MIU Urinary tract infections in females- management of. Clinical Director of Pharmacy

Transcription

1 Title: Ref No: 1972 Version: 3 Document Author: Ratified by: Matron - Minor Injury Units Care and Clinical Group Clinical Director of Pharmacy Date 17 October 2017 Date: 17 October December 2017 Review date: 12 January Purpose of this document This clinical protocol provides a clear framework for nurse/paramedic practitioners employed by Torbay & South Devon NHS Foundation Trust when providing care to female patients over 12 years of age presenting at Minor injury Units with a Urinary Tract Infection. 2. Scope of the Policy: This protocol is for the use by Minor Injury Unit (MIU) and Emergency Department (ED) practitioners employed by Torbay and South Devon NHS Foundation Trust who has achieved the agreed Trust clinical competencies to work under this protocol Exclusions: include all females under the age of 12 years, all female patients who are pregnant, men and boys of all ages. 3. Assessment 3.1. Presenting signs and symptoms; may include some of the following; Urinary frequency, fever, haematuria, urgency, painful micturition, burning/stinging sensation, cystitis, suprapubic pain, cloudy or offensive urine, back pain, incontinence, 3.2 History: refer to protocol for History taking and Clinical Documentation Specific History; Dysuria/frequency Duration Obvious haematuria Abdominal or back pain associated with urinary symptoms Nausea or vomiting Vaginal discharge Previous history of urinary Tract Infections and treatment received Previous history of renal stones or pyelonephritis Page 1 of 6

2 Other associated symptoms. Is the patient immunocompromised? Past medical history. e.g. diabetes. Recent surgery in perineal area or recent catherisation. Possibility of pregnancy. 4. Clinical Examination: refer also to protocol for the management of abdominal pain Look/observe patient for: Pallor Sweating/flushed Lethargy/malaise Pain/discomfort Pyrexia Dehydration Acute onset of confusion (elderly patients) 4.2. Feel (palpate) as per abdominal protocol. Kidney/loin region for tenderness Abdomen Note any bladder distension 4.3. Investigations Urinalysis: used to help with diagnosis of UTI, but it should be remembered that urine culture alone provides the definitive diagnosis. Most urinary pathogens reduce nitrate to nitrite, thus a positive nitrite test is suggestive of bacturia but, a negative test does not rule out infection as not all pathogens produce nitrate reductase and frequent urination gives insufficient time for the enzyme to react. Leucocyte esterase is a marker for leucocytes and a positive test indicates pyuria, which suggests UTI. It can also indicate contamination of the specimen, so a positive test does not necessarily mean UTI. A negative Leucocyte esterase test does not rule out UTI as pyuria is not always present in UTI. Blood and protein may be found in infected urine, but neither absence nor presence help with diagnosis. Evidence from the literature suggests If either nitrite or leucocyte esterase (LE) dipstick tests are positive diagnose UTI If both nitrite and leucocyte esterase (LE) dipstick tests are negative exclude UTI Pregnancy Test: If there is a possibility that a patient may be pregnant, do a pregnancy test before continuing examination. If positive refer to the doctor Blood glucose: Check patient Blood glucose if evidence of glucose on urinalysis testing or history of frequency with no other indicators of urinary tract infection to exclude diabetes. If raised Blood glucose refer to duty doctor or GP Clinical observations to include Temperature Page 2 of 6

3 5. Treatment 5.1 Possible Urinary Tract Infection in an otherwise healthy patient: Clinical Indications: Urinalysis shows either nitrites or leucocyte esterase with associated urinary symptoms. Treatment For children under 16 years and recently treated adults with recurrent Urinary tract infections. Send midstream urine sample for micro-culture & sensitivity before commencing antibiotic treatment Treat with Trimethoprim as per Patient Group Direction Advise the patient to increase their oral fluid intake Provide or advise the patient to take Paracetamol for pain relief or as per Patient Group Direction in accordance to patients pain level and to reduce their temperature Advise patient to seek further advice from their GP if they are no better in 3 days, or if their symptoms worsen 5.2 Acute Non- bacterial cystitis Clinical findings: patient has acute urinary symptoms but dipstick urinalysis is negative. Treatment; Give Paracetamol as per Patient Group Direction or advise over the counter analgesia. Advise the patient to increase oral fluid intake. Some people may find over the counter alkalising agents helpful in symptom control, although there is no evidence of their efficacy. Advise patients that most episodes of acute cystitis get better after 2-3 days, but if they are no better, or if their symptoms get worse, they should seek further medical advice. 5.3 Possible pyelonephritis Clinical findings; patient has acute urinary symptoms, has pyrexia and has associated flank pain and tenderness Treatment Send a urine sample for micro-culture & sensitivity. If patient is systematically unwell refer to Emergency department or GP (same day) review. Treat with Co-amoxiclav as per Patient Group Direction. Advise patient to take over the counter paracetamol for pain relief and fever reduction or give paracetomol as per Patient Group Direction. Advise the patient to increase their oral fluid intake. If no improvement in 24 hours, or if symptoms worsen, they should seek further medical advice. Advise patient to see their GP 5 days after commencement of treatment For children under 16 years discuss with paediatric team on call. Page 3 of 6

