A Multifaceted Intervention to Implement Guidelines Improved Treatment of Nursing Home–Acquired Pneumonia in a State Veterans Home

Development and verification of a prediction model for outcomes of elderly patients with nursing home-acquired pneumonia

BACKGROUND

Among all infections in nursing homes, pneumonia has the highest mortality. Nurses have a 24-h relationship with patients and have a key role in identifying and preventing adverse outcomes. However, tools to engage nurses in pneumonia patient outcomes evaluation have not occurred.

PURPOSE

This study aimed to develop and validate a prediction model to predict the outcome of elderly patients with nursing home-acquired pneumonia (NHAP).

METHODOLOGY

A retrospective observational study was conducted with 219 elderly NHAP patients. Baseline characteristics, health history, and treatment/nursing status were collected. Variables for constructing nomograms were screened by univariate and multivariate analysis. The nomogram model was evaluated using the concordance index (C-index), decision curve analysis (DCA) curves, and receiver operating characteristic (ROC) curves.

RESULTS

9 independent risk factors were identified and assembled into the nomogram. The nomogram exhibited reasonably accurate discrimination (area under the receiver operating characteristic curve (AUC-ROC): 0.931, P < 0.05) and calibration (C-index: 0.931, 95 % CI: 0.898-0.964) in the validation cohort. DCA and clinical impact curves demonstrated that the nomogram was clinically beneficial.

CONCLUSIONS

A visualization nomogram model was successfully established for predicting the outcome of the NHAP elderly patients. The model has extremely high reliability, extremely high predictive ability, and good clinical applicability.

Assessment of implementation strategies adopted for antimicrobial stewardship interventions in long-term care facilities: a systematic review

BACKGROUND

The implementation of antimicrobial stewardship (AMS) interventions in long-term care facilities (LTCFs) is influenced by multi-level factors (resident, organizational, and external) making their effectiveness sensitive to the implementation context.

OBJECTIVES

This study assessed the strategies adopted for the implementation of AMS interventions in LTCFs, whether they considered organizational characteristics, and their effectiveness.

DATA SOURCES

Electronic databases until April 2022.

STUDY ELIGIBILITY CRITERIA

Articles covering implementation of AMS interventions in LTCFs.

ASSESSMENT OF RISK OF BIAS

Mixed Methods Appraisal Tool for empirical studies.

METHODS OF DATA SYNTHESIS

Data were collected on AMS interventions and context characteristics (e.g. type of facility, staffing, and residents). Implementation strategies and outcomes were mapped according to the Expert Recommendations for Implementing Change (ERIC) framework and validated taxonomy for implementation outcomes. Implementation and clinical effectiveness were assessed according to the primary and secondary outcomes results provided in each study.

RESULTS

Among 48 studies included in the analysis, 19 (40%) used implementation strategies corresponding to one to three ERIC domains, including education and training (n = 36/48, 75%), evaluative and iterative strategies (n = 24/48, 50%), and support clinicians (n = 23/48, 48%). Only 8/48 (17%) studies made use of implementation theories, frameworks, or models. Fidelity and sustainability were reported respectively in 21 (70%) and 3 (10%) of 27 studies providing implementation outcomes. Implementation strategy was considered effective in 11/27 (41%) studies, mainly including actions to improve use (n = 6/11, 54%) and education (n = 4/11, 36%). Of the 42 interventions, 18/42 (43%) were deemed clinically effective. Among 21 clinically effective studies, implementation was deemed effective in four and partially effective in five. Two studies were clinically effective despite having non-effective implementation.

CONCLUSIONS

The effectiveness of AMS interventions in LTCFs largely differed according to the interventions' content and implementation strategies adopted. Implementation frameworks should be considered to adapt and tailor interventions and strategies to the local context.

Provider adherence to training components from the Trial to Reduce Antimicrobial use In Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD) intervention

Background

The Trial to Reduce Antimicrobial use In Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD) was a cluster randomized clinical trial evaluating a multicomponent program to improve infection management among residents with advanced dementia. This report examines facility and provider characteristics associated with greater adherence to training components of the TRAIN-AD intervention.

Methods

Logistic regression was used to identify facility and provider characteristics associated with: 1. Training seminar attendance, 2. Online course completion, and 3. Overall adherence, defined as participation in neither seminar nor course, either seminar or course, or both seminar and course.

Results

Among 380 participating providers (nurses, N = 298; prescribing providers, N = 82) almost all (93%) participated in at least one training activity. Being a nurse was associated with higher likelihood of any seminar attendance (adjusted odds ratio (AOR) 5.37; 95% confidence interval (CI), 2.80–10.90). Providers who were in facilities when implementation begun (AOR, 3.01; 95% CI, 1.34–6.78) and in facilities with better quality ratings (AOR, 2.70; 95% CI, 1.59–4.57) were more likely to complete the online course. Prevalent participation (AOR, 2.01; 95% CI, 1.02–3.96) and higher facility quality (AOR, 2.44; 95% CI, 1.27–4.66) were also significantly associated with greater adherence to either seminar or online course.

Conclusion

TRAIN-AD demonstrates feasibility in achieving high participation among nursing home providers in intervention training activities. Findings also suggest opportunities to maximize adherence, such as enhancing training efforts in lower quality facilities and targeting of providers who join the facility after implementation start-up.

•

High levels of participation was due in part to flexibility of training options and engagement, making it easily accessible.

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Stakeholder engagement on priority issues and the start-up period on site were important to get buy-in from participants.

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Lessons learned provide insight into improving adherence for interventions, particularly for NHs with lower resources.

Interventions on health care providers to improve seasonal influenza vaccination rates among patients: a systematic review and meta-analysis of the evidence since 2000

BACKGROUND

Seasonal influenza vaccination (SIV) rates remain suboptimal in many populations, even in those with universal SIV.

OBJECTIVE

To summarize the evidence on interventions on health care providers (physicians/nurses/pharmacists) to increase SIV rates.

METHODS

We systematically searched/selected full-text English publications from January 2000 to July 2019 (PROSPERO-CRD42019147199). Our outcome was the difference in SIV rates between patients in intervention and non-intervention groups. We calculated pooled difference using an inverse variance, random-effects model.

