Background: Urinary tract infection is the most diagnosed infection in older people. It accounts for more than 50% of antibiotic prescriptions in care homes and is a frequent reason for care home residents being hospitalised.
Objective: This realist review developed and refined programme theories for preventing and recognising urinary tract infection, exploring what works, for whom and in what circumstances.
Design: The review used realist synthesis to explore existing literature on the detection and prevention of urinary tract infection, complemented by stakeholder consultation. It applies to the UK context, although other healthcare systems may identify synergies in our findings.
Data sources: Bibliographic databases searched included MEDLINE, CINAHL, EMBASE, Cochrane Library, Web of Science Core Collection (including the Social Sciences Citation Index), Sociological Abstracts, Bibliomap and National Institute for Health and Care Research Journals Library.
Data selection and extraction: Title and abstract screening were undertaken by two researchers independently of each other. Selection and assessment were based on relevance and rigour and cross-checked by a second researcher. Data extracted from the included studies were explored for explanations about how the interventions were considered to work (or not). Evidence tables were constructed to enable identification of patterns across studies that offered insight about the features of successful interventions.
Data analysis and synthesis: Programme theories were constructed through a four-stage process involving scoping workshops, examination of relevant extant theory, analysis and synthesis of primary research, teacher-learner interviews and a cross-system stakeholder event. A process of abductive and retroductive reasoning was used to construct context-mechanism-outcome configurations to inform programme theory.
Results: The scoping review and stakeholder engagement identified three theory areas that address the prevention and recognition of urinary tract infection and show what is needed to implement best practice. Nine context-mechanism-outcome configurations provided an explanation of how interventions to prevent and recognise urinary tract infection might work in care homes. These were (1) recognition of urinary tract infection is informed by skills in clinical reasoning, (2) decision-support tools enable a whole care team approach to communication, (3) active monitoring is recognised as a legitimate care routine, (4) hydration is recognised as a care priority for all residents, (5) systems are in place to drive action that helps residents to drink more, (6) good infection prevention practice is applied to indwelling urinary catheters, (7) proactive strategies are in place to prevent recurrent urinary tract infection, (8) care home leadership and culture fosters safe fundamental care and (9) developing knowledgeable care teams.
Limitations: We adapted our approach and work to online interactions with stakeholders and as a research team because of COVID-19. This also had an impact on bringing stakeholders together at a face-to-face event at the end of the project. Studies focusing on the prevention of urinary tract infection 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 have some differences, particularly in the USA where national reporting plays a significant role in driving improvements in care.
Conclusions: Care home staff have a vital role in the prevention and recognition of urinary tract infection, which can be enabled through integration and prioritisation within the systems and routines of care homes and delivery of person-centred care. Promoting fundamental care as a means of facilitating a holistic approach to prevention and recognition of urinary tract infection helps staff to recognise how they can contribute to antimicrobial stewardship and recognition of sepsis. Challenging assumptions made by staff about the presentation of urinary tract infection is complex and requires education that facilitates 'unlearning' and questioning of low-value practices. Programmes to prevent urinary tract infection need to be co-designed and supported through active and visible leadership by care home managers with support from specialist practitioners.
Future work: We will focus on co-designing tools that facilitate implementation of our findings to ensure they fit with the care home context and address some of the challenges faced by care home leaders. This will underpin action at care home and system levels. Further research is needed to better understand the perspectives of residents and family carers, the effectiveness of non-pharmacological, pharmacological and specialist practitioner interventions and non-traditional approaches to training and educating the workforce in care home settings.
Study registration: This study is registered as PROSPERO CRD42020201782.
Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR130396) and is published in full in Health Technology Assessment; Vol. 28, No. 68. See the NIHR Funding and Awards website for further award information.
Keywords: ANTIMICROBIAL STEWARDSHIP; CATHETERS; FUNDAMENTAL CARE; HYDRATION; INDWELLING; LEADERSHIP; LONG-TERM CARE; REALIST SYNTHESIS; URINARY TRACT INFECTIONS.
This study was about how interventions to prevent and recognise urinary tract infections might work in care homes to reduce urinary tract infection in older people. We used an approach called realist synthesis. This aims to understand everything that influences how care is delivered to find out what works in particular situations and settings. We did this by talking to care home staff, residents, family carers and other experts about how to reduce urinary tract infection in older people living in care homes. We combined their experiences and ideas with the evidence from the research literature. From this, we developed three areas of focus: care approaches to support accurate recognition of urinary tract infection care approaches to prevent urinary tract infection/catheter-associated urinary tract infection making best practice happen. Our research shows that care staff are best placed to recognise subtle changes in a resident’s behaviour or well-being which might indicate an infection. There are several things care staff can do to proactively help residents from developing a urinary tract infection such as prioritising residents’ hydration needs and addressing poor fluid intake. Putting in place infection prevention measures such as caring for, or where possible, removing a urinary catheter can also help. Actively monitoring residents to determine reasons for changes in behaviour can increase the focus on preventative activities and help avoid inappropriate treatment. The detection and prevention of urinary tract infection in older people could be improved in several ways, including: education tailored to the roles and work of care home staff leaders of care homes providing a culture of safety and improvement where urinary tract infection is recognised as something preventable rather than unavoidable having a safe and supportive environment where staff are confident to communicate their concerns all care team members, residents and their families and other professionals linked with the home having a common language and shared goals in the recognition, prevention and diagnosis of urinary tract infection. 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. While this provided opportunities to extend our reach to a wider group of stakeholders, it also limited some of our engagement work.