Sheryl Zimmerman, C. Madeline Mitchell, Anna Song Beeber, Christine Kistler, David Reed, Latarsha Chisholm, Rosanna Bertrand, Philip D. Sloane
This paper describes and examines the implementation of a quality improvement (QI) program to reduce potentially inappropriate antibiotic prescribing in residential care/assisted living (RC/AL) and nursing homes (NHs) in the context of organizational performance. A QI program that included evidence-based medical provider training related to prescribing, use of a standardized form to communicate signs and symptoms of infection, resident and family education, and ongoing monitoring and feedback and monthly QI meetings was implemented in four RC/AL settings and six NHs in North Carolina. Program fidelity was assessed during monthly team meetings and by medical record review, and facilitators and barriers to implementation were identified by interviews with medical providers and staff. Results were considered in light of both setting types operating as complex adaptive systems. It was challenging to train the numerous medical providers in RC/AL settings, but it was markedly easier to train the NH providers, who championed the QI program. On the other hand, evidence of change in staff practices was more evident in RC/AL, but staff in both settings were receptive to learning the signs and symptoms of infection that need to be communicated to better inform antibiotic prescribing. Change in antibiotic prescribing in RC/AL and NHs can be achieved through better informed and increased communication between long-term care staff and medical providers. By implementing the same QI program in both RC/AL and NH settings, the centrality of the role of the health care supervisor in RC/AL and the need for medical provider endorsement in NHs became clear. Consequently, efforts to change prescribing behavior must be tailored according to the setting.
Over 2 million Americans live in long-term care settings, including residential care/assisted living (RC/AL) and nursing homes (NHs).1,2 Residents in these settings are at greater risk than others of developing infections, due to their age and disability, but the overuse and sometimes inappropriate use of antimicrobials to treat suspected infections has led to the development of resistant organisms, thereby complicating treatment.3–6 Attesting to the magnitude of the challenge resulting from antibiotic resistance, the World Health Organization calls it one of the three greatest threats to human health and, along with the Centers for Disease Control and Prevention, has issued recommendations targeted to long-term care and other high-risk populations.7,8
Numerous strategies have been implemented to address the problem of overprescribing in NHs, including establishing prescribing guidelines,9 studying the prevalence and incidence of antibiotic use, and designing interventions to improve prescribing. These interventions range from monitoring to complex protocols that provide didactic sessions and performance feedback. Their goal has been either to reduce a specific type of infection or to increase the appropriateness of the choice of antibiotic; unfortunately, all have had limited success, in part due to insufficient adoption and sustainability.10–15
The extent to which change is successfully adopted and sustained in health care organizations depends on a host of considerations, which are reflected in the theory of complex adaptive systems.16–20 Complex adaptive systems are characterized by diverse, interrelated yet independent stakeholders whose interactions are complex, varied, and unpredictable. Modifications in the system are nonlinear and emerge from learning, adaptation, and self-reorganization.16,19,20 Based on this framework, interventions to increase appropriate antibiotic prescribing should identify all stakeholders and their interconnections, understand existing practices, maximize communication and collaboration, use influence rather than power, and establish a method for ongoing self-monitoring as the system learns, adapts, and changes over time.16,19–24 Flexibility in implementation is to be expected as the system evolves, but the intent is to maintain the integrity of the intervention.21,22
Based on our understanding of health care organizations as complex adaptive systems, we worked with four RC/AL communities and six NHs in North Carolina to implement a multicomponent quality improvement (QI) program to reduce potentially inappropriate antibiotic prescribing. The effort was grounded in a conceptual model that views the prescribing decision as a result of the interplay between the patient and his/her clinical condition; patient and family knowledge, attitudes, and beliefs regarding the illness and treatment; the structures and care processes in the setting, as well as staff knowledge, attitudes, and beliefs related to the illness and treatment; and the provider, including the characteristics of the medical practice.