RESULTS

We included 39 studies from 8370 retrieved citations. Compared with no intervention, team-based training/education of physicians significantly increased SIV rates in adult patients: 20.1% [7.5-32.7%; I2 = 0%; two randomized controlled trials (RCTs)] and 13.4% [8.6-18.1%; I2 = 0%; two non-randomized intervention studies (NRS)]. A smaller increase was observed in paediatric patients: 7% (0.1-14%; I2 = 0%; two NRS), and in adult patients with team-based training/education of physicians and nurses together: 0.9% (0.2-1.5%; I2 = 30.6%; four NRS). One-off provision of guidelines/information to physicians, and to both physicians and nurses, increased SIV rates in adult patients: 23.8% (15.7-31.8%; I2 = 45.8%; three NRS) and paediatric patients: 24% (8.1-39.9%; I2 = 0%; two NRS), respectively. Use of reminders (prompts) by physicians and nurses slightly increased SIV rates in paediatric patients: 2.3% (0.5-4.2%; I2 = 0%; two RCTs). A larger increase was observed in adult patients: 18.5% (14.8-22.1%; I2 = 0%; two NRS). Evidence from both RCTs and NRS showed significant increases in SIV rates with varied combinations of interventions.

CONCLUSIONS

Limited evidence suggests various forms of physicians' and nurses' education and use of reminders may be effective for increasing SIV rates among patients.

Antimicrobial stewardship programmes in nursing homes: a systematic review and inventory of tools

BACKGROUND

Antimicrobial overuse/misuse is common in nursing homes and although the effectiveness of antimicrobial stewardship (AMS) programmes has been well explored and demonstrated in hospitals, data are scarce for the nursing-home setting. Our objectives for this systematic review were to make an inventory of: (i) all interventions that could be considered as part of AMS programmes in nursing homes; and (ii) all stewardship tools and guidance that are freely available.

METHODS

We performed a systematic review using the MEDLINE database from inception to June 2018, including all interventional studies, reviews, opinion pieces and guidelines/guidance exploring AMS programmes in nursing homes. For the inventory of freely available tools and guidance to help implement an AMS programme, we also performed screening of professional societies and official agencies' websites and a questionnaire survey among a panel of international experts.

RESULTS

A total of 36 articles were included in our systematic review. Most interventions took place in North America and have explored education or persuasive interventions within multifaceted interventions, showing that they can improve guideline adherence and decrease antibiotic use and unnecessary microbiological testing. Most reviews also highlighted the importance of accountability, monitoring and feedback. A large number of tools (156) available for free on the internet were identified, mostly about education, patient assessment and outcome measurement.

CONCLUSIONS

Although high-quality interventional studies are lacking, multifaceted interventions including education, monitoring and feedback seem the most promising strategy. Many tools are available on the internet and can be used to help implement AMS programmes in nursing homes.

Effectiveness of Implementing a Locally Developed Antibiotic Use Guideline for Community-Acquired Cellulitis at a Large Tertiary Care University Hospital in Thailand

Background

To determine the effectiveness of implementing a locally developed clinical practice guideline (CPG) for antibiotic treatment in adults with community-acquired cellulitis at Siriraj Hospital in Bangkok, Thailand.

Methods

The CPG for antibiotic treatment of community-acquired cellulitis was developed based on local data during June to December 2016. The CPG was introduced by multifaceted interventions, including posters, brochures, circular letters, social media, conference, classroom training, and interactive education during January to September 2018.

Results

Among 360 patients with community-acquired cellulitis, 84.4% were ambulatory and 15.6% were hospitalized. The median age of patients was 62 years, and 59.4% were female. Antibiotic prescription according to CPG (CPG-compliant group) was observed in 251 patients (69.7%), and CPG noncompliance was found in 109 patients (30.3%) (CPG-noncompliant group). The demographics and characteristics of patients were comparable between groups. Patients in the CPG-compliant group had a significantly lower rate of intravenous antibiotics (18.7% vs 33.9%, P = .007), lower prescription rate of broad-spectrum antibiotics (14.7% vs 78.9%, P &lt; .001) and antibiotic combination (6.4% vs 13.8%, P = .022), shorter median duration of antibiotic treatment (7 vs 10 days, P &lt; .001), lower median cost of antibiotic treatment (US $3 vs $7, P &lt; .001), and lower median hospitalization cost (US $601 vs $1587, P = .008) than those in the CPG-noncompliant group. Treatment outcomes were not significantly different between groups.

Conclusions

Adherence to CPG seems to reduce inappropriate prescription of broad-spectrum antibiotic or antibiotic combination and treatment costs in adults with community-acquired cellulitis without differences in favorable outcomes or adverse events.

Interventions to improve appropriate antibiotic prescribing in long-term care facilities: a systematic review

BACKGROUND

Overuse of antibiotics has contributed to antimicrobial resistance; a growing public health threat. In long-term care facilities, levels of inappropriate prescribing are as high as 75%. Numerous interventions targeting long-term care facilities' antimicrobial stewardship have been reported with varying, and largely unexplained, effects. Therefore, this review aimed to apply behavioural science frameworks to specify the component behaviour change techniques of stewardship interventions in long-term care facilities and identify those components associated with improved outcomes.

METHOD

A systematic review (CRD42018103803) was conducted through electronic database searches. Two behavioural science frameworks, the Behaviour Change Wheel and Behaviour Change Technique Taxonomy were used to classify intervention descriptions into intervention types and component behaviour change techniques used. Study design and outcome heterogeneity prevented meta-analysis and meta-regression. Interventions were categorised as 'very promising' (all outcomes statistically significant), 'quite promising' (some outcomes statistically significant), or 'not promising' (no outcomes statistically significant). 'Promise ratios' (PR) were calculated for identified intervention types and behaviour change techniques by dividing the number of (very or quite) promising interventions featuring the intervention type or behaviour change technique by the number of interventions featuring the intervention type or behaviour change technique that were not promising. Promising intervention types and behaviour change techniques were defined as those with a PR ≥ 2.

RESULTS

Twenty studies (of19 interventions) were included. Seven interventions (37%) were 'very promising', eight 'quite promising' (42%) and four 'not promising' (21%). Most promising intervention types were 'persuasion' (n = 12; promise ratio (PR) = 5.0), 'enablement' (n = 16; PR = 4.33) and 'education' (n = 19; PR = 3.75). Most promising behaviour change techniques were 'feedback on behaviour' (n = 9; PR = 8.0) and 'restructuring the social environment' (e.g. staff role changes; n = 8; PR = 7.0).

CONCLUSION

Systematic identification of the active ingredients of antimicrobial stewardship in long-term care facilities was facilitated through the application of behavioural science frameworks. Incorporating environmental restructuring and performance feedback may be promising intervention strategies for antimicrobial stewardship interventions within long-term care facilities.

Clinical features, therapy and outcome of patients hospitalized or not for nursing-home acquired pneumonia

BACKGROUND

nursing home-acquired pneumonia (NHAP), is among the main causes of hospitalization and mortality of frail elderly patients. Aim of this study was analysis of patients residing in long-term care facilities (LTCF) and developing pneumonia to reach a better knowledge of criteria for hospitalization and outcomes.

