Key PointsQuestionDoes external facilitation improve adoption and effects of a complex antibiotic stewardship intervention in nursing homes?FindingsThis trial protocol describes a cluster-randomized hybrid type 2 effectiveness-implementation clinical trial of implementation of a multicomponent toolkit focused on improving the recognition and management of suspected urinary tract infection (UTI) in nursing homes. The trial seeks to evaluate whether delivery of external facilitation—coaching, collaborative learning, and peer comparison feedback—to implement this toolkit results in higher rates of toolkit adoption and reduced rates of urine testing and initiation of antibiotics for treatment of suspected UTI.MeaningIf successful, external facilitation could become an effective approach for improving spread and adoption of antibiotic stewardship interventions, as well as other quality improvement initiatives, in the nursing home setting.

Background: Suspicion of urinary tract infection (UTI) is the most common justification for prescribing antibiotics in nursing homes. More than half of antibiotic prescriptions for treatment of UTI in nursing homes are either unnecessary or inappropriate. Achieving a better understanding of the factors that underlie UTI treatment decisions is necessary to improve the quality of antibiotic prescribing in nursing homes. An ongoing hybrid type 2 effectiveness-implementation cluster randomized trial of a recently developed nursing home UTI recognition and management tool kit provided us with an opportunity to explore the influence of organizational, clinical, and staff attributes on UTI antibiotic prescribing practices in nursing homes. Methods: Data on antibiotic starts for suspected UTIs were collected in 29 nursing homes over a 9-month period. Antibiotic practices evaluated included total antibiotic starts per 1,000 resident days, % antibiotic starts with treatment duration >7 days, % antibiotic starts in which the initial antibiotic choice was a fluoroquinolone, and % antibiotic starts meeting UTI tool-kit criteria of appropriateness. Prior research and bivariate analyses were used to select clinical and organizational attributes as well as individual nursing staff-level retention rates for inclusion in a stepwise linear regression model for each antibiotic practice outcome. Results: In total, 602 UTI antibiotic events were evaluated. Four associations were identified for antibiotic starts including nursing home urine culture rate, ICP status, nonprofit and part-time LPN retention. Nursing homes with higher full-time LPN retention had a lower rate of antibiotic treatment duration >7 days. Full-time CNAs and part-time LPNs retention and for-profit status was associated with the proportion of fluoroquinolone antibiotic starts. No attributes influenced the proportion of antibiotic starts meeting appropriateness criteria (Fig. 1). Urine culture rates are driving overall nursing home antibiotic prescribing. Conclusions: Urine culture practices was strongly associated with UTI treatment rates in nursing homes. A variety of organizational characteristics were also associated with UTI treatment rates as well as other UTI antibiotic prescribing practices. Some of these associations appear paradoxical but may reflect increasing resident acuity and increased capacity to standardize practices through organizational centralization.Funding: Support for the project provided by the Wisconsin Partnership Program.Disclosures: None