Workflow Barriers and Strategies to Reduce Antibiotic Overuse in Nursing Homes

Abstract

OBJECTIVES: Antibiotic overuse is a significant problem in nursing homes (NHs). Strategies to improve antibiotic prescribing practices in NHs are a critical need. In this study, we analyzed antibiotic prescribing workflows to identify strategies for improving antibiotic prescribing in NHs. DESIGN: Qualitative descriptive study using prospective field-based assessment of workflows. SETTING: Six NHs in Wisconsin (n = 3) and Pennsylvania (n = 3). PARTICIPANTS: A total of 44 interviews with 68 NH professionals, including leadership, nurses, and prescribers. MEASUREMENTS: During a 1-day field visit in each NH, we conducted semistructured interviews with NH professionals, collected artifacts (policies, procedures, and documentation and communication tools), and observed clinical meetings. Study participants were interviewed (30-60 minutes) about antibiotic prescribing workflows in their facility. Information collected during site visits was used to create a representative workflow map of NH antibiotic prescribing. The workflow map guided thematic analysis to identify barriers corresponding to workflow steps across multiple NHs. RESULTS: The representative antibiotic preprescribing workflow map included 17 steps, beginning with resident change in condition and ending with the decision to prescribe an antibiotic. Thematic analysis identified common step-specific barriers to antibiotic stewardship centering on three themes: (A) information barriers, comprising (A1) inconsistent nurse assessment report and (A2) misalignment between the work and tools of information sharing within the facility, (B) communication barriers, comprising (B1) mismatched perception of prescriber information needs and (B2) difficulty reaching prescribers for direct interaction, and (C) professional barriers, comprising (C1) low prescriber confidence in nurse assessment report and (C2) nurse reluctance to express their professional opinions. CONCLUSION: Strategies addressing workflow barriers are important targets for antibiotic stewardship. Such strategies include structured information tools, nurse and prescriber education, and organizational improvement. Future research can build on combinations of existing and new strategies to measure their effects in improving antibiotic prescribing.

Characteristics of telemedicine workflows in nursing homes during the COVID-19 pandemic

“…The SEIPS model has been employed to identify human factors involved in the implementation of telemedicine encounters in NHs during the COVID-19 pandemic [17] and identify work system enhancements in NHs that had newly adopted telemedicine [18]. The creation of process maps, as done in this study, can help identify barriers and opportunities for improvement [23,24], and shows that there are multiple opportunities to enhance the effectiveness and efficiency of telemedicine encounters. Specific weaknesses identified in this study include challenges with scheduling, lack of electronic health record (EHR) interoperability, absence of preencounter planning, and problems with post-encounter information exchange.…”

Nurses’ perceptions of the potential evolution of their role in antibiotic stewardship in nursing homes: a French qualitative study

“…with GPs, pharmacists and microbiologists), which plays a prominent role in ABS, 45 as already reported. This may be done through regular interdisciplinary meetings 47 , 48 and use of shared tools (e.g. protocols, guidelines) to guide infection management.…”

Rheumatology Clinic Staff Needs

“…26 Notably, our study methodologically paralleled process mapping for intervention development in other work by our study group. 27 First, a member of the research team (M.T.) who was not involved in the data collection reviewed a subset of transcripts and the preliminary coding scheme.…”