MATERIALS/METHODS

this is a prospective, observational study in which patients residing in 3 LTCFs (metropolitan area of Rome, Italy) and developing pneumonia, hospitalized or treated in LTCF, were recruited and followed up from January 2017 to June 2019. Primary endpoint was 30-day mortality, secondary endpoint was analysis of risk factors associated with hospitalization.

RESULTS

Overall, 146 episodes of NHAP were enrolled in the study: 57 patients were treated in LTCF, while 89 patients were hospitalized. Overall incidence rates of NHAP varied from 2.6 to 7.5 per 1000 residents. Methicillin-resistant Staphylococcus aureus was the most frequently isolated pathogen (25%), and in 28 (55%) patients was documented a MDR pathogen. For hospitalized patients was reported a higher 30-day mortality (43.8% Vs 7%, p < 0.001). Multivariate analysis showed that severe pneumonia, neoplasm, chronic hepatitis, antibiotic monotherapy, and malnutrition were independent risk factors for hospitalization from LTCF. MDR pathogen, severe pneumonia, COPD, and moderate to severe renal disease were independently associated with death at 30 days.

CONCLUSION

frail elderly patients in LTCF have a high risk of MDR etiology with a higher risk to receive an inadequate antibiotic therapy and a fatal outcome. These results point to the need for increased provision of acute care and strategies in LTCF.

Effectiveness of interventions targeting antibiotic use in long-term aged care facilities: a systematic review and meta-analysis

OBJECTIVES

There are high levels of inappropriate antibiotic use in long-term care facilities (LTCFs). Our objective was to examine evidence of the effectiveness of interventions designed to reduce antibiotic use and/or inappropriate use in LTCFs.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase and CINAHL from 1997 until November 2018.

ELIGIBILITY CRITERIA

Controlled and uncontrolled studies in LTCFs measuring intervention effects on rates of overall antibiotic use and/or appropriateness of use were included. Secondary outcomes were intervention implementation barriers from process evaluations.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently applied the Cochrane Effective Practice and Organisation of Care group's resources to classify interventions and assess risk of bias. Meta-analyses used random effects models to pool results.

RESULTS

Of include studies (n=19), 10 had a control group and 17 had a high risk of bias. All interventions had multiple components. Eight studies (with high risk of bias) showed positive impacts on outcomes and included one of the following interventions: audit and feedback, introduction of care pathways or an infectious disease team. Meta-analyses on change in the percentage of residents on antibiotics (pooled relative risk (RR) (three studies, 6862 residents): 0.85, 95% CI: 0.61 to 1.18), appropriateness of decision to treat with antibiotics (pooled RR (three studies, 993 antibiotic orders): 1.10, 95% CI: 0.64 to 1.91) and appropriateness of antibiotic selection for respiratory tract infections (pooled RR (three studies, 292 orders): 1.15, 95% CI: 0.95 to 1.40), showed no significant intervention effects. However, meta-analyses only included results from intervention groups since most studies lacked a control group. Insufficient data prevented meta-analysis on other outcomes. Process evaluations (n=7) noted poor intervention adoption, low physician engagement and high staff turnover as barriers.

CONCLUSIONS

There is insufficient evidence that interventions employed to date are effective at improving antibiotic use in LTCFs. Future studies should use rigorous study designs and tailor intervention implementation to the setting.

The trial to reduce antimicrobial use in nursing home residents with Alzheimer's disease and other dementias: study protocol for a cluster randomized controlled trial

BACKGROUND

Infections are common in nursing home (NH) residents with advanced dementia but are often managed inappropriately. Antimicrobials are extensively prescribed, but frequently with insufficient evidence to support a bacterial infection, promoting the emergence of multidrug-resistant organisms. Moreover, the benefits of antimicrobials remain unclear in these seriously ill residents for whom comfort is often the goal of care. Prior NH infection management interventions evaluated in randomized clinical trials (RCTs) did not consider patient preferences and lack evidence to support their effectiveness in 'real-world' practice.

METHODS

This report presents the rationale and methodology of TRAIN-AD (Trial to reduce antimicrobial use in nursing home residents with Alzheimer's disease and other dementias), a parallel group, cluster RCT evaluating a multicomponent intervention to improve infection management for suspected urinary tract infections (UTIs) and lower respiratory tract infections (LRIs) among NH residents with advanced dementia. TRAIN-AD is being conducted in 28 facilities in the Boston, USA, area randomized in waves using minimization to achieve a balance on key characteristics (N = 14 facilities/arm). The involvement of the facilities includes a 3-month start-up period and a 24-month implementation/data collection phase. Residents are enrolled during the first 12 months of the 24-month implementation period and followed for up to 12 months. Individual consent is waived, thus almost all eligible residents are enrolled (target sample size, N = 410). The intervention integrates infectious disease and palliative care principles and includes provider training delivered through multiple modalities (in-person seminar, online course, management algorithms, and prescribing feedback) and an information booklet for families. Control facilities employ usual care. The primary outcome, abstracted from the residents' charts, is the number of antimicrobial courses prescribed for UTIs and LRIs per person-year alive.

DISCUSSION

TRAIN-AD is the first cluster RCT testing a multicomponent intervention to improve infection management in NH residents with advanced dementia. Its findings will provide an evidence base to support the benefit of a program addressing the critical clinical and public health problem of antimicrobial misuse in these seriously ill residents. Moreover, its hybrid efficacy-effectiveness design will inform the future conduct of cluster RCTs evaluating nonpharmacological interventions in the complex NH setting in a way that is both internally valid and adaptable to the 'real-world'.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03244917 . Registered on 10 August 2017.

Implementing Antimicrobial Stewardship in Long-term Care Settings: An Integrative Review Using a Human Factors Approach

Implementing effective antimicrobial stewardship in long-term care facilities (LTCFs) is associated with challenges distinct from those faced by hospitals. LTCFs generally care for elderly populations who are vulnerable to infection, have prescribers who are often off-site, and have limited access to timely diagnostic testing. Identification of feasible interventions in LTCFs is important, particularly given the new requirement for stewardship programs by the Centers for Medicare and Medicaid Services (CMS). In this integrative review, we analyzed published evidence in the context of a human factors engineering approach as well as educational interventions to understand aspects of multimodal interventions associated with the implementation of successful stewardship programs in LTCFs. The outcomes indicate that effective antimicrobial stewardship in long-term care is supported by incorporating multidisciplinary education, tools integrated into the workflow of nurses and prescribers that facilitate review of antibiotic use, and involvement of infectious disease consultants.