In this paper, we describe the adoption and sustainability of that program in the context of organizational behaviors and health care as a complex adaptive system. While the sample was small and the region local, the results have implications for the dissemination of this and similar QI interventions in other RC/AL communities and NHs.
Based on the conceptual model (Figure 1), the program to reduce potentially inappropriate antibiotic prescribing included four key components: (1) evidence-based training geared to medical providers who prescribe medications for RC/AL or NH residents; (2) use of a standardized communication form for long-term care staff to convey relevant signs and symptoms to inform prescribing; (3) a brochure for residents, their families, and direct care staff to explain the risks associated with the overuse of antibiotics and situations in which antibiotics are not indicated; and (4) ongoing monitoring and feedback in the context of a QI program. In addition, in-service training was provided to all staff so that they were aware of the QI program and sensitized to the importance of antibiotic overuse and resistance.
Figure 1. Conceptual model related to prescribing decisions in residential care/assisted living and nursing homes
The project was first initiated in four RC/AL settings and 3 months later in six NHs; in addition, six NHs served as control sites. In the intervention NHs, one provider practice (a group of providers who work together under the auspices of the same corporate entity) served the majority of residents, and the medical directors chose to participate to better inform and reduce their practice's potentially inappropriate prescribing. All settings were located in North Carolina and enrolled in the Collaborative Studies of Long-Term Care. Approval for this work was received from the institutional review boards of the University of North Carolina and Abt Associates Inc., and from the Office of Management and Budget.
Evidence-Based Medical Provider (Prescriber) Training
The content of the prescriber training was based on a comprehensive literature review5 and consultation with an expert medical panel; in addition, it included baseline data regarding prescribing rates and the extent to which prescribing practices met the Loeb prescribing guidelines.9 Training began with an overview of the problem of antibiotic resistance and inappropriate prescribing, followed by case-based training on prescribing for urinary, respiratory, and skin infections, as well as situations where antibiotics are often inappropriately prescribed. Guidelines were then presented for selecting an antibiotic. The training was packaged as a five-module, Internet-based program to facilitate later dissemination and adoption. Also, a laminated pocket card was developed that summarized 12 common situations in which systemic antibiotics are generally not indicated. Completion of the five modules took approximately 90 minutes, and trainees involved in the project (individuals who prescribed antibiotics in the study sites) received 10 hours of continuing education credit.
Use of a Standardized Communication Form
Medical provider training addressed the signs and symptoms to be considered according to antibiotic prescribing guidelines. The research team developed a standardized communication form based on these signs and symptoms for completion by long-term care staff to ensure that the provider was informed about the resident's condition. This Medical Care Referral Form (MCRF) was shared in draft form with staff in each setting and modified to meet their needs (e.g., an area was included for providers to record orders). The form also included an area for open-ended text to describe the problem and areas to record vital signs and (if appropriate) information related to a fall, the resident's general health status, and relevant medical history. Some of this information (e.g., related to a fall) was included to increase the suitability of the form for all medical encounters. The form was intended to be used in all instances when contact was made with a medical care provider for anything other than routine care or a followup visit. A 45-minute training session was held with the staff responsible for completing the form, which covered problems of antibiotic overuse and associated risks, use of the MCRF, case studies, and information indicating the extent to which previous prescribing met guidelines.
Resident and Family Education
Recognizing that many lay people consider antibiotics to be the first line of treatment, the research team developed a pamphlet that illustrated common side effects of antibiotics and explained situations where antibiotics are not needed, why a doctor might prescribe an antibiotic when it was not needed, what the patient/family can do to promote better prescribing and recovery, and what the patient/family should not do (e.g., demand an antibiotic). This pamphlet was intended for distribution to all current residents, to new residents at the time of admission, and when hospice was being considered.