4 5.4 Urinary retention Clinical Indications: patient unable to pass urine for 6 hours or more and has a tender abdomen. Treatment: If recurrent problem and history of catherisation discuss with patients GP New history of retention refer to Emergency Department. 5.5 Renal or Ureteric retention Clinical indications; patients may have severe intermittent pain in loin or groin, nausea and haematuria. Refer patient to GP (same day) if conditions are mild otherwise refer patient to the Emergency Department administer analgesia as per Patient Group Direction for moderate or severe pain Where pain is acute administer entonox as per patient Group direction and refer patient to the emergency department via ambulance. 5.6 Immunocompromised patient with urinary symptoms Refer patient to GP (same day) if condition is stable otherwise refer patient to the Emergency Department administer analgesia as per Patient Group Direction according to patients pain level. 5.7 Suspected Urinary infection in a pregnant patient. Refer patient to GP (same day) if conditions is mild/moderate otherwise refer patient to the Emergency Department. Consider need for referral to midwife. 5.8 Patients with repeated episodes of urinary symptoms but negative Dipstick urinalysis Refer patient to GP practice (routine) Advise patient on over the counter analgesia such as paracetomol and encourage a good fluid intake. 5.9 Pyelonephritis and upper Urinary Tract infections Clinical Indications: Temperature 38c or above with Bacteraemia. Temperature less than 38c with loin pain/tenderness and bacteraemia. Give analgesia as per patient group directions according to patients pain score Refer patient for emergency GP appointment or acute hospital Emergency department as appropriate. 6. Documentation 6.1. Clinical records must be written in accordance with Torbay and South Devon NHS Foundation Trust History Taking and Clinical Documentation protocol, Nursing & Midwifery Council standards including record keeping or relevant registering body e.g. Health & care professional Council (HCPC) standards including record keeping guidance. Page 4 of 6

5 6.2. A summary letter of the MIU/ED attendance and the care delivered must also be sent to the General practitioner and also the health visitor if less than 5yrs or school nurse if aged between 5yrs and 16yrs to ensure the central medical record of the patient is accurate For patients being transferred to the Emergency department, ensure clinical records are completed in a timely manner on the shared symphony IT system. A summary will be sent to the General practitioner in the normal manner For patients seeing the General practitioner or specialist within the next 24 hours ensure the patient has a copy of the attendance record to take with them. A copy will be sent to the General practitioner in the normal manner. 7. Discharge information 7.1 Ensure those patients who have been referred for further acute intervention has appropriate transport to meet their needs, all relevant treatment has been prescribed and/or administered and correct information & documentation is given to the patient. 7.2 The patient /carer understand that if the condition deteriorates or they have any further concerns to seek medical advice. 7.3 The patient and /or carer demonstrate understanding of advice given during consultation. 7.4 The patient/carer has been provided with written advice leaflet to reinforce advice given during consultation 7.5 The patient/carer demonstrates and understanding of how to manage. 8. Training and implementation: MIU Network meeting Cascade. All staff adhering to protocols must have agreed training and proven competence to work within protocol. Each protocol must be agreed and signed by line manager. 9. Monitoring tool _ Regular review of clinical practice to ensure individuals are adhering to clinical protocol. 10. References Accident & Emergency, theory into practice. Dolan B, Holt L Acute Medical Emergencies, a nursing guide. Harrison R, Daly L British National Formulary 2017 Differential Diagnosis. Rafley, A. Lim, E. 2 nd edition 2005 Guide to physical examination and History Taking. Bickley 2003 Page 5 of 6

6 Nurse Practitioners, clinical skills & professional issues. Walsh M, Crumbie A, Reveley S NICE (CG160) Fever in eh under 5s; assessment and initial management 2017 NICE Lower urinary tract infections May 2010 NICE (CG54)Urinary Tract infections in under 16 s: diagnosis and management 2017 Minor Emergencies Splinters to fractures. Butteovolli P, Stair T 2000 Minor Injuries, A Clinical guide. Purcell D. 2 nd edition 2010 South& west Devon Formulary Amendment History Issue Status Date Reason for Change Authorised 1 Ratified February 2013 Merger of Torbay Care Trust and NHS Devon Protocols for urinary tract infections 2 Ratified August 2015 Reviewed - no clinical changes Documentation amendments to reflect new Matron - Minor Injury Units Matron - Minor Injury Units symphony IT system 3 Ratified 12 January 2018 Revised Care and Clinical Group Clinical Director of Pharmacy 3 12 February 2018 Review date extended from 2 years to 3 years Page 6 of 6

