Fundamental care

The prevention of UTI and CAUTI in older people living in care homes requires attention to their fundamental care needs (Figure 18), with clear communication across the whole care team that is trusted and valued by residents and their family or significant others.⁴⁹ This necessitates a context of person-centred care and a culture of quality and safety, promoted by commissioners, regulators and providers, where leadership and resources are committed to supporting preventative action by knowledgeable care staff.

FIGURE 18

Fundamental Care Framework. Image obtained from %https://ilccare.org/the-framework/; Content within image derived from Feo et al. (2017).

Our synthesis suggests that ownership and empowerment among direct care staff for the prevention and recognition of UTI and CAUTI can be improved through its integration into care home systems and routines designed to meet residents’ needs and through its proper alignment with AMS goals. Linking fundamental care as a means of preventing UTI and CAUTI helps care staff to recognise how their role is important. Education and training that challenges assumptions and low-value practices assists in building confidence to communicate observations and arrive at informed decisions.

Integrating urinary tract infection prevention and recognition as part of person-centred care of older people

In the conception of this review, our reasoning for exploring both the prevention and recognition of UTI was that the latter was critical to developing effective prevention strategies. However, the evidence we have found has highlighted other hidden synergies between these two concepts, which emphasise the value of integrating them into the design and delivery of person-centred care.

Preventing and recognising UTI in older people is complex. Not only do underlying risk factors in older people increase their susceptibility to UTI, but they commonly present with atypical symptoms. The prevalence of UTI among care home residents can lead staff to assume non-specific symptoms are most likely due to UTI and that acquiring UTI is an inevitability for some residents. They may not appreciate the extent to which inappropriate treatment of UTI makes infections more difficult to treat and impacts on resident health and well-being in addition to driving the emergence of antimicrobial-resistant infection. If care staff are not aware that it is possible to prevent UTI and lack knowledge and training in how to do so, they are likely to see their role as exclusively about supporting its diagnosis and treatment.

Decisions about a UTI diagnosis are often based on observations of non-specific signs such as changes in the characteristics of urine or alertness of the resident combined with a urine dipstick test, which is perceived by some as being an objective test that provides a definitive indication that a UTI is present. Resources that aim to improve the reliability of UTI recognition can help care staff to distinguish and communicate evidence-based signs and symptoms of UTI.^32,60,61 However, given the overlap between some non-specific symptoms, which are common to both UTI and dehydration, existing decision-support tools may be missing an important opportunity to address hydration as a fundamental care need. Figure 19 illustrates the signs and symptoms of dehydration and UTI. The sets in the Venn diagram illustrate those signs and symptoms for which there is evidence of association with dehydration or UTI, while the intersection shows the signs and symptoms common to both. Signs that are often used as indicators, but are less reliable on their own, are listed outside of the circles. If attention was directed at improving a resident’s hydration, this might alleviate their symptoms and reduce the risk of them developing UTI, as indicated by the arrows in Figure 19.

FIGURE 19

Distinguishing UTI from dehydration. Derived from evidence contained in references.,,,

The importance of recognising the synergy between UTI diagnosis and prevention is illustrated by the work of Lean et al.¹¹⁷ They demonstrated a reduction in UTI-related hospital admissions associated with a strategy that combined increasing residents’ fluid intake with reducing the reliance on urine dipsticks to diagnose UTI. Decision-support tools targeting the appropriate diagnosis of UTI by care home staff should also incorporate decision-making about increasing fluid intake to exclude or manage dehydration as a potential cause of the symptoms and emphasise the role hydration plays in preventing UTI.

Our realist synthesis has identified proactive management of residents with urinary catheters together with informed decision-making about signs and symptoms of CAUTI as critical to preventing CAUTI and reducing inappropriate use of antimicrobials. However, this also necessitates support at a system level, including education that empowers staff to remove catheters and influence appropriate antibiotic prescribing decisions.

In relation to the proactive management of residents with RUTI, we found a single improvement study in a care home setting.¹²⁸ However, we used evidence from our stakeholders and relevant clinical guidelines to inform CMOc 7. The actions that care home staff take are often informed by their knowledge that a resident has had a prior UTI or has a history of septicaemia, which can result in heightened concern about the risk of deterioration and an early decision to contact the GP.⁶⁰ Conversely, ‘labelling’ a resident as having RUTI raises concerns about encouraging the treatment of ASB.⁶⁴

However, this overlooks the value of strategies aimed at the preventing RUTI, which would be available to older people outside a care home setting.^27,54,56 A combination of factors is a barrier to the proactive management of RUTI in care home residents. These include a lack of awareness about pharmacological options and guidelines on their use, lack of access to specialist staff such as CAs or urologists who could advise on investigation and treatment, and an absence of systems which could support the identification of repeat episodes of UTI and trigger action to offer treatment to affected residents. This further illustrates the need to integrate recognition with the prevention of UTI.

