To determine what information is most important to registered nurses' (RNs) decisions to call clinicians about suspected urinary tract infections (UTIs) in nursing home residents.
Web-based discrete choice experiment with 19 clinical scenarios.
Setting and Participants
Online survey with a convenience sample of RNs (N = 881) recruited from a health care research panel.
Clinical scenarios used information from 10 categories of resident characteristics: UTI risk, resident type, functional status, mental status, lower urinary tract status, body temperature, physical examination, urinalysis, antibiotic request, and goals of care. Participants were randomized into 2 deliberation conditions (self-paced, n = 437 and forced deliberation, n = 444). The degree to which evidence- and non–evidence-based information was important to decision-making was estimated using unconditional multinomial logistic regression.
For all nurses (22.8%) and the self-paced group (24.1%), lower urinary tract status had the highest importance scores for the decision to call a clinician about a suspected UTI. For the forced-deliberation group, body temperature was most important (23.7%), and lower urinary tract status was less important (21%, P = .001). The information associated with the highest odds of an RN calling about a suspected UTI was painful or difficult urination [odds ratio (OR) 4.85, 95% confidence interval (CI) 4.16–5.65], obvious blood in urine (OR 4.66, 95% CI 3.99–5.44), and temperature at 101.5° (OR 3.80, 95% CI 3.28–4.42). For the self-paced group, painful or difficult urination (OR 5.65, 95% CI 4.53–7.04) had the highest odds, whereas obvious blood in urine (OR 4.39, 95% CI 3.53–5.47) had highest odds for the forced-deliberation group.
Conclusions and Implications
This study highlighted the importance of specific resident characteristics in nurse decision-making about suspected UTIs. Future antimicrobial stewardship efforts should aim to not only improve the previously studied overprescribing practices of clinicians, but to improve nurses' assessment of signs and symptoms of potential infections and how they weigh resident information.
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- Antimicrobial use in long-term-care facilities. SHEA Long-Term-Care Committee.Infect Control Hosp Epidemiol. 2000; 21: 537-545
- Antibiotic prescribing in Dutch Nursing homes: How appropriate is it?.J Am Med Dir Assoc. 2015; 16: 229-237
- The development of a decision tool for the empiric treatment of suspected urinary tract infection in frail older adults: A Delphi Consensus Procedure.J Am Med Dir Assoc. 2018; 19: 757-764
- Systematic review of interventions to reduce urinary tract infection in nursing home residents.J Hosp Med. 2017; 12: 356-368
- Implementing antimicrobial stewardship in long-term care settings: An integrative review using a human factors approach.Clin Infect Dis. 2017; 65: 1943-1951
- Nurses' actions in response to nursing assistants' observations of signs and symptoms of infections among nursing home residents.Nursing Open. 2015; 2: 97-104
- Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people? A qualitative study of physicians' and nurses' perceptions.CMAJ. 2000; 163: 273-277
- An online course improves nurses' awareness of their role as antimicrobial stewards in nursing homes.Am J Infect Control. 2017; 45: 466-470
- Antimicrobial stewardship in long-term care facilities.Infect Dis Clin North Am. 2014; 28: 237-246
- Antibiotic prescribing in long-term care facilities: A qualitative, multidisciplinary investigation.BMJ Open. 2014; 4: e006442
- Managing urinary tract infections in nursing homes: A qualitative assessment.Pharm World Sci. 2005; 27: 159-165
- The effect of clinical experience, judgment task difficulty and time pressure on nurses' confidence calibration in a high fidelity clinical simulation.BMC Med Inform Decis Mak. 2012; 12: 113
- Nurses as antibiotic brokers: Institutionalized praxis in the hospital.Qual Health Res. 2017; 27: 1924-1935
- Effect of time pressure on the burnout of home-visiting nurses: The moderating role of relational coordination with nursing managers.Jpn J Nurs Sci. 2019; 16: 221-231
- Interactive effects of nurse-experienced time pressure and burnout on patient safety: A cross-sectional survey.Int J Nurs Stud. 2010; 47: 1442-1450
- The effects of time pressure and experience on nurses' risk assessment decisions: A signal detection analysis.Nurs Res. 2008; 57: 302-311
- Nurses' decisions, irreducible uncertainty and maximizing nurses' contribution to patient safety.Healthc Q. 2009; 12: e178-e185
- Do nurses reason ‘adaptively’ in time limited situations: The findings of a descriptive regression analysis.BMC Med Inform Decis Mak. 2014; 14: 96
- Antibiotic use in long-term care facilities.J Antimicrob Chemother. 2011; 66: 2856-2863
- Measuring antibiotic appropriateness for urinary tract infections in nursing home residents.Infect Control Hosp Epidemiol. 2017; 38: 998-1001
- Diagnostic value of symptoms and signs for identifying urinary tract infection in older adult outpatients: Systematic review and meta-analysis.J Infect. 2018; 77: 379-390
- Prospective evaluation of the management of urinary tract infections in 134 French nursing homes.Med Mal Infect. 2018; 48: 359-364
