process. This includes developing a fool-proof documentation system to increase the accuracy of diagnosis, maximise appropriate antibiotic prescribing and ensure the correct patients are referred for investigation and paediatric follow up.
The aim of this process is to deliver high quality evidence based care to children presenting to the Emergency Department.
1.To ensure suspected UTIs in children are appropriately investigated.
2.To ensure antibiotic prescribing follows local microbiology guidance and is appropriate whether the child has an upper or lower UTI.
3.To ensure children with a proven UTI are referred for imaging and specialist review as per NICE recommendations.
Reasons for implementing your project
Prior to the publication of NICE CG54, our department's UTI management was based on the Consensus Guideline from the Royal College of Physicians (1991). At the time we were taking 2 urine samples and arranging follow up at our Paediatric Emergency Department UTI clinic, when the urine culture result was available. Imaging was arranged for all children with a confirmed first UTI and prophylactic antibiotics were prescribed.
We reviewed the guideline and realised it implied a considerable departure from our existing practice including urine collection, imaging and follow up. To establish a baseline we retrospectively audited 100 cases, the standards for which were chosen from the recommendations described in CG54.
As a result a new SOP incorporating a standardised proforma was introduced in July 2008. This proforma was used to collect data at the time of attendance to the Paediatric Emergency Department; it was completed following microbiology urine culture results within 48hrs. The completed proforma enabled the Paediatric Emergency Medicine Registrar to plan further management. Instead of attending the weekly clinic, parents were telephoned to establish the wellbeing of the patient, inform them of the culture result and of any further investigations and referrals that were required. Given the considerable change in practice we collected the proforma data to prospectively audit the implementation of the new SOP.
How did you implement the project
Data from 100 consecutive SOP proformas was collected between July 2008 and Aug 2009 and the results analysed.
80% of children had one clean catch urine sample collected, while 20% still had a second sample. This high percentage of only one urine sample being collected was a direct result of paediatric nurse education within the Emergency Department.
Children discharged from the Paediatric Emergency Department with features of a lower UTI were prescribed the antibiotic of choice, trimethoprim, in 81% of cases. However the correct duration, 3 days, was only adhered to in 48% of cases. Systemically well children discharged with features of an upper UTI were prescribed the appropriate first line antibiotic co-amoxiclav (cefalexin if allergic) in only 28% of cases. 54% were prescribed trimethoprim. One of the main barriers to effective implementation of correct antibiotic use was educating clinicians in differentiating between upper UTI and lower UTI according to CG54. Another barrier to overcome was to change clinicians practice of routinely prescribing trimethoprim for 5days for a UTI.
The new SOP directly addressed both this issues however further implementation work is required for improvement to occur.
Imaging and paediatric out-patient referral procedures were adhered to 96% of the time in first UTIs (only 7% required an US scan) and 79% in recurrent UTIs. The high percentage reduction in US scan requests for first UTIs were as a direct result of clear steps within the new SOP.
In the months following the introduction of the new SOP, departmental education raising awareness of the new changes continued, sample proformas were checked regularly to ensure the implementation was being followed and the Paediatric Emergency Registrars fed back any difficulties that they had encountered. The main impact on patient outcome was the excellent uptake of the new NICE imaging strategy.
Even in children with recurrent UTIs where compliance was 79%, the other 21% were all appropriately referred on to specialist out-patient follow-up for a decision on investigation. The poor performance on antibiotic choice in upper UTIs appears to be due to lack of distinction between upper and lower UTI. Further departmental education has taken place to ensure clinicians can differentiate between lower and upper UTIs. We have also re-designed the entire document as a flow chart to work as a decision making tool alongside its data collection role. This should ensure that upper and lower UTIs are distinguished early on and appropriate antibiotics prescribed. The effectiveness of these changes is being monitored in the current re-audit data collection phase of the audit cycle.
Analysis of the audit data revealed not only performance in clinical care as described above, but also financial savings for the department. When these 100 cases were compared to the department's previous practice, it showed that 10 children under 2 were spared prophylactic antibiotics, 24 USS were no longer necessary, saving £1200, and 80 urine dips were prevented, saving £9.60. This audit was presented as a poster presentation at the Autumn Conference of the College of Emergency Medicine in Sept 2009 and will be submitted to various paediatric journals.
Key learning points
The audit results have allowed evaluation of what has and has not worked well in the new SOP. The proforma design appears to be the key. One page of the proforma document was designed as a decision making tool. This resulted in good compliance with imaging and follow up recommendations. The documentation of antibiotic prescribing on the other hand was a simple 'fill in the box' exercise. Appropriate prescribing required you to have read the online SOP document and have full understanding on how to differentiate and upper from a lower UTI. The audit results reveal that this is an area that requires improvement and has lead to the re-design of the proforma paperwork. The proforma now encompasses the whole SOP in the form of a flow chart to work as a decision making tool alongside its data collection role. Continued education, including case based UTI in children teaching, as clinicians rotate every few months has also been important to continue the implementation process.