Problem

Reducing Unnecessary Use of Antibiotics in Nursing Homes with a Complex Multi-Level Intervention: A Study Protocol

Inappropriate antibiotic use, an extraordinarily common and high-variation problem in nursing homes (NH), increases the resident’s risk of adverse drug events, Clostridium difficile infection and acquisition of antibiotic-resistant bacteria.

Our group has developed a novel antibiotic stewardship intervention that targets three loci of control:

a) Change-in-condition: pre-prescribing communication and decision-making about resident changes in condition

b) Antibiotic Timeout: post-prescribing de-escalation of antibiotic therapy focused on stopping unnecessary antibiotics, narrowing from broad to narrow spectrum antibiotics and shortening excessively long treatment courses

c) Quality Improvement Support: regular feedback of various process and outcome measures.

E Ramly2, J Ford2, DA Nace3, M Bahrinian1, C Crnich1

1) University of Wisconsin-Madison (UW) School of Medicine and Public Health, 2) UW Department of Industrial and Systems Engineering, 3) University of Pittsburgh Medical Center

Funding for this project was provided by a grant from the Agency for Healthcare Research and Quality (R18HS022465)

Work System Factors

Intervention: Optimizing Antibiotic Stewardship In Skilled Nursing Facilities (OASIS)

• This intervention will be evaluated in a prospective study in 12 facilities (6 intervention, 6 control).

• We will use human factors analyses to identify barriers and facilitators to implementation of the antibiotic stewardship intervention.

• Components of the intervention will be tailored to overcome these barriers and an implementation package will be developed with structured input from key informants in study NHs.

Study

The impact of and mechanisms by which antibiotic stewardship interventions work in NHs remains poorly studied. There is a need for NH antibiotic stewardship studies that not only identify strategies that work but to also the mechanisms by which they mediate behavioral change in this context.

ComponentsChange in Condition Form

Antibiotic Timeout Form

Quality Improvement Audit & Feedback

0

5

10

15

20

25

30

0 1 2 3 4 5 6 7 8 9 10 >15

%ofFacilities

Antimicrobialcoursesper1,000rdays

AntibioticStartsin73U.S.NHs

0

0.2

0.4

0.6

0.8

1 2 3 4 5ExplicitCrite

riaM

et(%

)

Facility

“Appropriateness”ofAntibioticUseinFiveWisconsinNursingHomes

MetEitherCriteria McGeer Loeb

k =

k =0.41k =0.18

k =0.19

k =0.24

< 60%

• Signs&Symptoms• Communicationcapacity• Clinicalstability

ChangeinCondition(CIC) AntibioticDecision

• Comorbidity/Frailty• Outcomeswithpriorepisodes• Advanceddirectives

Pre-CICHealthStatus• BeliefsaboutcausesofCIC• Knowledge,attitudesandbeliefstowardsantibiotics

FamilyCharacteristics

• Staffmodel&retention• Education&training• Structureandavailabilityofhealthinformation

• Availability&timelinessofdiagnostictestresults

• Qualityofleadership• Monitoring&improvementstructure&process

• Familyeducation/outreach

FacilityStructure&Process

• Training/experience/skills• Familiaritywithresident• Knowledge,attitudes,&beliefstowardsantibiotics

• Perceptionsaboutresident/familyexpectations

NHStaffCharacteristics• Clinicstaffskills/experience• Otherclinicalworkload• CapacitytoaccessNHdataremotely

• Cross-coveragestructure&process

PracticeStructure&Process

• Training/experience/skills• Familiaritywithresident• Knowledge,attitudes,&beliefstowardsantibiotics

• Riskaversion• Perceptionsaboutresident/familyexpectations

PrescriberCharacteristics

Trust&Communication

Resident&FamilyFactors

NursingHomeFactors PrescriberFactors

DoITreat? HowDoITreat? CanIRefine?

WhatAntibiotic? HowLong?

•StandardizeassessmentandcommunicationofCIC

•Differentiatelow- fromhigh-riskCIC

•Promoteactivemonitoringinlow-riskCIC

Pre-PrescribingComponent

•Discontinueunnecessaryantibiotics

•Promoteuseofnon-fluoroquinoloneagents

•Promoteshorterdurationsoftherapy

Post-PrescribingComponent

• Promoteconsistentuseofpre-prescribingtoolsandtasks• Promoteconsistentuseofpost-prescribingtoolsandtasks

Meso-LevelAudit&FeedbackComponent

• Track&trendkeyinterventionprocessandoutcomemeasures• Tailorinterventiontasksandtools

Macro-LevelAudit&FeedbackComponent•Pre-

interventionfacilityworkflowanalyses

•Kickoffmeetings

•Educationalmaterials

•Collaborativemeetings

•Coaching&mentorship

Facilitated

Implem

entatio

n

AntibioticDecision-MakingProcess

(a) (b)

(c)

•Pre-interventionfacilityworkflowanalyses

•Kickoffmeetings

•Educationalmaterials

•Collaborativemeetings•Coaching&mentorship

Facilitated

Implem

entatio

n

Wisc

onsin

Penn

sylvan

iaWisc

onsin

Penn

sylvan

ia

Interventionhomes

Controlhomes BASELINEWORK

STATEASSESSM

ENT

OUTCOMESI.ClinicalA.(1’)DOTsper1,000rdays

B.(1’)%ofASmeetingLoeb

C.(2’)ASper1,000rdaysD.(2’)FQDper1,000rdaysE.(2’)LabID CDIper1,000rdays

II.SafetyA.Unplannedhospitaladmitsper1,000rdays

B.Deathsper1,000rdaysIII.ExploratoryA.%ofFQRurinaryisolates

B.%ofenterococcalurinaryisolates

C.%ofCandidaurinaryisolates

DOT=daysofantibiotictherapyAS=antibioticstartsFQD=fluoroquinolonedaysoftherapyLabID CDI=laboratoryconfirmedClostridiumdifficileinfectionFQR=fluoroquinolone-resistantbacteria

I.AssessmentofinterventionfidelityA.Quantitative

•Tooluse•Collaborativeparticipation

A.Qualitative•Walkthroughs• Interviews

II.Assessmentofinterventionsustainability

FOLLOW-UPWORK

SYSTEM

ASSESSM

ENT

Implementation(3m) Sustainment(9m)Pre-Intervention(10m)

Clinical Stand-Up MeetingsMeso-Level, Daily

• Tools & tasks integrated into existing inter-disciplinary rounding structure

• RN Lead, NCM or DON owns process

• Checklist format• Tool used? • Tasks completed?• Near-time feedback to

frontline staff• Process measures fed up

to QAPI committee

QualityAssuranceandPerformanceImprovementMacro-Level, Monthly

• Processmeasurestrackedandtrended

• Outcomemeasurestrackedandtrended

• Opportunitiesforimprovingexistingprocessidentifiedandimplemented

Contact:ramly@wisc.edu