Antibiotic Stewardship Programs in Nursing Homes: A Systematic Review

INTRODUCTION

Antibiotic stewardship programs (ASPs) are coordinated interventions promoting the appropriate use of antibiotics to improve patient outcomes and reduce microbial resistance. These programs are now mandated in nursing homes (NHs) but it is unclear if these programs improve resident outcomes. This systematic review evaluated the current evidence regarding outcomes of ASPs in the NH.

METHODS

PubMed, CINAHL, EMBASE, and the Cochrane Library were systematically searched for intervention trials of ASPs performed in NHs that evaluated final health outcomes (mortality and Clostridium difficile infections), healthcare utilization outcomes (emergency department visits and hospital admissions) and intermediate health outcomes (number of antibiotics prescribed, adherence to recommended guidelines).

RESULTS

A total of 14 studies rated good or fair quality were included. Eight studies reported a reduction in antibiotic prescriptions. Ten found an increase in adherence to guidelines proposed by the studied ASP. None reported a statistically significant change in NH mortality rates, C. difficile infection rates, or hospitalizations.

DISCUSSION

The limited research to date suggests that NH ASPs can affect intermediate health outcomes, but not key health outcomes or health care utilization.

CONCLUSION

Larger trials evaluating more intensive interventions over longer durations may be needed to determine whether ASPs in NHs improve health outcomes as they have in hospitals.

Antimicrobial Stewardship in Long-Term Care Facilities: A Call to Action

Antimicrobial resistance is a global public health crisis and a national security threat to the United States, as stated in an executive order signed by the president in September 2014. This crisis is a result of indiscriminant antimicrobial use, which promotes selection for resistant organisms, increases the risk of adverse drug events, and renders patients vulnerable to drug-resistant infections. Antimicrobial stewardship is a key measure to combat antimicrobial resistance and specifically seeks to do this by improving antimicrobial use. Antimicrobial stewardship compliments infection control practices and it is important to note that these 2 disciplines are distinct and cannot be discussed interchangeably. Antimicrobial stewardship promotes the appropriate diagnosis, drug, dose, and duration of treatment. The appropriate diagnosis falls into the hands of the prescriber and clinical staff. Optimal antimicrobial drug selection, dosing strategy, and duration of treatment, however, often require expertise in antimicrobial therapy, such as an infectious disease-trained physician or pharmacist. Therefore, successful antimicrobial stewardship programs must be comprehensive and interdisciplinary. Most antimicrobial stewardship programs focus on hospitals; yet, in long-term care, up to 75% of antimicrobial use is inappropriate or unnecessary. Thus, one of the most pressing areas in need for antimicrobial stewardship is in long-term care facilities. Unfortunately, there is little evidence that describes effective antimicrobial stewardship interventions in this setting. This review discusses the need for and barriers to antimicrobial stewardship in long-term care facilities. Additionally, this review describes prior interventions that have been implemented and tested to improve antimicrobial use in long-term care facilities.

Effect of tailored antibiotic stewardship programmes on the appropriateness of antibiotic prescribing in nursing homes

OBJECTIVES

To evaluate the effect of tailored interventions on the appropriateness of decisions to prescribe or withhold antibiotics, antibiotic use and guideline-adherent antibiotic selection in nursing homes (NHs).

METHODS

We conducted a quasi-experimental study in 10 NHs in the Netherlands. A participatory action research (PAR) approach was applied, with local stakeholders in charge of selecting tailored interventions based on opportunities for improved antibiotic prescribing that they derived from provided baseline data. An algorithm was used to evaluate the appropriateness of prescribing decisions, based on infections recorded by physicians. Effects of the interventions on the appropriateness of prescribing decisions were analysed with a multilevel logistic regression model. Pharmacy data were used to calculate differences in antibiotic use and recorded infections were used to calculate differences in guideline-adherent antibiotic selection.

RESULTS

The appropriateness of 1059 prescribing decisions was assessed. Adjusting for pre-test differences in the proportion of appropriate prescribing decisions (intervention, 82%; control, 70%), post-test appropriateness did not differ between groups (crude: P = 0.26; adjusted for covariates: P = 0.35). We observed more appropriate prescribing decisions at the start of data collection and before receiving feedback on prescribing behaviour. No changes in antibiotic use or guideline-adherent antibiotic selection were observed in intervention NHs.

CONCLUSIONS

The PAR approach, or the way PAR was applied in the study, was not effective in improving antibiotic prescribing behaviour. The study findings suggest that drawing prescribers' attention to prescribing behaviour and monitoring activities, and increasing use of diagnostic resources may be promising interventions to improve antibiotic prescribing in NHs.

Predictors of mortality for nursing home-acquired pneumonia: a systematic review

Background. Current risk stratification tools, primarily used for CAP, are suboptimal in predicting nursing home acquired pneumonia (NHAP) outcome and mortality. We conducted a systematic review to evaluate current evidence on the usefulness of proposed predictors of NHAP mortality. Methods. PubMed (MEDLINE), EMBASE, and CINAHL databases were searched for articles published in English between January 1978 and January 2014. The literature search elicited a total of 666 references; 580 were excluded and 20 articles met the inclusion criteria for the final analysis. Results. More studies supported the Pneumonia Severity Index (PSI) as a superior predictor of NHAP severity. Fewer studies suggested CURB-65 and SOAR (especially for the need of ICU care) as useful predictors for NHAP mortality. There is weak evidence for biomarkers like C-reactive protein and copeptin as prognostic tools. Conclusion. The evidence supports the use of PSI as the best available indicator while CURB-65 may be an alternative prognostic indicator for NHAP mortality. Overall, due to the paucity of information, biomarkers may not be as effective in this role. Larger prospective studies are needed to establish the most effective predictor(s) or combination scheme to help clinicians in decision-making related to NHAP mortality.

Strategies and challenges of antimicrobial stewardship in long-term care facilities

As people are living longer the demand for long-term care facilities (LTCFs) continues to rise. For many reasons, antimicrobials are used intensively in LTCFs, with up to a half of this use considered inappropriate or unnecessary. Over-use of antimicrobials can have direct adverse consequences for LTCF residents and promotes the development and spread of resistant bacteria. It is therefore critical that LTCFs are able to engage in antimicrobial stewardship programmes, which have the potential to minimize the antibiotic selective pressure, while improving the quality of care received by LTCF residents. To date, no antimicrobial stewardship guidelines specific to LTCF settings have been published. Here we outline the scale of antimicrobial use in LTCFs and the underlying drivers for antibiotic over-use. We further describe the particular challenges of antimicrobial stewardship in LTCFs, and review the interventional studies that have aimed to improve antibiotic use in these settings. Practical recommendations are then drawn from this research to help guide the development and implementation of antimicrobial stewardship programmes.

