One successful model takes an engineering approach to patient safety outcomes focusing on work system improvements.
Long-term care facilities (LTCFs) help to provide both medical and personal care services to millions of Americans each year.1 As the population of adults over age 65 increases, this number is predicted to rise over 21% of the US population by 2040; there will be a corresponding increase in patient enrollment in LTCFs.2
LTCF residents are at an increased risk of developing infections due to many underlying comorbid conditions, frequent use of invasive devices, age-related physiologic changes, and institutional exposure.3-5 These risk factors lead to approximately 1 million to 3 million infections occurring each year1,4 in LTCF residents, consisting mostly of urinary tract infections, respiratory tract infections, skin and soft tissue infections, and gastroenteritis.2 Roughly 63% of all LTCF deaths can be attributable to infections.6 Approximately 79% of all residents of these facilities receive systemic antibiotics each year, with close to 75% of these antibiotics inappropriately prescribed.5 This results in an increased number of adverse drug events (second only to antipsychotics), including the development of antibiotic-resistant organisms and Clostridium difficile (C. diff) infection.2,3 It is also well documented that LTCF residents have a high rate of colonization and infection with antibiotic-resistant organisms2,3,7 and C. diff.8 Isolation of antibiotic-resistant organisms is more common in LTCFs than in acute care facilities, further emphasizing that LTCFs serve as reservoirs for these difficult-to-treat organisms in the community.9
Recently, there have been a number of resources released from the US Centers for Disease Control and Prevention (CDC), American Society of Consultant Pharmacists (ASCP), and the Agency for Healthcare Research and Quality (AHRQ) to aid LTCFs in creating antimicrobial stewardship programs (ASPs). Additionally, the Centers for Medicare & Medicaid Services issued a mandate in October 2016 stating that all LTCFs must fully implement an ASP by November 2019.10 However, many facilities lack access to the resources that are available to help them develop a strong program. This limitation can be the result having clinical providers located off-site, which leads to difficulty in appropriately diagnosing infections; relying on front-line staff to provide information on which to base clinical decisions; and lacking access to lab and microbiology reports and sufficient funding to hire staff, both physicians and pharmacists.2,11 Other barriers to optimizing antimicrobial use in LTCFs include frequent antibiotic use in end-of-life patients, with up to 42% still receiving antibiotics despite a lack of evidence for relief of discomfort. Additionally, patients and family members expect antibiotic prescriptions to ease the suffering, thus making appropriate antibiotic prescribing difficult.12 These factors, along with minimal evidence of effective LTCF stewardship strategies, have prevented many facilities from implementing ASPs.3,4,13 Additionally, although each facility should be able to customize their stewardship programs to meet their individual needs, there is still a lack of standardization of stewardship program components for all LTCFs.3
Reports of successful strategies to implement antimicrobial stewardship in LTCFs are starting to emerge within the review literature. A recent integrative review by Gurses and colleagues used the Systems Engineering Initiative for Patient Safety (SEIPS) model, an engineering approach to patient safety outcomes focusing on work system improvements. They reviewed tools, technologies, tasks, organizational condition, person(s), and environments to determine which aspects of workflow improvements it made more sense to modify to implement an ASP.14 Based on their approach, they were able to identify the following areas as fruitful aspects of an ASP: integrating postprescriptive recommendations into prescribers’ workflow, utilizing consultants in the infectious disease field; multidisciplinary education, and integrating preprescriptive data into nurses’ workflow.14
Previous ASPs focused on providing education through a variety of methods. Schwartz et al trained their physicians and nurses on recent guideline updates and created pocket cards of new guideline recommendations. By doing this, they found they decreased overall antibiotic use and have maintained that decrease for 2 years post intervention.15 Monette and colleagues provided antibiotic prescribing guidelines to all their physicians, but also supplied a report to the physicians in the intervention group of their antibiotic prescribing habits and indicated if each prescription complied with the current prescribing guidelines.6 They found that the physicians who received the feedback, in addition to the prescribing guidelines, were more likely to follow the antibiotic prescribing recommendations. Zimmerman et al evaluated training sessions for nurses and staff of multiple nursing homes. As part of the training session, they developed pocket guides and medical referral forms for the nursing staff to use.16 Nurses and prescribers also were given ongoing feedback regarding their antibiotic prescribing rates and habits. Results of this study showed that the overall rate of antibiotics used decreased.
A common theme for ASPs is that a multimodal approach is likely to be more successful. If a facility is only adding services, including education to patients, caregivers, and nursing staff, but not providing additional reinforcement, the knowledge gained from the educational sessions will not be retained.2,6,17,18 Furano et al evaluated the use of developing a nursing home-specific antibiogram as a tool.19 They found a modest increase in appropriate antibiotic prescribing after implementation of the antibiogram (32% vs 45%), but as it was not accompanied by recurrent education, the benefit was less than expected.
The programs that identified greater decreases in their inappropriate antibiotic use incorporated a variety of methodologies, including development of pocket cards with new antibiotic prescribing recommendations, nursing communication forms that contained specific checkbox information to identify patient-specific symptoms, and 72-hour bundle policies, in accordance with CDC recommendations, that allow for re-evaluation of antibiotic orders and reassessment of symptoms and microbiological culture results to highlight key areas still needing improvement. Kassett and colleagues evaluated a multimodal program that included changes to 4 key areas: the use of ASP guidelines and policies, audit and feedback between physicians and clinical pharmacists, creation of information technology tools, and educational sessions.20 These programs were implemented in both their hospital and LTCF. This specific analysis did not note any significant decrease in number of antibiotics prescribed, but there was a sizeable drop in prescribed days of therapy and actual days of therapy counts, which led to decreases in overall antibiotic exposure. At this time, the literature has not identified a single approach to LTCF ASPs as the gold standard approach. However, it is clear that the more multifaceted a program is, the greater likelihood that it will achieve successful results in antibiotic prescribing habits, decrease overall antibiotic exposure, and decrease antibiotic resistance rates in LTCFs. Clinicians practicing in LTCFs must use all available epidemiologic, clinical, and objective data to optimize infection-related care for their patients.
Dr. Wagner is a clinical assistant professor at the University of Mississippi School of Pharmacy. She received a PharmD from Midwestern University— Chicago College of Pharmacy, completed a PGY1 residency at Henry Ford Hospital, and an infectious diseases pharmacotherapy outcomes fellowship at Wayne State University / Henry Ford Hospital. She serves on the SIDP Antimicrobial Stewardship Committee and is chair of the Long- Term Care Stewardship Subcommittee.
Dr. Clifford is an assistant professor of pharmacy practice at Texas Tech University Health Sciences Center School of Pharmacy in Dallas, Texas. He received a PharmD from Butler University College of Pharmacy and Health Sciences in Indianapolis, Indiana, completed a PGY-1 in pharmacy practice from Columbus Regional Hospital in Columbus, Indiana, and a PGY-2 in geriatric pharmacy practice from the University of Maryland, School of Pharmacy in Baltimore, Maryland. He is a board-certified pharmacotherapy specialist, and a board-certified geriatric pharmacist. He is an active member of SIDP.