Standardized Antibiotic Use in Long-Term Care Settings (SAUL Study)

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Slide 1

Standardized Antibiotic Use in Long-Term Care Settings (SAUL Study)

Steven Garfinkel
American Institutes for Research
AHRQ Annual Conference, Bethesda, MD, September 10, 2012

Project Cosponsored by the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality under AHRQ Contract# HHSA290200600019I.

Images: The logos of the American Institutes for Research, Texas A&M Health Science Center, TMF Health Quality Institute, and the University of Maryland (MU) are shown.

Slide 2

The Intervention

• Reduce inappropriate antibiotic use.
• Communication and Order Form:
  • SBAR format.
  • Loeb criteria.
  • For use by nurses and physicians.

Slide 3

SAUL Project SBAR Tool

B - Background

Indwelling catheter: ___ No ___ Yes

Incontinence: ___ No ___ Yes If yes, is this new/worsening? ___ No ___ Yes

Active diagnoses (especially, bladder, kidney/genitourinary conditions):
Specify:
___________________________________________

Medication Allergies: ___ No ___ Yes
Specify: ___________________________________________

The resident is on: Warfarin (Coumadin™) ___ No ___ Yes

The resident is diabetic: ___ No ___ Yes

Slide 4

SAUL Project SBAR Tool

S - Situation
___ I am contacting you about a suspected UTI for [state name of resident]

Current Assessment:
___ Increased Urgency
___ Increased frequency
___ Hematuria
___ Rigors (shaking, chills)
___ Deirium (sudden onset of condusion, disorentation, dramatic change in mental status)

Vital signs: BP ___/___ Pulse ___ Resp. rate ___ Temp. ___

Resident complaints:
___ Dysuria (painful, burning, difficult urination) ___ Suprapubic pain ___ ___ Costovertebral tenderness (flank pain/tenderness)

Recent Urinalysis Results if Available:

UA results that were obtained on ________ (due date) due to ___________ (reason).
The results ___ accompany this fax ___ are as follows: __________________________

Slide 5

SAUL Project SBAR Tool

Image: The tool cross-references Assessment (What do you think is going on with the resident?) and Recommendation. Two key points are considered—whether or not the resident has an indwelling catheter and whether or not the protocol criteria under each is met.

Slide 6

SAUL Project SBAR Tool

Image: A form page from the tool featuring Physician/NP/PA Orders is shown.

Slide 7

Research Activities

1. Literature Review.
2. Usability testing of data collection instruments with NH staff.
3. Small-Scale Trial (SST)of intervention with 4 homes.
4. Field test (FT) with 12 homes.
5. Debriefing interviews with NH staff.

Slide 8

Data Collection Process (Monthly)

Infection Log in home to identify all those with a Rx for a suspected UTI.
MDS data for these residents.
Medical records for orders and notes related to Rx and Dx.

Slide 9

Research Design For Field Test

Slide 10

Outcomes

• Shift in distribution of prescriptions between symptomatic and asymptomatic UTIs.
• Number of prescriptions written.

Slide 11

Results: Implementation

Fidelity to implementation protocol varied.
Was not dependent upon the level of education and training provided.
Four homes were "implementers" (high level of fidelity)—three were from the high intensity education arm and one from the low intensity arm.

Slide 12

Rx For UTIs (?) By Homes Classified According To Fidelity (per protocol)

Slide 13

% Change In Prescriptions Without Localized Symptoms

Image: A bar graph shows the following data:

• Training Intensity (Intent to Treat):
  • High Intensity: -8.7%.
  • Low Intensity: -13.6%.
  • Comparison, 2.5%.
• Fidelity (Per-Protocol):
  • High Fidelity: -23.8%.
  • Low Fidelity: -3.16%.
  • Comparison, 2.59%.

Slide 14

Rx For Suspected UTIs Dropped Significantly, And Then Rebounded

Image: A line graph compares Implement and Non-implement rates per month from March until the following February.

Slide 15

Results: Barriers To Implementation

Turnover, particularly in leadership.
Competing demands from the corporate level.
Resistance from nurses and physicians.
Lack of champions/mandates.