Reducing inappropriate antibiotic prescribing in the residential care setting: current perspectives

Residential aged care facilities are increasingly identified as having a high burden of infection, resulting in subsequent antibiotic use, compounded by the complexity of patient demographics and medical care. Of particular concern is the recent emergence of multidrug-resistant organisms among this vulnerable population. Accordingly, antimicrobial stewardship (AMS) programs have started to be introduced into the residential aged care facilities setting to promote judicious antimicrobial use. However, to successfully implement AMS programs, there are unique challenges pertaining to this resource-limited setting that need to be addressed. In this review, we summarize the epidemiology of infections in this population and review studies that explore antibiotic use and prescribing patterns. Specific attention is paid to issues relating to inappropriate or suboptimal antibiotic prescribing to guide future AMS interventions.

A realist review of interventions and strategies to promote evidence-informed healthcare: a focus on change agency

Background

Change agency in its various forms is one intervention aimed at improving the effectiveness of the uptake of evidence. Facilitators, knowledge brokers and opinion leaders are examples of change agency strategies used to promote knowledge utilization. This review adopts a realist approach and addresses the following question: What change agency characteristics work, for whom do they work, in what circumstances and why?

Methods

The literature reviewed spanned the period 1997-2007. Change agency was operationalized as roles that are aimed at effecting successful change in individuals and organizations. A theoretical framework, developed through stakeholder consultation formed the basis for a search for relevant literature. Team members, working in sub groups, independently themed the data and developed chains of inference to form a series of hypotheses regarding change agency and the role of change agency in knowledge use.

Results

24, 478 electronic references were initially returned from search strategies. Preliminary screening of the article titles reduced the list of potentially relevant papers to 196. A review of full document versions of potentially relevant papers resulted in a final list of 52 papers. The findings add to the knowledge of change agency as they raise issues pertaining to how change agents’ function, how individual change agent characteristics effect evidence-informed health care, the influence of interaction between the change agent and the setting and the overall effect of change agency on knowledge utilization. Particular issues are raised such as how accessibility of the change agent, their cultural compatibility and their attitude mediate overall effectiveness. Findings also indicate the importance of promoting reflection on practice and role modeling. The findings of this study are limited by the complexity and diversity of the change agency literature, poor indexing of literature and a lack of theory-driven approaches.

Conclusion

This is the first realist review of change agency. Though effectiveness evidence is weak, change agent roles are evolving, as is the literature, which requires more detailed description of interventions, outcomes measures, the context, intensity, and levels at which interventions are implemented in order to understand how change agent interventions effect evidence-informed health care.

Translating research into practice in nursing homes: can we close the gap?

PURPOSE

A gap between research and practice in many nursing home (NH) care areas persists despite efforts by researchers, policy makers, advocacy groups, and NHs themselves to close it. The reasons are many, but two factors that have received scant attention are the dissemination process itself and the work of the disseminators or change agents. This review article examines these two elements through the conceptual lens of Roger's innovation dissemination model.

DESIGN AND METHODS

The application of general principles of innovation dissemination suggests that NHs are characteristically slow to innovate and thus may need more time as well as more contact with outside change agents to adopt improved practices.

RESULTS

A review of the translation strategies used by NH change agents to promote adoption of evidence-based practice in NHs suggests that their strategies inconsistently reflect lessons learned from the broader dissemination literature.

IMPLICATIONS

NH-related research, policy, and practice recommendations for improving dissemination strategies are presented. If we can make better use of the resources currently devoted to disseminating best practices to NHs, we may be able to speed NHs' adoption of these practices.

The coach is in: improving nutritional care in nursing homes

PURPOSE

 This article describes and evaluates a long distance coaching course aimed at improving nutritional care in nursing homes (NHs). The course was structured to provide more support than traditional training programs offer. 

METHODS

 In a series of 6 monthly teleconferences led by an expert in NH nutritional care, participating NH staff received step-by-step instructions for implementing an evidence-based nutritional management program. After each session, participants were asked to implement the care step they had just learned. Coaching calls helped facilitate implementation. Staff in 18 NHs in 12 states completed the course. Evaluation data were collected using a resident data form, pre- and post-training quizzes, a participant course evaluation survey, and a supervisor's report. 

RESULTS

 NH staff attended an average of 4.8 teleconferences, with 5 staff members typically attending each teleconference. Average quiz scores increased 30% (p < .0001) from pre- to post-training. A majority of course participants (N = 35) said they would participate in a similar course (82.9%) and would recommend the course (80%). Just under half preferred the coaching course to a more traditional 1- to 2-day conference. Nine of 12 reporting supervisors said their facility planned to continue the new nutritional care program. The 10 NHs that submitted resident data assessed an average of 5 residents using the recommended protocols. 

IMPLICATIONS

 We recommend the coaching course format. Dissemination outcomes may improve if resources currently used for short-duration training activities are used instead on coaching activities that support NHs over extended periods.

Conceptual model for reducing infections and antimicrobial resistance in skilled nursing facilities: focusing on residents with indwelling devices

Infections in skilled nursing facilities (SNFs) are common and result in frequent hospital transfers, functional decline, and death. Colonization with multidrug-resistant organisms (MDROs) - including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacilli (R-GNB) - is also increasingly prevalent in SNFs. Antimicrobial resistance among common bacteria can adversely affect clinical outcomes and increase health care costs. Recognizing a need for action, legislators, policy-makers, and consumer groups are advocating for surveillance cultures to identify asymptomatic patients with MDROs, particularly MRSA in hospitals and SNFs. Implementing this policy for all SNF residents may be costly, impractical, and ineffective. Such a policy may result in a large increase in the number of SNF residents placed in isolation precautions with the potential for reduced attention by health care workers, isolation, and functional decline. Detection of colonization and subsequent attempts to eradicate selected MDROs can also lead to more strains with drug resistance. We propose an alternative strategy that uses a focused multicomponent bundle approach that targets residents at a higher risk of colonization and infection with MDROs, specifically those who have an indwelling device. If this strategy is effective, similar strategies can be studied and implemented for other high-risk groups.

Nursing home acquired pneumonia: approach to management

PURPOSE OF REVIEW

Pneumonia is among the leading causes of mortality in nursing home residents and a primary reason for transfer to acute care facilities. Compared with community-dwelling individuals, residents of long-term care facilities have extensive underlying medical illnesses and more functional disabilities and are at increased risk of acquiring drug-resistant pathogens. This review focuses on recent recommendations for diagnostic work up, validity of prognostic models, and current approach to treatment of nursing home acquired pneumonia (NHAP).