These findings highlight a need to unify the content of education and decision-support resources so that they align to the goals of fundamental care⁴⁹ and highlight the intersection between the prevention and recognition of UTI.

Aligning urinary tract infection prevention with sepsis prevention and diagnostic stewardship

The recent emphasis on sepsis prevention and the development of tools for use in care homes to detect early ‘soft signs’ of deterioration and sepsis has focused efforts on early recognition and escalation of concerns using structured communication tools. This creates a sense of the imperative to act and a fear of missing infection/sepsis, rather than a broader approach, which considers UTI as a possible cause and recognises the prevention of UTI as a goal and safety priority.

In addition, early warning tools aim to streamline observations and communicate changes in a resident to the GP to support the early identification of rapid deterioration/sepsis (e.g. RESTORE2, NEWS2, Stop and Watch). These tools are different to those designed to improve decision-making and communication about suspected UTI.^60,65 However, because both tend to be structured around SBAR communication tools, these differences may not be apparent to care staff.^60,70 It is therefore conceivable that these tools create conflicting messages about (1) the need to act rapidly to avoid deterioration and (2) considering alternative explanations for a change in a resident’s condition and avoiding unnecessary antibiotic prescribing. The focus on structured communication in these tools may divert from a more holistic assessment which recognises dehydration as a driver of deterioration and the need to support a resident to drink.

Delivering education that works

Non-clinical staff deliver most of the resident care and may not have the underpinning clinical knowledge to help them make sense of the complex concepts involved in the identification and prevention of UTI. Residential homes have less access than nursing homes to registered nurses who understand pathophysiology and fundamentals of nursing care and across the care home sector there are significant difficulties in recruiting and retaining nurses to work in care home settings because of recent changes in UK policy and the impact of COVID-19.³

Education needs to resonate with the experience of care staff if it is to change thinking and embed learning¹³¹ and care home leaders need to create the time and opportunity for education to occur and fosters a culture where staff are supported to share their knowledge and observations.⁶¹ Although the use of virtual approaches to education provides flexibility and extends the reach across the workforce, it is not always preferred by care staff and does not easily support discussion and reflection.⁶¹ Interactive approaches to education that draw on real cases enable care staff to articulate their thoughts and experience and encourage them to reflect on the resident’s needs are key to the learning process and critical to building a solid understanding to underpin effective and appropriate decision-making.^5,70 However, interactive education is resource intensive and needs to be sustainable, especially in the context of a high staff turnover.^61,124,125 Our synthesis identified that reflective conversations, huddles and ‘stop and think’ strategies allow time for staff to discuss and pay attention to how a resident’s condition is developing. This also provides brief, but protected time, for education messages to be reinforced.^6,61,117,70

Even where care homes employ registered nurses, ensuring education is appropriate, evidence-based and supports the ‘unlearning’ of existing beliefs requires input from specialists and expert facilitation.^5,124 Routine care may be informed by misconceptions and myths, with staff placing emphasis on practices that have little evidence of efficacy or relevance (e.g. cranberry juice), or a lack of knowledge about what strategies are effective in preventing UTI. Stopping ineffective or harmful practices which are embedded as a routine will not happen without a de-implementation strategy that focuses on system changes rather than education alone. Interventional studies aimed at improving diagnostic stewardship in care homes illustrate how difficult it can be for care staff to change their intuitive understanding of UTI and differentiate between UTI and other diagnoses. De-implementation strategies also need to consider the relationship between the care staff, resident and their relatives to ensure that it is managed in a clear and supportive way.⁹¹

Facilitating improvement in practice in care homes

Alignment and fit of improvement strategies with care home systems and routines of care is key to making best practice happen.^124,131 Co-design of interventions, education and monitoring processes is important to achieve this so that those with knowledge of the setting and those with relevant clinical expertise can inform the creation of resources that work in the context of the knowledge and skills of staff, and residents who have limited ability to communicate their symptoms. The facilitation available to long-term care settings is also a crucial component of getting buy-in from staff to make improvements sustainable and this is not always available within care homes outside the research programme. External and internal facilitation are required, and Mody et al.¹²⁴ demonstrated that this can work but requires considerable resource and access to a range of different specialist expertise to support local facilitators. Working in a network that provides peer support enables learning across the system.¹²⁵

