Improving preventative practice across primary care is essential for long-term patient safety, infection control and the growing problem of antimicrobial resistance. Giovanna Forte, CEO of Forte Medical, explains why.
COVID-19 has placed routine testing into sharp focus; testing of one kind or another takes place across all aspects of healthcare, the most common setting being primary care, the established avenue for all patient concerns around ill-health however early.
Without preventative practice being rigorously implemented, conditions worsen, fail to respond to first-line treatment, can become chronic, cause unplanned hospital admissions and ultimately lead to an overwhelming burden on the NHS or indeed any healthcare provider.
During these tricky C19 months, patients have delayed presenting with routine health problems either for fear of burdening an overstretched system or fear of acquiring the infection through healthcare settings. These concerns have delayed diagnosis and treatment of routine conditions putting patient health at risk and storing up problems for the months and years ahead. In turn, time off work will increase and adversely impact the economy – which let’s face it, needs all the help it can get.
Sir Chris Whitty’s statement “no test is better than a bad test,” chimes just as much with day-to-day diagnostic practice as it does to C-19 testing. Most importantly, it applies to the most common routine diagnostic process of all – urine analysis – one in four of which are estimated to be unreliable (that’s around 14.6m a year). Urine is also essential for diligent pregnancy screening, which looks not only for urinary tract infection (UTI) but protein, glucose and other clues to potential problems for mother and the unborn alike. A pre-operative Orthopaedic patient must be shown to be clear of UTI prior to surgery; if not, the operation is cancelled at a cost of thousands to the Trust.
Blood and urine have diagnostic parity. We all know that there is a strict protocol for blood collection; non-touch, non-spill with strict timing for delivery to the lab. That there is no parallel system for urine is a mystery, given so many more samples are taken in different settings. The investment in blood collection intervention must more than pay its way; a similar argument is solid for urine collection, yet no protocol or established system exists and the problem remains overlooked or dismissed.
Urine is collected in myriad ways up and down the country – sometimes with a patient using a water-dispenser cup, sometimes a pulp bowl or other vessel from which the sample must be decanted at least once before it reaches the lab; here, it will be poured into a lab-friendly tube that fits the urinalysis machine. Imagine that process being accepted for blood analysis? You can’t. The upshot is a 1% to 70% contamination rate of urine samples across the UK, a variation that would give rise to an outcry for blood-related diagnoses.
The AMR issue
Broad-spectrum antibiotics are readily dispensed as the first line of attack on UTI despite guidelines around AMR stating that problem bacteria must be identified before prescribing a targeted medicine. Guidelines for UTI testing and AMR remain conflicted, an anomaly that must be ratified if AMR is to be seriously tackled; 60% of the global rise of AMR has a urinary source and I present the possibility that this striking figure could be reduced were diligence implemented around sample collection with stricter controls around prescribing. My own experience of a GP prescribing without adherence to guidelines resulted in a visit to A&E with borderline sepsis. If this happened to me how many times has it happened all over the UK at huge cost to the NHS and patient wellbeing.
I have attended a number of AMR conferences where the focus of debate lies in funding, research and development of new treatments and where the word prevention has not even been mentioned. First-line preventative practice would not only reduce the rise of AMR but give the Phama businesses a longer runway to discover, trial and commercialise the necessary medicines. The problem is that the pharma industry holds huge sway over policy makers where the voices of smaller innovation businesses like mine, struggle to be heard.
Intervention and innovation
In the case of urine, our own innovation Peezy Midstream was trialled by Public Health Wales; it delivered reduced dipped false-positives, fewer retests and lower antibiotic prescribing together with a 66% reduction in lab spend. Those involved in the trial claim it allowed them to deliver improved, smoother patient care and greater infection control. As awareness to bacterial cross infection grows, the elimination of urine spills, splashes and wet collection tubes holds greater sway than ever before.
Importantly, those involved in the trial introduced changes to the patient pathway, introducing a valuable and effective triage system. Change is often – and sometimes understandably – resisted within the NHS because it can be temporarily disruptive. But in this case, and doubtless in others, a little effort to implement simple improvements to the diagnostic process went a long way to improve patient safety, reduce long-term conditions reduce repeat patient visits and create much needed savings for our NHS.
The necessary amplification of proven SME innovation applies to other unrecognized, proven, low-cost and preventative interventions such as early stage foot neuropathy testing for diabetes patients (neuropad.co.uk) and even an online platform to spread best practice between healthcare professionals (improvewell.com), both of which could be hugely valuable right now. Dig a little deeper and many more wonderful life-and-cost-saving innovations will rise to the surface.
The need for prevention to achieve healthcare system efficiency is clear and to achieve this an open mind to modernized practice and diagnostic methods is needed together with a more eager response to proven MedTech innovation. The key to encouragement and implementation of such change relies on policymakers, procurement and innovation leaders, all of whom must be persuaded to open their eyes and ears – and act.
Preventative practice can potentially save our healthcare providers an otherwise inevitable tsunami of more serious and costly conditions. Prevent and treat early, or our healthcare providers will struggle to cope.
URINE TROUBLE: SOME STATS
50% global rise of AMR has a urinary source
47% Gram negative blood infections that can lead to sepsis have a urinary source
250k annual unplanned elderly patient admissions are due to untreated UTI
£434m the cost to the NHS of treating elderly unplanned hospital admissions in 2013-14