P09 Feasibility of retrospective chart review to assess alignment of urinary tract infection diagnosis, testing and treatment decisions with UKHSA diagnostic guidance in patients 65 years+ in the emergency department
Authors: Slatter Mandy , Hay Alastair , Jones Matthew 
Published: August 2023

Abstract

Background
UKHSA urinary tract infection (UTI) diagnostic guidance uses presence/absence of specific symptoms/signs to guide decisions on urine culture and antibiotic treatment.1 The goal is treatment of those with highest risk of infection, avoiding serious illness, whilst limiting antibiotic overuse. UK improvement initiatives2,3 encourage hospitals to align with UKHSA guidance. UTI is a common infection in the emergency department (ED) and diagnosis can be challenging in the elderly.4,5

Objectives
To explore retrospective chart review to quantify UTI treatment alignment with UKHSA UTI guidance.1 Identify ED patients aged 65 years+ (65+) with primary diagnosis of UTI. Limit to non-admitted for manageable sample. Complete retrospective chart review to elicit documented UTI symptoms/signs and associated: (i) urine dipstick testing; (ii) urine sampling for microscopy, culture and susceptibility (MC&S); and (iii) antibiotic treatment. Assess alignment with relevant UKHSA guidance. Estimate time taken.

Methods
Electronic patient record search for key terms (Table 1) identified 6076 ED attendances 65+ between 1 August and 31 October 2021. Forty patients met inclusion criteria. Paramedic/ED notes were reviewed, and information gathered regarding presence/absence of: UTI symptoms/signs as per UKHSA guidelines;1 urine dipstick test; urine for MC&S; and UTI antibiotic treatment. Findings were mapped to illustrate if UKHSA diagnostic pathway and intended antibiotic prescribing decisions followed. Table 1.Key termsSearch termsSearch fieldsUrin, UTI, pyelonephritis, cystitis, urosepsis, CAUTI, AKI, Acute Kidney Injury, Flank painReason for visit, Chief Complaint, Presenting Complaint, ECDS

Results
Twenty-seven of 40 patients matched UKHSA criteria for lower UTI/pyelonephritis. Three of 27 followed recommended pathway of: no dipstick; urine for MC&S; and antibiotic. Twenty of 27 had urine dipstick test (not recommended); 16/27 had urine sample for MC&S (recommended); 26/27 received an antibiotic (recommended). Twenty-three who received antibiotics had dipstick testing, no urine for MC&S or both. One patient did not receive indicated antibiotic treatment. Documented symptoms/signs did not indicate UTI/pyelonephritis in 13/40 patients. Two of 13 followed the recommended pathway of: no dipstick; no urine for MC&S; and no antibiotic. Seven of 13 received a dipstick test; 6/13 had urine for MC&S; 9/13 received antibiotics which were not indicated. Five of 40 followed the recommended pathway; 30/40 received the recommended treatment. The time cost was around 30 min/patient.

Conclusions
UKHSA guideline alignment was low. Testing in asymptomatic patients appeared to result in unnecessary antibiotic use. Retrospective chart review generated detailed data to assess alignment, however results may represent poor documentation not poor alignment. Retrospective chart review time cost too high for large numbers and assumes accurate documentation.