Our research suggests that the access to specialist support for care home staff is not uniform and where expertise could be available, this is not always recognised or utilised appropriately. For example, where care staff mentioned specialists such as CAs, this was most likely in relation to accessing incontinence pads, rather than advise on preventing UTI. Our stakeholders identified that different models of support were currently in existence, some of which had grown out of the historical set up of services and others where acute hospital staff supported homes with a specialist frailty service or through community matrons. Understanding the local context in which a care home or group of care homes operates is vital to understanding how support is accessed and how preventative fundamental care can be optimised. In the UK, specialist pharmacists and community matrons are untapped potential sources of expertise and advice that could be used to support the identification and prevention of UTI, for example, by undertaking a clinical review of residents who have been frequently prescribed antibiotics for UTI. Specialist practitioners could play a role in:

• developing systems to collect, analyse and interpret data to support improving the quality of care
• designing and facilitating education programmes
• adapting evidence-based guidance to inform care homes policies and procedures
• advising on the investigation and treatment of residents who have RUTI
• co-creating systems to support decision-making by care staff, for example, catheter removal, recognition of UTI/CAUTI.

‘Champions’ were used in several studies, often as part of a wider intervention programme and as an internal resource and facilitator. There was some evidence that champions could be helpful in facilitating change or improving care.^60,74 However, they need to be endorsed and supported by managers, enabled to develop the right knowledge and skills and have dedicated time and sufficient authority to enable them to deliver the role.^60,74,131

Involving the resident and family carers

This review has highlighted the important role that family members can play in the prevention and early detection of UTI in residents. Although relatives often feel powerless, they can also overrule staff decisions about the need to contact a GP.⁸⁹ Stakeholders in this research described the value of the knowledge that families have about the resident, how they can recognise subtle signs or changes in behaviour which are unusual for their relative and can alert staff to intervene early with strategies that may avert a UTI. Care staff described the importance of involving family members in decisions about care, including the rational for active monitoring as opposed to prescribing and in preventative strategies such as promoting hydration. However, care staff also reported that dealing with relatives’ demands for action to be taken could be challenging. Training for staff on how to handle discussions with relatives was proposed by participants in the study by Potter.⁸⁹ Furthermore, Powell et al.⁹⁰ suggest that legitimising family involvement is a possible solution to supporting those who do wish to contribute.

Leadership in care homes

The importance of leadership by care home managers in the implementation of interventions in care homes was apparent in the evidence included in this review. This is not surprising given their crucial role in instigating changes to how care is delivered in care homes. Researchers have noted a difference between managers who see their participation in an intervention study as something requiring their co-operation and those who are actively and visibly engaged in delivering and sustaining changes to practice.^60,74

Amidst the many other competing priorities and demands placed on care homes, emphasis on UTI prevention can be lost. The prominence given to UTI prevention and recognition as a safety priority and regulatory imperative will impact on the attention it receives by care home managers and the value and resource directed towards it by their staff.¹³¹

Taking a system-level approach

Care homes in England are predominantly privately owned, with some not-for-profit providers. They range from stand-alone small homes to large care home groups. Care home residents reflect a mixture of both private and local authority funded places. The limited resource available to fund care, the variability in size of care homes, the low number of registered clinical staff employed in the sector and a lack of information technology infrastructure make it challenging for some care homes to harness the skills and resources required to drive best practice. Regulatory and inspection frameworks aligned to evidence on the prevention and recognition of UTI and person-centred approaches can help to prioritise the focus for improvement and mobilise the resources needed as demonstrated by the AHRQ study in the USA.¹²⁴

The formation of Integrated Care Services (ICS) in England that are now responsible for developing integrated care strategies across health and social care will offer new opportunities to address the challenges of recognising and preventing UTI in care homes. They have a role in creating a better co-ordinated system-wide approach to framing priorities for UTI prevention, distilling programmes with actionable interventions based on easily collected data that align and fit with the priorities of care homes.^124,131 There is also an opportunity to increase the specialist practitioner resource to provide the required access to expertise, which supports the co-design and implementation of improvement initiatives in care homes.

