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Feasibility of a Nursing Home Antibiotic Stewardship Intervention

  • Rosa R. Baier
    Correspondence
    Address correspondence to Stefan Gravenstein, MD, MPH, Warren Alpert Medical School of Brown University, 110 Lockwood Street, #438 POB, Providence, RI 02903, USA; or Rosa R. Baier, MPH, Brown University School of Public Health, Box G-S121-6, 121 South Main Street, Providence, RI 02912, USA.
    Affiliations
    Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, RI, USA

    Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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  • Robin L.P. Jump
    Affiliations
    Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System, Cleveland, OH, USA

    Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Population & Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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  • Tingting Zhang
    Affiliations
    Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA

    Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA
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  • Sarah Kabbani
    Affiliations
    Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
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  • David R. Gifford
    Affiliations
    American Health Care Association/National Center for Assisted Living, Washington, DC, USA
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  • Stefan Gravenstein
    Correspondence
    Address correspondence to Stefan Gravenstein, MD, MPH, Warren Alpert Medical School of Brown University, 110 Lockwood Street, #438 POB, Providence, RI 02903, USA; or Rosa R. Baier, MPH, Brown University School of Public Health, Box G-S121-6, 121 South Main Street, Providence, RI 02912, USA.
    Affiliations
    Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, RI, USA

    Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA

    Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA

    Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI, USA

    Center of Innovation in Long-Term Services and Supports (LTSS-COIN), Providence Veterans Affairs Medical Center, Providence, RI, USA
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Published:September 07, 2021DOI:https://doi.org/10.1016/j.jamda.2021.08.019

      Abstract

      Objective

      To evaluate a bundled electronic intervention to improve antibiotic prescribing practices in US nursing homes.

      Design

      Prospective mixed-methods quality improvement intervention.

      Setting and Participants

      Nursing staff and residents in 13 nursing homes, and residents in 8 matched-control facilities (n = 21 facilities total, from 2 corporations).

      Methods

      This study involved a 2-month design period (n = 5 facilities) focused on the acceptability and feasibility of a bundled electronic intervention consisting of 3 tools, followed by a 15-month implementation period (n = 8 facilities) during which we used rapid-cycle quality improvement methods to refine and add to the bundle. We used mixed-methods data from providers, intervention tools, and health records to assess feasibility and conduct a difference-in-difference analysis among the 8 intervention sites and 8 pair-matched controls.

      Results

      Nurses at 5 pilot sites reported that initial versions of the electronic tools were acceptable and feasible, but barriers emerged when 8 different facilities began implementing the tools, prompting iterative revisions to the training and bundle. The final bundle consisted of 3 electronic tools and training that standardized digital documentation to document and track a change in resident condition, infections, antibiotic prescribing, and antibiotic follow-up. By the end of the implementation phase, all 8 facilities were using at least 1 of the 3 tools. Early antibiotic discontinuation increased 10.5% among intervention sites, but decreased 10.8% among control sites.

      Conclusions and Implications

      The 3 tools in our bundled electronic intervention capture clinical and prescribing data necessary to assess changes in antibiotic use and were feasible for nurses to adopt. Achieving this required modifying the tools and training before the intervention reached its final form. Comparisons of rates of antibiotic use at intervention and control facilities showed promising improvement in antibiotic discontinuation, demonstrating that the intervention could be evaluated using secondary electronic health record data.

      Keywords

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