RECENT FINDINGS

The inconsistency in defining NHAP is considered a potential hindrance for a uniform approach to the management of pneumonia. Diagnostic evaluation varies between facilities and depends on severity of illness and access to laboratory facilities. The role of prognostic models in stratifying severity of disease remains largely unknown due to paucity of studies and lack of a specific scoring system for hospitalized patients with NHAP. A controversy still exists concerning the best therapeutic option for NHAP, but it is reasonable to believe that each setting is adapting the existing evidence according to the best local practice.

SUMMARY

A unified approach to defining, assessing, and stratifying pneumonia is essential to decrease morbidity and mortality in nursing home residents. High-quality randomized, controlled trials examining empiric antibiotic therapy are needed.

A validated risk score to estimate mortality risk in patients with dementia and pneumonia: barriers to clinical impact

BACKGROUND

The clinical impact of risk score use in end-of-life settings is unknown, with reports limited to technical properties.

METHODS

We conducted a mixed-methods study to evaluate clinical impact of a validated mortality risk score aimed at informing prognosis and supporting clinicians in decision-making in dementia patients with pneumonia. We performed a trial (n = 69) with physician-reported outcomes referring to the score's aims. Subsequently, physician focus group discussions were planned to better understand barriers to clinical impact, and we surveyed families (n = 50) and nurses practicing in nursing homes (n = 29). We finally consulted with experts and key persons for implementation.

RESULTS

Most (71%) physicians who used the score considered it useful, but mainly for its learning effects. Families were never informed of numerical risk estimates. Two focus group discussions revealed a reluctance to use a numerical approach, and physicians found that outcomes conditional on antibiotic treatment were inadequate to support decision-making. Nurses varied in their perceived role in informing families. Most families (88%) wished to be informed, preferring a numerical (43%), verbalized (35%), or other approach (18%) or had no preference (5%). Revising the score, we added an ethical framework for decision-making to acknowledge its complexity, an explanatory note addressing barriers related to physicians' attitudes, and a nurses' form.

CONCLUSION

The combined quantitative and qualitative studies elicited: substantial barriers to a numerical approach to physicians' end-of-life decision-making; crucial information for revisions and further score development; and a need for implementation strategies that focus on education.

Systematic review of practice guideline dissemination and implementation strategies for healthcare teams and team-based practice

AIM

To synthesis the literature relevant to guideline dissemination and implementation strategies for healthcare teams and team-based practice.

METHODS

Systematic approach utilising Joanna Briggs Institute methods. Two reviewers screened all articles and where there was disagreement, a third reviewer determined inclusion.

RESULTS

Initial search revealed 12,083 of which 88 met the inclusion criteria. Ten dissemination and implementation strategies identified with distribution of educational materials the most common. Studies were assessed for patient or practitioner outcomes and changes in practice, knowledge and economic outcomes. A descriptive analysis revealed multiple approaches using teams of healthcare providers were reported to have statistically significant results in knowledge, practice and/or outcomes for 72.7% of the studies.

CONCLUSION

Team-based care using practice guidelines locally adapted can affect positively patient and provider outcomes.

Nursing home-acquired pneumonia: a review of risk factors and therapeutic approaches

OBJECTIVE

To review the risk factors, etiologic profile, treatment approaches, and guidelines for the management of nursing home-acquired pneumonia (NHAP).

RESEARCH DESIGN AND METHODS

A search of the current literature was conducted using the MEDLINE and Embase databases. This search, limited to studies performed in humans and published in English between January 1, 1990 and October 31, 2009, included the terms 'acquired pneumonia', 'associated pneumonia', 'nursing home', 'long-term care', 'institution', and 'healthcare'.

RESULTS

Older age, male gender, swallowing difficulty, and inability to take oral medications are all significant risk factors for pneumonia. Medications such as antipsychotics and anticholinergics, histamine receptor blockers and proton pump inhibitors have also been linked to higher risk of pneumonia. The etiology of NHAP overlaps with that of community-acquired pneumonia (CAP), with Streptococcus pneumoniae and Haemophilus influenzae as predominant pathogens in long-term care facilities. In patients who require hospitalization, Chlamydophila pneumoniae, Staphylococcus aureus, and influenza virus have also been identified. In contrast, the etiology of severe NHAP overlaps with that of hospital-acquired pneumonia (HAP), with S. aureus, including methicillin-resistant S. aureus (MRSA), Pseudomonas aeruginosa, and enteric Gram-negative bacilli as important causative pathogens. Therapy is dependent on disease severity and, on the treatment setting. Respiratory fluoroquinolones or β-lactams plus a macrolide are recommended in patients with NHAP. Patients hospitalized with severe NHAP may require triple combination therapy that covers both MRSA and P. aeruginosa. However, there is little evidence of the clinical superiority of one regimen over another, making it challenging to establish guidelines for the treatment of NHAP in the nursing home setting.

CONCLUSION

There is a pressing need for clinical trials of antibiotic therapy in nursing home patients that would help establish uniform guidelines to standardize therapy in the nursing home setting.

A multifaceted intervention to implement guidelines did not affect hospitalization rates for nursing home-acquired pneumonia

OBJECTIVE

Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home-acquired pneumonia (NHAP) affected hospitalization rates.

DESIGN

Quasi-experimental, mixed-methods, multifaceted, unblinded intervention trial.

SETTING

Sixteen nursing homes (NHs) from 1 corporation: 8 in metropolitan Denver, CO; 8 in Kansas and Missouri during 3 influenza seasons, October to April 2004 to 2007.

PARTICIPANTS

Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI); NH staff and physicians were eligible.

INTERVENTION

Multifaceted, including academic detailing to clinicians, within-facility nurse change agent, financial incentives, and nursing education.

MEASUREMENTS

Subjects' NH medical records were reviewed for resident characteristics, disease severity, and care processes. Bivariate analysis compared hospitalization rates for subjects with stable and unstable vital signs between intervention and control NHs and time periods. Qualitative interviews were analyzed using content coding.

RESULTS

Hospitalization rates for stable residents in both NH groups remained low throughout the study. Few critically ill subjects in the intervention NHs were hospitalized in either the baseline or intervention period. In control NHs, 8.7% of subjects with unstable vital signs were hospitalized during the baseline and 33% in intervention year 2, but the difference was not statistically significant (P = .10). Interviews with nursing staff and leadership confirmed there were significant pressures for, and enablers of, avoiding hospitalization for treatment of acute infections.

CONCLUSIONS

Secular pressures to avoid hospitalization and the challenges of reaching NH physicians via academic detailing are likely responsible for the lack of intervention effect on hospitalization rates for critically ill NH residents.

Frequency and diagnoses associated with 7- and 30-day readmission of skilled nursing facility patients to a nonteaching community hospital

OBJECTIVES

To determine the frequency and diagnoses associated with 7- and 30-day acute hospital readmissions of patients discharged to a skilled nursing facility (SNF) from an acute hospital.