Strengths

The realist approach used in this review enabled us to bring together multiple types of evidence to inform our theory-driven explanation of how interventions to improve the prevention and recognition of UTI might work in care homes for older people. The evidence we drew upon helped us to build explanations based on detailed accounts of processes underlying the implementation of complex interventions. Many of the studies we used would not have been included in a systematic review of evidence but were relevant to our review. Consequently, our programme theory, comprising nine CMOc, offers new insight into the requirements for current and future local or national initiatives aimed at preventing UTI/CAUTI in care homes which can be used by care commissioners, regulators, care providers and care home leaders and staff to put evidence into action.

The high degree of stakeholder engagement throughout the lifetime of the project has enabled us to sense-check our programme theory and take account of multiple perspectives, including those of people living in, working with and visiting care homes in England.

We intended to produce materials to support the prevention and recognition of UTI in care home settings but questioned the value of adding further tools to the existing range of resources we identified. Instead, we conducted a gap analysis to establish where additional resources might be useful, thereby informing where the development of future tools will add value and meet the needs of care homes.

Limitations

The COVID-19 pandemic required us to adapt our approach and work mainly online both in our interactions with stakeholders and as a research team. Care home staff were quite rightly focused on the imperatives of safeguarding residents and securing access to staff was challenging. We also wanted to have greater input from residents and their families, but this was not possible in the circumstances. While it is hard to tell what consequences the move to online workshops had on theory formulation in stage 1, we were satisfied that the level of engagement achieved through virtual meetings with care home staff facilitated contributions that were important in shaping the review. Moreover, the shift to online working made it possible to expand on the workshops planned in stage 1 by holding two additional meetings with healthcare practitioners. We were disappointed that our ability to consult with care home residents and family carers was severely hampered as this would have added valuable insights to inform the review. The move to virtual meetings also had an impact on our intention to bring a wide range of stakeholders together, including representatives of care home residents, at a face-to-face event towards the end of the project with many preferring to meet virtually. We acknowledge that these adaptations may have limited the generation of insights and discussion to inform both the review and our strategies for development and dissemination of outputs. For this reason, we recognise the importance of continuing to engage with stakeholders as part of our ongoing work, reporting this process and any outcomes.

Studies focusing on the prevention of UTI and CAUTI in care home settings were predominantly from the USA and Europe where the regulatory and funding systems for the long-term care of the elderly has some differences, particularly in the USA where national reporting plays a significant role in driving improvements in care. Furthermore, care homes (also known as nursing homes) in the USA provide a range of medical services including post-acute care, rehabilitation, palliative and hospice care, as well as long-term care. Medicare is the federal health insurance programme for people who are 65 years or older, certain younger adults with disabilities and those with end-stage renal disease. It covers short nursing home stays for older adults. Long-term care in nursing homes is covered by either private pay or Medicaid. Medicaid provides health coverage, which includes eligible low-income older adults and those with disabilities. The studies undertaken in the UK and Europe were focused primarily on interventions to reduce antimicrobial resistance through stewardship but had significant learning that was transferable to the prevention and recognition of UTI.

Our synthesis tried to take account of these differences, but we are aware that we will not have reflected all realities. This is particularly true of the limited evidence that we were able to identify in relation to family involvement, which as a research team we felt was a potentially important theory area. Although we conducted a supplementary search, we found insufficient evidence to develop a stand-alone theory but included it as a thread through our final theories.

Similarly, our supplementary search on continence care and UTI found there was a lack of evidence demonstrating that urinary incontinence was a cause of UTI, although UTI could be a contributory factor to urinary incontinence. There was also a paucity of evidence on the effect of using incontinence pads or alternative approaches to toileting on the risk of UTI. Therefore, while programmes aimed at improving the management of urinary incontinence may include proactive management of patients at risk of RUTI,¹²⁸ there is insufficient evidence to include continence care and support with toileting as a potential strategy for preventing UTI. This perhaps reflects the lack of prioritisation of research on problems that are considered inevitable for the frail elderly and may therefore be an important area for further research.

Through the review, we identified several tools and resources that were being used by staff in care homes in addition to those reflected in the literature. It became clear that adding another set of tools was not going to be helpful and that any resource we developed needed to follow the principles of co-design and fit discussed earlier and address some of the challenges faced by care home leaders. The difficulty in bringing stakeholders together to achieve this was insurmountable within the period for this review. However, we will continue this element of the project over the next 12 months with the funding that was made available in the grant.