Ongoing Monitoring and Feedback and Monthly QI Meetings
A QI team and team leader were identified in each setting, with the intent that this team meet at least monthly. Members of the research team participated in QI meetings, during which they provided updated information about prescribing and the extent to which reported signs and symptoms were meeting guidelines. Team members also discussed the process of prescribing and use of the MCRF and helped to solve problems. Additional QI efforts included in-service education for all staff and training for new staff; distribution of five "practice briefs" related to antibiotic prescribing to all providers and involved long-term care staff; periodic ongoing contact with providers and staff; and education for residents and their families.
Results related to the four methods of the antibiotic prescribing program are summarized separately for RC/AL settings and NHs in Table 1 and described in more detail below.
Table 1. Implementation of the four components of the antibiotic prescribing program, by setting type
|Component||Residential Care / Assisted Living (N=4)||Nursing Homes (N=6)|
|Provider training||Attempted to train 243 providers; 7% completed the training||Attempted to train 9 providers; 7 (78%) completed the training|
|Standardized form (MCRF) used by long-term care staff||In final month of implementation, presumed infection was documented on the form 25% of the time antibiotics were prescribed*||Overall, the form was used in less than 2% of presumed infections|
|Brochure for residents, families, and others||Positively received by long-term staff; anecdotal report of use||Positively received by long-term staff and providers; anecdotal report of use|
|QI program||Barriers to implementation included staff turnover; limited number of supervisory staff; limited number of staff using MCRF; lack of physician involvement; and medical care provision off-site||Barriers to implementation included policy and practices (especially related to the use of the MCRF); resident or family concerns; and staff turnover and resistance to change|
MCRF = Medical Care Referral Form; QI = quality improvement.
*It is not certain that the form was used for the same prescribing event. A total of 39 antibiotics were prescribed, and 10 forms documented presumed infection; however, some of these forms may not have resulted in an antibiotic prescription.
Evidence-Based Medical Provider (Prescriber) Training
In the four RC/AL settings, 243 medical providers were identified as those who served as the residents' primary care providers or prescribed them medications (e.g., emergency department physicians). All received a letter informing them of the QI project, stressing the important issue of antibiotic resistance, and providing information about and a link to the Web-based training. Due to low uptake (only 11 providers accessed the Web site), the five providers in each RC/AL community who had prescribed the most antibiotics at baseline were offered an honorarium of $250 if they completed the five training modules. In total, 20 individuals (8 percent) began the training, and 16 (7 percent) completed it.
As the time approached to train the NH medical providers, the research team decided to conduct their training on-site, face-to-face, in a 4-hour session. All seven providers in the engaged medical practice attended the training, although two additional providers who treated residents in those NHs did not.
Use of a Standardized Communication Form
Nurses are not uniformly employed in RC/AL settings,25 and in only one of the four RC/AL sites was completion of the MCRF the responsibility of a nurse; elsewhere, this task was assigned to individuals such as medication aides. Over time, use of the form became common but not always when an antibiotic was prescribed. For example, in the last month of the study, 39 prescriptions for antibiotics were written across the four settings, and the form was completed 40 times; however, only 10 forms (25 percent) indicated the presence of a possible infection, and the majority of the forms (73 percent) were not fully completed. Medical providers wrote a response (e.g., a medical order) on 34 (85 percent) of the forms. Staff in all four settings indicated that the specificity of this form provided them direction and was a great improvement over the one previously in use, which was essentially an open-ended field in which the staff described the presenting problem.
In the NHs, the staff quickly noted that the form was burdensome and unnecessary for many of their contacts with providers. Here, higher resident acuity translated to more medical encounters, many of which were related to chronic care. Further, the nursing staff were better able to discern the reason for contact than were the RC/AL staff; they were in more frequent contact with the providers, and they regularly documented changes in resident condition in the nursing chart. Consequently, the staff and providers asked that use of the form be limited to times when a resident had a new condition and an infection was suspected. Even with that change, the MCRF was rarely completed (e.g., it was completed for fewer than 2 percent of infections that were treated with an antibiotic). However, nursing staff reported that the form served as a means to sensitize them to the information they needed to compile when communicating with a medical provider.
