Enhanced implementation on the adoption of evidence-based antibiotic stewardship in nursing homes focused on the recognition and management of urinary tract infections (UTIs) may improve the quality of antibiotic prescription in nursing homes, according to a trial protocol published in JAMA Network Open.

Antibiotics are the most commonly prescribed medications in nursing homes, with at least 1 course of antibiotics prescribed to individuals who have been residents of the facility for longer than 6 months. The most common trigger of antibiotic prescription and most common reason for inappropriate antibiotic use in nursing homes is the suspicion of a UTI. This highlights a need for improvement in the recognition and management of UTIs in nursing homes. In addition, to achieve a wider dissemination of antibiotic stewardship interventions in nursing homes, a better understanding of how intervention adoption is influenced by implementation approach is needed, and studies focused on the implementation of quality improvement interventions in nursing homes are rare. Therefore, this cluster-randomized hybrid type 2 effectiveness-implementation clinical trial aims to compare the effects of 2 implementation strategies on the adoption and effects of a quality improvement toolkit to enhance the recognition and management of UTIs in nursing homes (ClinicalTrials.gov identifier: NCT03520010).

This study will be performed during a 6-month baseline period and a 12-month post-implementation period. This study hopes to include a minimum of 20 nursing homes in Wisconsin that have ³50 beds; each nursing home will be randomly assigned in block sizes of 2, stratified by rurality: either rural or urban. Every patient tested for or treated for a UTI in study nursing homes will be included in the study analysis.

Enhancement of both the recognition and management of UTIs will be implemented in all included nursing homes via a quality improvement toolkit. The included nursing homes will be randomly assigned to either a usual or an enhanced implementation approach. The usual approach will include a kick-off meeting to introduce the components of the toolkit and will provide access to web-based training resources and improvement tools. The enhanced approach will include the same kick-off meeting and online resources, but will also include external facilitation/coaching, peer comparison feedback, and collaborative peer learning. The coaching will be delivered via a trained nurse through regular telephone calls. Nursing homes in the enhancement group will also be able to visualize their performance over time and compare their performance to other nursing homes. The protocol authors hypothesized that nursing homes with enhanced implementation will show improvements in adoption of the quality improvement toolkit and clinical outcomes.

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The primary outcomes of this study are the number of urine cultures per 1000 resident-days and the number of antibiotic prescriptions for treatment of suspected UTI per 1000 resident-days. Secondary outcomes include appropriateness of UTI treatments, use of fluoroquinolones, treatment length, and resident transfers and mortalities. To assess the extent and determinants of adoption of the UTI quality improvement toolkit, a mixed-methods evaluation approach will be used.

Once this study has concluded, the study authors hope to have assessed the effects of enhanced implementation on adoption of evidence-based antibiotic stewardship practices in Wisconsin nursing homes and to have determined the key facilitators and barriers associated with the 2 implementation approaches used.

Overall, the authors highlighted that, “The knowledge generated from this project could benefit subsequent projects focused on dissemination of the Wisconsin UTI Improvement Toolkit to other facilities in the state and facilitating implementation of other types of interventions to improve the quality of antibiotic prescribing in [nursing homes].”

Reference

Ford II JH, Vranas L, Coughlin D, et al. Effect of a standard vs enhanced implementation strategy to improve antibiotic prescribing in nursing homes: a trial protocol of the improving management of urinary tract infections in nursing institutions through facilitated implementation (IMUNIFI) study. JAMA Network Open. 2019;2(9):e199526.