Participant representation

As a realist synthesis, this study included stakeholders representative of the community of interest, which in this case was people residing in care homes, their families and individuals working in and with care homes. We had originally planned to host our stakeholder discussions at care homes across three geographical locations, but this was not feasible because of the pandemic. We instead ran online workshops and individual interviews that sought to ensure we included in these the views of staff working within the home, across the primary care and secondary care interface. We also sought views from a resident in the home who was supported in taking part and from relatives of residents. We recognise that having to alter our approach meant it was harder for residents and their families to participate in the stakeholder discussions and we may have had greater representation from these groups had we been able to conduct the stakeholder interviews face to face as originally planned.

Reflections on the research team

Our research team was predominantly female and included researchers from different geographies and at different career stages and with a range of experience and expertise in health and social care research and in realist synthesis. This was the first opportunity for JP to lead a major study and she was supported in this role by the co-chief investigator HL with mentoring from JRM, who oversaw the methodological approach to the realist review. Our most junior member of staff was provided with a development opportunity as this was their first role as a research assistant. They were given support and training to develop in their role.

We sought to include several patient and public representatives in this research, all with experience of the care home sector as carers. One of our PPI members was themselves physically disabled and because of this, had significant experience of UTI. We had a PPI co-applicant with considerable experience in health and social care research to chair our PAG and, finally, we purposely sought a male PPI representative as our other representatives were female.

While the benefits for people that participated in the research, either as stakeholders or lay representatives, may not be immediately obvious, this research has highlighted how strategies for the detection and prevention of UTI can be implemented as part of routine care across care homes, which serve a diverse population of older people.

Implications for practice

The review findings point towards actionable recommendations for UTI prevention and recognition in the care of older people living in care homes, which we describe in relation to organisational and system level actions. These centre on the need to align UTI prevention and recognition to the goals of person-centred, fundamental care and prioritise this in routine daily care to improve quality and safety. For example, understanding and targeting personal barriers to drinking more fluids, such as fears about incontinence and getting to the toilet, may assist in addressing poor fluid intake. This in turn can help to reduce falls, confusion and drowsiness, as well as UTI.

Care home providers

Best practice to prevent and recognise UTI in care home residents requires focusing on a set of evidence-informed actions as part of routine daily care with the involvement of the whole care team, including individual residents, their family carers and care home staff.

Preventative actions include:

• supporting each resident’s hydration preferences and needs
• using fluid intake monitoring systems that enable realistic targets and actions to be agreed for residents with poor fluid consumption
• accessing specialists who can support the care of residents with RUTI
• applying infection prevention practice to the care and management of IUCs.

Accurate recognition of UTI requires:

• knowledge of the individual resident and what is normal for them
• understanding of evidence-based signs and symptoms of UTI
• use of structured tools that align with existing care processes and a shared language to convey accurate and relevant information to HCPs.

Care home staff need opportunities to:

• develop knowledge and skills so they can interpret a resident’s signs and symptoms and consider possible explanations for generalised changes in their condition
• reflect on practice and learn from each other about how to recognise a UTI and support preventative actions.

System level

A system-wide approach with regulatory and inspection frameworks aligned to evidence on prevention and recognition of UTI is 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.

There is a need to:

• integrate the prevention of UTI with diagnostic and AMS in the care of older people living in care homes
• harmonise the prevention and recognition of UTI decision and communication tools with those focused on recognising deterioration to facilitate adoption and integration in care homes
• use co-creative approaches to develop and implement resources and improvement initiatives that involve the whole care team, residents and family carers
• build a knowledgeable workforce of care home support workers and registered nurses who can deliver evidence-informed care and communicate their observations in a way that enables care to be reviewed before escalation
• improve access to expert practitioners and services to support the provision of personalised, multidisciplinary assessment and treatment plans for residents with RUTI who have the greatest potential to benefit from effective treatment.

Research recommendations

Well-designed research to improve the prevention and recognition of UTI in older people living in care homes should address the following:

• perspectives and beliefs of residents and family carers relating to the prevention and recognition of UTI and the concept of active monitoring to avoid unnecessary treatment
• the effectiveness of specialist practitioners in supporting initiatives to recognise and prevent UTI, including expertise in facilitating improvement
• the effectiveness of preventative pharmacological and non-pharmacological interventions to manage RUTI in care homes
• the effectiveness of non-traditional education interventions such as huddles or structured reflection to facilitate decision-making in care homes
• in co-creating interventions research should be explicit about the elements of an intervention that can be tailored to individual care homes and those which are important to deliver as intended.