- Antibiotic prescribing practice in residential aged care facilities--health care providers' perspectives.Med J Aust. 2014; 201: 98-102
- Infection management and multidrug-resistant organisms in nursing home residents with advanced dementia.JAMA Intern Med. 2014; 174: 1660-1667
- Infections and antibiotic prescribing in Swedish nursing homes: A cross-sectional study.Scand J Infect Dis. 2008; 40: 393-398
- Reducing inappropriate antibiotics for urinary tract infections in long-term care: A replication study.J Nurs Care Qual. 2019; 34: 16-21
- Results of a Veterans Affairs employee education program on antimicrobial stewardship for older adults.Am J Infect Control. 2016; 44: 349-351
- Reducing the treatment of asymptomatic bacteriuria in seniors in a long-term care facility.Can Nurse. 2014; 110: 25-30
- A comparison of five elicitation techniques for elicitation of attributes of low involvement products.J Econ Psychology. 1999; 20: 315-341
- Labeled versus unlabeled discrete choice experiments in health economics: An application to colorectal cancer screening.Value Health. 2010; 13: 315-323
- Nursing home clinicians' decision to prescribe antibiotics for a suspected urinary tract infection: Findings from a discrete choice experiment.J Am Med Dir Assoc. 2020; 21: 675-682.e1
- Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America.Clin Infect Dis. 2009; 48: 149-171
- Surveillance definitions of infections in long-term care facilities: Revisiting the McGeer Criteria.Infect Control Hosp Epidemiol. 2012; 33: 965-977
- Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: Cluster randomised controlled trial.BMJ. 2005; 331: 669
- The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) consensus guidelines for the diagnosis of uncomplicated cystitis in nursing home residents.J Am Med Dir Assoc. 2018; 19: 765-769.e3
- Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: Results of a consensus conference.Infect Control Hosp Epidemiol. 2001; 22: 120-124
- Urine culture testing in community nursing homes: Gateway to antibiotic overprescribing.Infect Control Hosp Epidemiol. 2017; 38: 524-531
- Infection rate and colonization with antibiotic-resistant organisms in skilled nursing facility residents with indwelling devices.Eur J Clin Microbiol Infect Dis. 2012; 31: 1797-1804
- Urinary tract infection and asymptomatic bacteriuria in older adults.Infect Dis Clin North Am. 2017; 31: 673-688
- Association of clinician denial of patient requests with patient satisfaction.JAMA Intern Med. 2018; 178: 85-91
- Direct observation of requests for clinical services in office practice: What do patients want and do they get it?.Arch Intern Med. 2003; 163: 1673-1681
- Combined assessment of clinical and patient factors on doctors' decisions to prescribe antibiotics.BMC Fam Pract. 2016; 17: 63
- Perceived barriers to implementing individual choosing wisely(®) recommendations in two national surveys of primary care providers.J Gen Intern Med. 2017; 32: 210-217
- Understanding the culture of prescribing: Qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats.BMJ. 1998; 317: 637-642
- Urinary tract infections in older women: A clinical review.JAMA. 2014; 311: 844-854
- Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections.J Am Geriatr Soc. 2013; 61: 62-66
- Factors associated with time to identify physical problems of nursing home residents with dementia.Am J Alzheimers Dis Other Demen. 2010; 25: 317-323
- Risk factors for resistance to antimicrobial agents among nursing home residents.Am J Epidemiol. 2003; 157: 40-47
- Thinking, fast and slow.1st ed. Farrar, Straus and Giroux, New York2011
- Prospect theory - analysis of decision under risk.Econometrica. 1979; 47: 263-291
- A very brief measure of the Big-Five personality domains.J Res Pers. 2003; 37: 504-528
- Measuring personality in one minute or less: A 10-item short version of the Big Five Inventory in English and German.J Res Pers. 2007; 41: 203-212
- Normal personality assessment in clinical practice: The NEO Personality Inventory.Psychol Assess. 1992; 4: 5-13
- The role of the scale parameter in the estimation and comparison of multinomial logit models.J Market Res. 1993; 30: 305-314
- Nurse-perceived time pressure and patient-perceived care quality.J Nurs Manage. 2010; 18: 275-284
- Deliberation before determination: The definition and evaluation of good decision making.Health Expect. 2010; 13: 139-147
- Trust in deliberation: The consequences of deliberative decision strategies for medical decisions.Health Psychol. 2015; 34: 1090-1099
- Urinary tract infections: Does the smell really tell?.J Gerontol Nurs. 2004; 30: 4-9
- The 2017 National Nursing Workforce Survey.J Nur Reg. 2018; 9: S1-S88
- Combating antibiotic resistance: The role of nursing in antibiotic stewardship.Am J Infect Control. 2016; 44: 1454-1457
- Developing mobile clinical decision support for nursing home staff assessment of urinary tract infection using goal-directed design.Appl Clin Inform. 2017; 8: 632-650
Published online: August 21, 2020
The authors declare no conflicts of interest.
This work was supported by the Agency for Healthcare Research and Quality (grant 11921828, 1R01HS024519-01). The sponsor had no role in the design, methods, subject recruitment, data collections, analysis and preparation of paper.
© 2020 Published by Elsevier Inc. on behalf of AMDA - The Society for Post-Acute and Long-Term Care Medicine.