Developing Capacity in Long-Term Care to Implement Antimicrobial Stewardship: The Need for Synergy

BACKGROUND:  Despite myriad publications regarding antimicrobial stewardship (AS) in acute care hospitals (ACH), guidance is lacking for long-term care facilities (LTCF). Centers for Disease Control and Prevention Enhanced Laboratory Capacity funding enabled the Minnesota Department of Health (MDH) to collaborate with Minnesota LTCF to develop LTCF AS guidance based on ACH AS recommendations.

METHODS:  MDH identified infection preventionists and directors of nursing from two hospital-attached LTCF, and key hospital staff (e.g., administrators, pharmacists, laboratorians, quality). One to three on-site meetings and bi-monthly conference calls were held over 6 months to review hospital AS recommendations and discuss adaptations necessary for LTCF. The following LTCF AS foundational components were identified: 1) physician/ pharmacist AS champion; 2) AS Team; 3) medical leadership involvement; 4) establishment of antimicrobial utilization baseline; 5) access to microbiology data; 6) access to antimicrobial prescribing data; and 7) access to an antibiogram. Organizational assessments identified existing LTCF AS foundational components and gap analyses were conducted in both LTCF.

RESULTS:  Organizational assessments and gap analyses demonstrated that elements of each LTCF AS foundational component existed, yet resident infection-related data (e.g., antibiotic starts, nursing assessment, laboratory results) were collected for discrete record keeping purposes and not integrated with clinical documentation. Microbiology data were available for individuals, but were not aggregated by facility type at the laboratory; no LTCF-specific antibiogram was available. Hospital pharmacies provided line lists of prescribed antibiotics, but these lists were not representative of all antibiotics prescribed for LTCF residents, as prescriptions were filled by numerous outside pharmacies. Infection surveillance was conducted retrospectively, and was based on sparse clinical documentation; these data were utilized only to meet quarterly quality meeting reporting requirements. Nursing staff served as the hub of resident data, often facilitating the flow of data to and from relevant clinical partners.

CONCLUSIONS:  LTCF AS foundational components adapted from ACH AS recommendations provide necessary AS infrastructure.  However, adequate processes for nursing assessment, communication and documentation of resident data are essential to provide the synergy required to conduct comprehensive AS. Synergy can be achieved through implementation of LTCF-specific tools that facilitate in-depth analyses to determine strategies for integrating AS foundational components into existing LTCF processes. The importance of LTCF nursing staff involvement in AS capacity-building interventions cannot be overstated.