DESIGN

A quality improvement project focusing on 30-day hospital readmissions, using retrospective data derived from the hospital's electronic data repository.

SETTING

A 350-bed nonteaching community hospital in southeast Florida.

MEASUREMENTS

Data were collected on all discharges of Medicare fee-for-service patients age 75 and older for a 17-month period in 2007 and 2008. The primary source of data was the hospital's electronic data repository. Seven and 30-day hospital readmission rates were calculated for all discharges to SNFs. Index hospital and readmission diagnoses were determined by hospital coders and categorized by the physician coauthors.

RESULTS

Among 10,777 discharges of patients age 75 and older, 3254 (30%) were discharged to an SNF, and of these, 584 (18%) were readmitted to the hospital within 30 days; 191 (33%) of these readmissions occurred within 7 days. The index diagnostic categories with the highest readmission rates were genitourinary disorders (30%) and cardiovascular disorders (25%). Specific diagnoses associated with the highest readmission rates included congestive heart failure (CHF) (31%), urinary tract infection (28%), renal failure (27%), and pneumonia and chronic obstructive pulmonary disease (23% each). Infections and cardiovascular disorders were the primary diagnoses for 63% of the hospital readmissions (36% and 27% respectively). The most frequent readmission primary diagnosis was the same as the index admission primary diagnosis in less than half the cases.

CONCLUSION

In this community hospital population, close to 1 in 5 discharges to an SNF resulted in a hospital readmission within 30 days. CHF, renal failure, UTI, pneumonia, and COPD were common index hospital and readmission diagnoses. Care paths and guidelines are available for these conditions that should be helpful to SNFs in initiatives designed to improve transitional care and reduce potentially avoidable hospital readmissions, as well as their associated morbidity and cost.

Interventions to improve suboptimal prescribing in nursing homes: A narrative review

BACKGROUND

Appropriate medication prescribing for nursing home residents remains a challenge.

OBJECTIVE

The purpose of this study was to conduct a narrative review of the published literature describing randomized controlled trials that used interventions to improve suboptimal prescribing in nursing homes.

METHODS

The PubMed, International Pharmaceutical Abstracts, and EMBASE databases were searched for articles published in the English language between January 1975 and December 2009, using the terms drug utilization, pharmaceutical services, aged, long-term care, nursing homes, prescribing, geriatrics, and randomized controlled trial. A manual search of the reference lists of identified articles and the authors' files, book chapters, and recent review articles was also conducted. Abstracts and posters from meetings were not included in the search. Studies were included if they: (1) had a randomized controlled design; (2) had a process measure outcome for quality of prescribing or a distal outcome measure for medication-related adverse patient events; and (3) involved nursing home residents.

RESULTS

Eighteen studies met the inclusion criteria for this review. Seven of those studies described educational approaches using various interventions (eg, outreach visits) and measured suboptimal prescribing in different manners (eg, adherence to guidelines). Two studies described computerized decision-support systems to measure the intervention's impact on adverse drug events (ADEs) and appropriate drug orders. Five studies described clinical pharmacist activities, most commonly involving a medication review, and used various measures of suboptimal prescribing, including a measure of medication appropriateness and the total number of medications prescribed. Two studies each described multidisciplinary and multifaceted approaches that included heterogeneous interventions and measures of prescribing. Most (15/18; 83.3%) of these studies reported statistically significant improvements in >or=1 aspect of suboptimal prescribing. Only 3 of the studies reported significant improvements in distal health outcomes, and only 3 measured ADEs or adverse drug reactions.

CONCLUSIONS

Mixed results were reported for a variety of approaches used to improve suboptimal prescribing. However, the heterogeneity of the study interventions and the various measures of suboptimal prescribing used in these studies does not allow for an authoritative conclusion based on the currently available literature.

A Pilot Study Evaluating the Feasibility of Psychological First Aid for Nursing Home Residents

OBJECTIVES: The objectives of the pilot study were to modify existing psychological first aid (PFA) materials so they would be appropriate for use with institutionalized elders, evaluate the feasibility of using nursing home staff to deliver the intervention to residents, and solicit feedback from residents about the intervention. The STORM Study, an acronym for "services for treating older residents' mental health", is the first step in the development of an evidence-based disaster mental health intervention for this vulnerable and underserved population. METHOD: Demographic characteristics were collected on participating residents and staff. Program evaluation forms were completed by staff participants during the pilot test and nurse training session. Staff and resident discussion groups were conducted during the pilot test to collect qualitative data on the use of PFA in nursing homes. RESULTS: Results demonstrate the feasibility of the PFA program to train staff to provide residents with PFA during disasters. CONCLUSIONS: Future research should focus on whether PFA improves coping and reduces stress in disaster exposed nursing home residents.

Systematic Review of Interventions to Improve Prescribing

Objective:

To update 2 comprehensive reviews of systematic reviews on prescribing interventions and identify the latest evidence about the effectiveness of the interventions.

Data Sources:

Systematic searches for English-language reports of experimental and quasi-experimental research were conducted in PubMed(1951–May 2007). EMBASE (1974–March 2008), International Pharmaceutical Abstracts (1970–March 2008), and 11 other bibliographic databases of medical, social science, and business research. Following an initial title screening process and after selecting 6 specific intervention categories (identified from the previous reviews) in community settings, 2 reviewers independently assessed abstracts and then full studies for relevance and quality and extracted relevant data using formal assessment and data extraction tools. Results were then methodically incorporated into the findings of the 2 earlier reviews of systematic reviews.

Data Selection And Synthesis:

Twenty-nine of 26,314 articles reviewed were assessed to be of relevant, high-quality research. Audit and feedback, together with educational outreach visits, were the focus of the majority of recent, high-quality research into prescribing interventions. These interventions were also the most effective in improving prescribing practice. A smaller number of studies included a patient-mediated intervention; this intervention was not consistently effective. There is insufficient recent research into manual reminders to confidently update earlier reviews and there remains insufficient evidence to draw conclusions regarding the effectiveness of local consensus processes or multidisciplinary teams.

Conclusions:

Educational outreach as well as audit and feedback continue to dominate research into prescribing interventions. These 2 prescribing interventions also most consistently show positive results. Much less research is conducted into other types of interventions and there is still very little effort to systematically test why interventions do or do not work.

Practice Guideline Dissemination and Implementation Strategies for Healthcare Teams and Team-Based Practice: a systematic review

OBJECTIVES

The objective of this systematic review is to describe and identify the effectiveness of different practice guideline implementation strategies on team-based practice and/or patient outcomes.

