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Evid Based Nurs 9:59 doi:10.1136/ebn.9.2.59
  • Quality improvement

A multifaceted intervention reduced antimicrobial prescriptions for suspected urinary tract infections in nursing home residents


 
 Q Does a multifaceted intervention supporting the use of diagnostic and treatment algorithms reduce antimicrobial prescriptions for suspected urinary tract infections (UTIs) in nursing home residents?

METHODS

GraphicDesign:

clustered randomised controlled trial.

GraphicAllocation:

concealed.

GraphicBlinding:

blinded (outcome assessors).

GraphicFollow up period:

12 months.

GraphicSetting:

16 nursing homes in Ontario, Canada and 8 in Idaho, USA.

GraphicPatients:

4217 residents of 24 free standing, community based nursing homes that had ⩾100 residents, no stated policies for diagnosis or treatment of UTIs, and agreed to refrain from introducing new management strategies for antimicrobial use or clinical pathways for UTIs during the 12 month study. Nursing homes directly associated with tertiary care centres were excluded.

GraphicIntervention:

12 nursing homes (2156 residents) were allocated to the intervention, which comprised introduction of UTI diagnostic and treatment algorithms in 30 minute, interactive, small group sessions for registered nurses or nursing assistants (videotaped for subsequent viewing by existing and new staff) and individual meetings with physicians who cared for ⩾80% residents. Copies of the algorithms, explanatory materials, pocket cards, and large posters (for all nursing stations) were provided. Nurses and physicians were asked to use the algorithms when assessing residents for fever or suspected UTI. In addition, nurses were asked to complete a 1 page log of presenting symptoms and signs in residents with suspected UTI as a reminder to use the algorithms. 1 staff member in each nursing home was assigned to remind nurses to use the algorithms. 12 nursing homes (2061 residents) were allocated to usual care.

GraphicOutcomes:

antimicrobial prescriptions, hospital admissions, and deaths.

GraphicPatient follow up:

20 nursing homes (83%) and 3754 residents (89%) were included in the analyses.

MAIN RESULTS

The intervention group had a lower proportion of total antimicrobial courses prescribed for suspected UTIs and a lower rate of antimicrobial courses used for suspected UTIs than the usual care group (table). The groups did not differ for hospital admissions or mortality (although the study was underpowered to detect between-group differences).

CONCLUSION

A multifaceted intervention supporting the use of diagnostic and treatment algorithms reduced prescriptions and use of antimicrobials for suspected urinary tract infections in nursing home residents.

Commentary

  1. Jennifer Skelly, RN, PhD
  1. School of Nursing, McMaster University, Continence Program, St Joseph:s Healthcare, Hamilton, Ontario, Canada

      UTIs are the most common bacterial infection in residents of long term care facilities; prevalence of asymptomatic bacteriuria is 15–50%.1 Loeb et al evaluated the effects of 2 algorithms designed to reduce the number of urine cultures sent and prescriptions given for suspected UTIs. This is the first such intervention trial in a nursing home setting. The investigators incorporated study design features to reduce selection bias, increase the representativeness of nursing homes in the community, and enhance compliance with the algorithms in the intervention group.

      Although the algorithms are not complicated, they do require users to have knowledge of the signs and symptoms of UTIs and non-UTIs in frail elderly residents. Many direct caregivers in long term care settings will be unregulated healthcare workers, and in-service education of such workers would be required.

      Nursing has a key role in identifying the symptoms of UTIs and sending samples for culture. In many facilities, nurses might send samples for culture and then contact the physician by phone to obtain a verbal order to initiate treatment, often before the results are confirmed. In the study by Loeb et al, the rate of cultures sent did not differ significantly between groups, but use of antimicrobials was reduced in the intervention group. It appears that, in accordance with the diagnostic algorithm, staff in the intervention group waited for culture results before initiating treatment, thus ensuring that only symptomatic patients with positive cultures were treated.

      From a nursing perspective, it is important to remember that many factors, such as low fluid intake, constipation, incontinence, perineal care, and incontinence products, can contribute to the development of UTIs in frail elderly people.1 A focus on appropriate management of these factors could also go a long way to reducing the use of antimicrobials.

      References

      Multifaceted intervention v usual care for suspected urinary tract infections (UTIs) in nursing home residents*

      
 
 Q Does a multifaceted intervention supporting the use of diagnostic and treatment algorithms reduce antimicrobial prescriptions for suspected urinary tract infections (UTIs) in nursing home residents?

      Footnotes

      • For correspondence: Dr M Loeb, McMaster University, Hamilton, Ontario, Canada. loebm{at}mcmaster.ca

      • Source of funding: Agency for Healthcare Research and Quality.

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