Resident and Family Education
As planned, a supply of brochures was given to staff in all RC/AL and NH settings; however, other than anecdotal reports, there was no indication that the brochures were distributed. Further, in one RC/AL setting, rather than distributing the brochures, the staff left the brochures on a table. In the NHs, on the other hand, the medical care providers themselves requested that they be given a supply of brochures, so they could distribute them when indicated. Other activities directed toward residents, families, and staff were carried out in the NHs (but not in the RC/AL settings) at the research team's invitation and the administration's request, including presentations made at family night (three occurrences), at a resident council (one occurrence), and at a community health fair (one occurrence).
Ongoing Monitoring and Feedback and Monthly QI Meetings
QI team meetings were held monthly in the RC/AL settings to discuss implementation, barriers, and facilitators. Members of the team primarily included the health care coordinator, medication aides, and the administrator. These meetings were scheduled and attended by the research staff and endorsed by the RC/AL leadership program; however, it is unlikely that the meetings would have occurred absent the research team's initiative. Similarly, because it quickly became evident that the program required active involvement by the research team, a research liaison visited each RC/AL setting on a weekly basis to promote use of the MCRF, answer questions, and address concerns.
Barriers to program adoption identified by RC/AL staff included staff turnover; the limited number of supervisory staff available to train new staff; the limited number of staff qualified/allowed to use the MCRF (because most staff lacked medical training); the lack of physician involvement in the program; and the fact that medical care was typically provided off-site. Overall, program implementation was limited to the time that the health care coordinator was on site.
The QI meetings were also convened monthly in the NHs and attended by research staff. Participants included the director of nursing, the infection control nurse, the staff development coordinator, and often the administrator. During these meetings, clinical and infection control questions were raised and referred to the research team's infectious disease expert or the research clinicians in attendance. Identified challenges to implementation included NH policy and practices (especially related to the use of the MCRF), resident or family concerns, and staff turnover and resistance to change. Most often, the QI teams reported that the customary practice of reporting orally to on-site providers, or by telephone to off-site providers, was an impediment to the written use of the MCRF. Further, documentation policies often required duplicate recording of the signs and symptoms when staff used the MCRF, a disincentive to its use. However, in every NH, the form was considered to be a helpful informational tool by providing the specific signs and symptoms that are important to report to providers. The QI teams also reported that the informational brochure was helpful to review with residents and families when questions or concerns about the use of antibiotics arose. Further, every team endorsed the goals of the program, the content of the training and educational materials, and the inclusion of multiple stakeholders in the program (i.e., providers, staff, and residents/families).
Change in Antibiotic Prescribing
Despite the limited provider training achieved in RC/AL settings and little use of the MCRF in NHs, both settings evidenced change in antibiotic prescribing. In RC/AL settings, a non-significant decreased trend in potentially inappropriate prescribing was observed and described in a forthcoming paper;26 and in NHs, a significant reduction in antibiotic prescribing was achieved. These results will be described in forthcoming papers.
When conceiving this project to reduce antibiotic use in different settings, we assumed that implementation would be both more and less challenging in RC/AL settings compared to NHs. We assumed it would be more problematic to reach RC/AL providers due to their sheer number and the many practices in which they worked. On the other hand, we assumed it would be easier to effect change in staff practices—most notably through use of the MCRF—because the system is less stringently regulated. Both of these assumptions were borne out, yet change in prescribing practices was achieved, suggesting that RC/AL staff can be active change agents in regard to antibiotic prescribing. In the NHs, however, it was markedly easier to reach the providers but more challenging to change documentation practices. While there was anecdotal evidence that NH staff communication changed, we believe the more certain and likely change agents were the providers themselves because they asked to be involved in the project to better inform their prescribing. In both settings, there was no evidence that residents and families effected change, but that cannot be ruled out.
