A Multidisciplinary Approach to Antibiotic Stewardship in Long-Term Care

Abstract

Problem & purpose: The aim of this quality improvement project was to implement and evaluate the effectiveness of the Loeb Minimum Criteria within a long-term care (LTC) unit with the goal of decreasing unnecessary testing for urinary tract infections (UTIs). In older adults, a UTI is the most common diagnosis for which antibiotics are prescribed. Prevalence of asymptomatic bacteriuria ranges from 25-50%, and many of these patients are treated with antibiotics that are not warranted. The absence of clinical education and use of evidence-based practices lead to an increase in the potential for unnecessary testing and treatment. Methods: Within a 30-bed LTC unit in Howard County, Maryland, UTI’s are one of the most treated infections, however, there was no antibiotic stewardship program in place. A staff of 15 nurses, and 1 nurse practitioner (NP) participated in education sessions regarding the Loeb Minimum Criteria and were given the algorithm to follow. A post-test was administered to nursing staff following the education session to assess effectiveness. Change in behavior of the nursing staff when communicating symptoms to the provider was assessed by a pre/post- implementation survey completed by the NP. Pre-test results informed ongoing educational efforts. Urinalysis, culture, and sensitivity (UA C&S) orders were monitored pre-implementation and monthly to assess for the effective use of the algorithm on ordering practices. Results: Compared to the year prior, there was an 81% decrease in UA C&S sent during the implementation phase. Following the education session 66% of nursing staff identified greater than 50% of points outlined in the Loeb Minimum Criteria. Provider post-test indicated a 10% increase in the accuracy of reporting symptoms by the nursing staff. Conclusion: This project shows promise that increased education and awareness of antibiotic stewardship programs have the potential to influence the frequency of testing LTC residents receive with the potential to reduce unnecessary prescribing of antibiotics. Internal challenges related to staffing acted as a primary barrier to participation. Critical components of successful implementation of QI projects within the long-term care setting include buy in from administration, and collaboration with clinical staff. NPs are knowledgeable about antibiotic stewardship practices but lack the time needed to implement programs.