METHODS

A systematic review was conducted, using a comprehensive, reproducible search strategy that revealed 88 studies that met the inclusion criteria.

RESULTS

A descriptive analysis revealed multiple approaches using teams of health care providers with 72.7% of the studies reporting statistically significant results in knowledge, practice and/or outcomes. Of 10 dissemination strategies the most effective were reminders, and audit and feedback. The most popular strategy was education meetings. A secondary analysis revealed different populations with chronic or complex disorders where a team approach was effective in practice guideline dissemination and implementation.

CONCLUSIONS

Many of the studies provided caveats to explain how or why the strategies did or did not demonstrate improvements. Overall, authors described complex health care requiring increasingly complex approaches to ensure evidence based guidelines were utilised in practice, including using multiple dissemination and implementation strategies. The review has provided evidence that a multi-pronged approach to dissemination and implementation of practice guidelines will assist in gaining significant improvements in change in knowledge, practice and patient outcomes.

The evidence-based dentistry champions: a grassroots approach to the implementation of EBD

In order for evidence-based dentistry (EBD) to become part of decision making in practice, the most current and comprehensive research findings must be translated into practice. The use of Champions, influential individuals to support the transfer of knowledge among their peers, is one effective approach used by others in the health care field to successfully implement science research into clinical care. With the success of Champions in other health care areas, the American Dental Association (ADA) and the Journal of Evidence-Based Dental Practice, through an educational grant from Procter and Gamble, have launched a novel program to develop Evidence-Based Dentistry Champions. The EBD Champion program is developing a network of oral health care workers who will disseminate information about the application of an evidence-based approach to dental care and will serve as resources and mentors to their colleagues. The primary mechanism for developing the network of EBD Champions is through 3 annual EBD Champion Conferences, the first of which will be held at the ADA Headquarters in Chicago, IL, on May 2 and 3, 2008. The EBD Champion will serve as a resource to the practitioners in their communities, providing a grassroots approach to facilitating the implementation of an evidence-based approach to providing dental care.

Effect of an educational intervention on optimizing antibiotic prescribing in long-term care facilities

OBJECTIVE

To assess the effect of an educational intervention aimed at optimizing antibiotic prescribing in long-term care (LTC) facilities.

DESIGN

Cluster randomized, controlled trial.

SETTING

Eight public LTC facilities in the Montreal area.

PARTICIPANTS

Thirty-six physicians.

INTERVENTION

The educational intervention consisted of mailing an antibiotic guide to physicians along with their antibiotic prescribing profile covering the previous 3 months. Targeted infections were urinary tract, lower respiratory tract, skin and soft tissues, and septicemia of unknown origin. In the prescribing profile, each antibiotic was classified as adherent or nonadherent to the guide. Physicians in the experimental group received the intervention twice, 4 months apart, whereas physicians in the control group provided usual care.

MEASUREMENTS

Data on antibiotic prescriptions were collected over four 3-month periods: preintervention, postintervention I, postintervention II, and follow-up. A generalized estimating equation (GEE) model was used to compare the proportion of nonadherent antibiotic prescriptions of the experimental and control groups.

RESULTS

By the end of the study, nonadherent antibiotic prescriptions decreased by 20.5% in the experimental group, compared with 5.1% in the control group. Based on the GEE model, during postintervention II, physicians in the experimental group were 64% less likely to prescribe nonadherent antibiotics than those in the control group (odds ratio=0.36, 95% confidence interval=0.18-0.73).

CONCLUSION

An educational intervention combining an antibiotic guide and a prescribing profile was effective in decreasing nonadherent antibiotic prescriptions. Repetition of the intervention at regular intervals may be necessary to maintain its effectiveness.

Use of Diagnostic Tests for Presumed Lower Respiratory Tract Infection in Long-Term Care Facilities

OBJECTIVES

To describe the current use of diagnostic tests for management of presumed lower respiratory tract infection in selected long-term care facilities (LTCFs) in Canada and to correlate test use with facility and resident characteristics.

DESIGN

Prospective, 12-month multicenter cohort study.

SETTING

A convenience sample of 21 LTCFs in Canada.

PARTICIPANTS

LTCF residents prescribed antimicrobial therapy for presumed lower respiratory tract infection.

MEASUREMENTS

Data collection included facility characteristics, patient demographics, level of care, comorbidities, clinical presentations, diagnostic testing, and outcomes. Diagnostic test use was correlated with facility access and resident and episode characteristics.

RESULTS

Forty-two percent of 1,702 episodes had chest radiography obtained, 28.5% had pulse oximetry, 23.8% had peripheral leukocyte count, and 3.3% had sputum culture. On-site access correlated with obtaining chest radiography (odds ratio (OR)=4.4; 95% confidence interval (CI)=3.2-6.0) and oximetry (OR=30.3; 95% CI=16.4-55.8). Analyses stratified according to facility found that greater test use was associated with greater premorbid functional impairment and more-severe presentations. Advance directives, time to stabilization, and mortality did not correlate with test use. In multivariate analysis, significant variability between facilities for chest radiography and oximetry remained after incorporating differences in access to diagnostic testing and other facility or resident variables.

CONCLUSION

The use of diagnostic tests in the management of presumed lower respiratory tract infection in these Canadian LTCFs is highly variable. Access to diagnostic tests and severity of presentations correlate with test use but do not fully explain the variability in use in institutions.

Barriers to and facilitators of clinical practice guideline use in nursing homes

OBJECTIVES

To identify barriers to and facilitators of the diffusion of clinical practice guidelines (CPGs) and clinical protocols in nursing homes (NHs).

DESIGN

Qualitative analysis.

SETTING

Four randomly selected community nursing homes.

PARTICIPANTS

NH staff, including physicians, nurse practitioners, administrative staff, nurses, and certified nursing assistants (CNAs).

MEASUREMENTS

Interviews (n=35) probed the use of CPGs and clinical protocols. Qualitative analysis using Rogers' Diffusion of Innovation stages-of-change model was conducted to produce a conceptual and thematic description.

RESULTS

None of the NHs systematically adopted CPGs, and only three of 35 providers were familiar with CPGs. Confusion with other documents and regulations was common. The most frequently cited barriers were provider concerns that CPGs were "checklists" to replace clinical judgment, perceived conflict with resident and family goals, limited facility resources, lack of communication between providers and across shifts, facility policies that overwhelm or conflict with CPGs, and Health Insurance Portability and Accountability Act regulations interpreted to limit CNA access to clinical information. Facilitators included incorporating CPG recommendations into training materials, standing orders, customizable data collection forms, and regulatory reporting activities.

CONCLUSION

Clinicians and researchers wishing to increase CPG use in NHs should consider these barriers and facilitators in their quality improvement and intervention development processes.