These findings are consistent with the fact that there is no single point of control in a complex adaptive system.16 The fact that health care supervisors can influence medical care in RC/AL settings (surmised based on the decreased trend in potentially inappropriate prescribing despite little provider training) is an important finding, especially considering physicians' concerns about the skills of RC/AL staff. In other studies, physicians reported less confidence in the abilities of RC/AL staff compared to those in NHs but indicated that informed communication improved their confidence.27 At the same time, RC/AL health care supervisors considered clinical care coordination and communication to be an important component of their role,28 which is consistent with their receptivity to the MCRF. Training RC/AL staff to better communicate with medical providers, as was done with the MCRF, may well be the most effective way to improve medical care in these settings; further, it may ultimately improve the satisfaction of all stakeholders.29
Despite the fact that medical providers are more often on site in NHs (e.g., all NHs have medical directors), it should not be assumed that they are more involved in resident care than are RC/AL primary care providers. In fact, NH physicians have been charged with being "missing in action."30 Rather, as noted above, we believe the success of the project can be attributed to the buy-in of the involved provider group, rather than their presence in the NH per se. Influential leadership, such as that shown through the NH medical directors' commitment to the goals of the QI program, is more likely to achieve desired outcomes than directives from top management.16 In terms of training medical providers, the effective 4-hour classroom format could easily be replicated at national meetings, such as the annual meeting of the American Medical Directors Association.
Although fidelity in program implementation is necessary, systems-level interventions require flexibility to accommodate variation across settings.19,21,23 In this project, the MCRF was modified according to staff request, while still maintaining the integrity of the signs and symptoms related to infections. In future work, completion of the form may be advocated in RC/AL settings, whereas it may best be used as a training and reference tool in NHs; indeed, the nurses clearly indicated that this additional paperwork was burdensome, a lesson important for other QI efforts. Doing so would be similar to how NH staff used the laminated pocket card, which was well received (staff asked for additional copies). In fact, had the project continued longer, the protocol for use of the MCRF would have been changed in this very manner, consistent with current wisdom that adhering to fixed interventions may be short-sighted.31 It should be noted, though, that while the MCRF was not completed on a consistent basis, review and discussion of the form during QI meetings promoted dialogue about the importance of identifying and managing infections and communicating with providers. Research on intervention implementation highlights the importance of conversation for "sensemaking" and learning, when members of an organization discuss practice change, analyze the process, and strategize how to adapt to modify their practices.22
We framed our discussion based on the theory of complex adaptive systems because this theory describes the functioning of both NHs and RC/AL settings. In so doing, it is the only literature of which we are aware that recognizes RC/AL akin to other health care organizations in this regard. While the methods described here are consistent with other systems-level approaches as well and do not fully address all components of the theory, understanding both of these settings as complex adaptive systems provides several important observations and guidance for other QI efforts.
Change in antibiotic prescribing in RC/AL and NH settings may be achieved through better informed and increased communication between long-term care staff and medical providers. However, communication strategies of signs and symptoms must be consistent with the practices of the individual setting. Unless medical providers are more directly involved with RC/AL settings, health care supervisors can and should take an active role in helping to better inform antibiotic prescribing. In NHs, change in practices is more likely to occur when providers themselves are committed to the effort.
This project was funded under contract numbers HHSA 2902007100141 and HHSA 290200600011I from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. The authors thank the residents, staff, and other health care providers who participated in the Collaborative Studies of Long-Term Care.
Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC (SZ, CMM, DR, LC, PDS). School of Social Work, University of North Carolina at Chapel Hill (SZ). School of Nursing, University of North Carolina at Chapel Hill (ASB). Department of Family Medicine, University of North Carolina at Chapel Hill (CK, PDS). U.S. Health Division, Abt Associates Inc., Cambridge, MA (RB).
Address correspondence and requests for materials to: Sheryl Zimmerman, PhD, University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research, 725 Martin Luther King Jr. Boulevard, Campus Box 7590, Chapel Hill, NC 27599-7590; Email: Sheryl_Zimmerman@unc.edu.
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