7 The Mental Capacity Act 2005 The Mental Capacity Act provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they lack capacity in the future. It sets out who can take decisions, in which situations, and how they should go about this. It covers a wide range of decision making from health and welfare decisions to finance and property decisions Enshrined in the Mental Capacity Act is the principle that people must be assumed to have capacity unless it is established that they do not. This is an important aspect of law that all health and social care practitioners must implement when proposing to undertake any act in connection with care and treatment that requires consent. In circumstances where there is an element of doubt about a person s ability to make a decision due to an impairment of or disturbance in the functioning of the mind or brain the practitioner must implement the Mental Capacity Act. The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice, which provides guidance and information about how the Act works in practice. The Code of Practice has statutory force which means that health and social care practitioners have a legal duty to have regard to it when working with or caring for adults who may lack capacity to make decisions for themselves. The Act is intended to assist and support people who may lack capacity and to discourage anyone who is involved in caring for someone who lacks capacity from being overly restrictive or controlling. It aims to balance an individual s right to make decisions for themselves with their right to be protected from harm if they lack the capacity to make decisions to protect themselves. (3) All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy, Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment, checklists and Independent Mental Capacity Advocate referral forms on icare Infection Control All staff will have access to Infection Control Policies and comply with the standards within them in the work place. All staff will attend Infection Control Training annually as part of their mandatory training programme. The Mental Capacity Act Page 1 of 1

8 Rapid (E)quality Impact Assessment (EqIA) (for use when writing policies) Policy Title (and number) Policy Author Version and Date An (e)quality impact assessment is a process designed to ensure that policies do not discriminate or disadvantage people whilst advancing equality. Consider the nature and extent of the impact, not the number of people affected. Who may be affected by this document? Patients/ Service Users Staff Other, please state Could the policy treat people from protected groups less favorably than the general population? PLEASE NOTE: Any Yes answers may trigger a full EIA and must be referred to the equality leads below Age Yes No Gender Reassignment Yes No Sexual Orientation Yes No Race Yes No Disability Yes No Religion/Belief (non) Yes No Gender Yes No Pregnancy/Maternity Yes No Marriage/ Civil Partnership Yes No Is it likely that the policy could affect particular Inclusion Health groups less favourably than Yes No the general population? (substance misuse; teenage mums; carers 1 ; travellers 2 ; homeless 3 ; convictions; social isolation 4 ; refugees) Please provide details for each protected group where you have indicated Yes. VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusion Is inclusive language 5 used throughout? Yes No NA Are the services outlined in the policy fully accessible 6? Yes No NA Does the policy encourage individualised and person-centred care? Yes No NA Could there be an adverse impact on an individual s independence or autonomy 7? Yes No NA EXTERNAL FACTORS Is the policy a result of national legislation which cannot be modified in any way? Yes No What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?) Who was consulted when drafting this policy? Patients/ Service Users Trade Unions Protected Groups (including Trust Equality Groups) Staff General Public Other, please state What were the recommendations/suggestions? Does this document require a service redesign or substantial amendments to an existing Yes No process? PLEASE NOTE: Yes may trigger a full EIA, please refer to the equality leads below ACTION PLAN: Please list all actions identified to address any impacts Action Person responsible Completion date AUTHORISATION: By signing below, I confirm that the named person responsible above is aware of the actions assigned to them Name of person completing the form Signature Validated by (line manager) Signature Please contact the Equalities team for guidance: For South Devon & Torbay CCG, please call or marisa.cockfield@nhs.net For Torbay and South Devon NHS Trusts, please call or pfd.sdhct@nhs.net This form should be published with the policy and a signed copy sent to your relevant organisation. Rapid Equality Impact Assessment Page 1 of 1

9 Clinical and Non-Clinical Policies New Data Protection Regulation (NDPR) Torbay and South Devon NHS Foundation Trust (TSDFT) has a commitment to ensure that all policies and procedures developed act in accordance with all relevant data protection regulations and guidance. This policy has been designed with the EU New Data Protection Regulation (NDPR) in mind and therefore provides the reader with assurance of effective information governance practice. NDPR intends to strengthen and unify data protection for all persons; consequently, the rights of individuals have changed. It is assured that these rights have been considered throughout the development of this policy. Furthermore, NDPR requires that the Trust is open and transparent with its personal identifiable processing activities and this has a considerable effect on the way TSDFT holds, uses, and shares personal identifiable data. The most effective way of being open is through data mapping. Data mapping for NDPR was initially undertaken in November 2017 and must be completed on a triannual (every 3 years) basis to maintain compliance. This policy supports the data mapping requirement of the NDPR. For more information: Contact the Data Access and Disclosure Office on dataprotection.tsdft@nhs.net, See TSDFT s Data Protection & Access Policy, Visit our GDPR page on ICON. New Data Protection Regulation Page 1 of 1