Title: ‘StOP UTI’ - STrategies for Older People living in care homes to prevent Urinary Tract Infection: a realist synthesis of the evidence
Funder: Department of Health and Social Care

Abstract: What are we trying to find out?_x000D_ We are trying to find out how and why different approaches to preventing and recognising urine infections might work for older people in care home settings in a way that takes account of their complex needs and the care environment._x000D_ _x000D_ Why is this important?_x000D_ Urine infections are common in older people living in care homes and are often difficult to recognise because signs and symptoms, such as becoming confused, may look like other conditions such as dementia. This may result in over and under-treatment. Over-treatment with repeated antibiotic use leads to resistance to antibiotics, which means that they may not work in the future. Under-treatment may increase the risk of kidney infection, other problems including need for hospital admission, life-threatening infection, or even death due to sepsis. Guidance and research on preventing urine infections in older people relate mainly to hospitals. We do not know enough about this in long-term care settings in the UK such as nursing and residential homes._x000D_ _x000D_ How will we find out?_x000D_ We will review the evidence using a research approach called realist synthesis, focusing on how and why approaches to spotting and preventing urine infection in older people’s care may work, for whom and in what settings. We will also look at the evidence about how to support change in long-term care settings to make things better. Our initial theories about how these approaches may work will be discussed with a range of people and groups who are directly affected by problems with urine infections in care homes through a workshop and interviews. This will include care home residents, their carers, members of the public, care home providers, care home staff and experts working in the field of older people’s care. We will then look for further evidence to test and refine the theories so that we can describe how, why and in what settings the approaches work._x000D_ _x000D_ How will we involve residents and their carers?_x000D_ Involvement of care home residents, carers and the public is important to this realist synthesis project to ensure we include different viewpoints and that the research focuses upon what is important to care home residents. A carer of someone in residential care is a member of the project team and has contributed to the planning of the research and helped write this application. She will chair the Advisory Group we appoint to advise on the research and how to maximise the impact of our findings. This group, which included 2 lay members will be consulted with throughout the project. There will be PPI involvement in the workshop and some of the interviews will be conducted by our lay co-applicant._x000D_ _x000D_ How will we tell people about the results?_x000D_ Our research will be the start of a process of understanding what does work in the care home setting and identify where further research is needed. A report, summary and articles will provide practical examples and recommendations relevant to care home staff, care home managers, researchers, educators, carers and relatives for use to improve the recognition and prevention of urine infection in older people’s long-term care and to plan further research to investigate them. We will turn our findings into a range of different resources and digital communications with input from experts who support the adoption and spread of innovation, such as the Academic Health Sciences Network, for sharing via care home networks and associations.

Lay abstract: Research question: Preventing urinary tract infection (UTI) among older people with or without urinary catheters living in care homes: what works, for whom, why and in what circumstances?_x000D_ _x000D_ Background: The incidence of urinary tract infection increases with age and is highest among those living in care homes. Several factors predispose older people to UTI e.g. genitourinary tract disorders, asymptomatic bacteriuria, cognitive impairment, urinary catheters. Resistance to antibiotics commonly used to treat UTI is now common and infections caused by resistant bacteria more likely to spread to the bloodstream. One third of admissions to hospital from care homes are due to UTI and rates of emergency admissions to hospitals have increased markedly since 2001. However, guidance about strategies for preventing UTI in care homes is limited and does not account for the varying contexts in which care is delivered, challenges presented by residents with complex health needs, or demands of care delivery by unqualified staff with limited supervision. Systems that support early recognition of UTI by care home staff are critical to driving improvements in UTI prevention to monitor the effectiveness of prevention strategies. Over-diagnosis of UTI is recognised as a problem in this setting and it is not clear how complex diagnostic algorithms are understood and applied. _x000D_ _x000D_ Aims & objectives: This research proposes a realist synthesis of existing evidence to produce evidence-informed programme theories identifying which strategies are effective (or not) in preventing older people in care homes from acquiring UTI. Potential theories will be developed by searching different bodies of evidence/sources and consultation with stakeholders. _x000D_ _x000D_ Method and timeline for delivery:_x000D_ The realist synthesis will draw on evidence from health and social care, primary research relating to UTI prevention in older people in care homes, improvement project reports in grey literature. Purposive searching will also include wider literature that provides opportunities for transferable learning, such as evidence on how patterns of care, organisation culture and leadership in care homes support outcomes of implementation. The synthesis will examine the relationship between interventions/phenomena of interest and the context in which they are applied, thereby providing explanations about the causal mechanisms and what outcomes they produce. The review will be conducted in 4 iterative stages over 18 months to (1) construct a theoretical framework and initial programme theory(s); (2) retrieve, review and synthesise evidence relating to interventions designed to prevent UTI, guided by the programme theory; (3) test and refine the programme theory(s) in consultation with stakeholders to establish practical relevance and potential for implementation and (4) formulate recommendations for preventing and recognising UTI in a care home setting._x000D_ _x000D_ Anticipated impact and dissemination: Our findings will address an important gap in evidence by providing evidence-informed programme theories identifying which strategies are effective in preventing and recognising UTI in older people in care homes. The study will provide unique recommendations that are relevant for care home settings, which can be incorporated into policy, guidance and educational programmes to help guide successful delivery of optimum care and future research. The incidence of UTI, recurrent UTI and CAUTI will be reduced.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;7.3 MANAGEMENT AND DECISION MAKING
Health categories: INFECTION