Assessing and Enhancing Capacity in Long-Term Care to Implement Antimicrobial Stewardship: Toolkit Development

BACKGROUND:  Antimicrobial stewardship (AS) recommendations are available for acute care hospitals (ACH), but guidance is lacking for long-term care facilities (LTCF). Developing LTCF AS guidance is more complex than adapting ACH AS strategies, instead requiring a reframed perspective due to differences in population and care delivery. Centers for Disease Control and Prevention Enhanced Laboratory Capacity funding enabled the Minnesota Department of Health (MDH) to collaborate with LTCF on AS capacity-building. We developed a toolkit to aid LTCF in the implementation of evidence-based AS practices, with a focus on nursing’s role.

METHODS:  MDH recruited five Minnesota LTCF (represented by nurses, nursing assistants, nursing leadership, consulting pharmacists, medical directors, and administrators) to participate in a one-year pilot, which entailed bi-monthly conference calls, and an average of two on-site meetings per facility. LTCF piloted and provided feedback on toolkit resources, including: 1) LTCF AS guidance/audit tools; 2) nursing/provider antibiotic use attitudes/beliefs surveys; 3) nursing process evaluation; 4) antibiotic use assessment; and 5) communication tools. 

RESULTS:  The AS guidance and audit tools were refined throughout the pilot and feedback process; first as a checklist to determine existing AS components and later incorporated into a comprehensive list of strategies and recommendations. Administrative, clinical, and pharmacy leadership expectations consistent with evidence-based antimicrobial prescribing recommendations are vitally important, however, it became clear that nursing leadership and direct care staff drive AS efforts in LTCF. Many of the tools developed reflect this finding. Nursing and provider antibiotic use attitudes/beliefs surveys were found to be valuable in identifying areas for potential interventions (e.g., education, policy changes). Four of five LTCF performed nursing process evaluations to identify strengths and weaknesses in facility processes for the assessment, communication, and documentation of resident changes in condition; two LTCF subsequently implemented process changes, including use of communication tools. Three LTCF performed antibiotic use assessments which included detailed inspection of resident data for documentation of infection. One LTCF engaged the consulting pharmacist in the process which was advantageous for evaluating appropriateness of antibiotics. 

CONCLUSIONS:   Implementation of AS strategies requires a systems-level, primary prevention approach that values the contribution of all those involved in resident care. The toolkit uses a “bottom-up” approach, providing a critical complement to the traditional “top-down” approach, by recognizing nursing’s central role in facilitating the flow of resident data among clinical partners. Nursing assessment, communication, and documentation facilitate the foundation of AS, namely: right diagnosis, drug, dose, duration, and de-escalation.