Standardized Antibiotic Use in Long-Term Care Settings (SAUL Study)

Steven GarfinkelAmerican Institutes for Research AHRQ Annual Conference, Bethesda, MD, September 10, 2012

Project Cosponsored by the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality

under AHRQ Contract# HHSA290200600019I,

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The Intervention

• Reduce inappropriate antibiotic use• Communication and Order Form

SBAR format Loeb criteria For use by nurses and physicians

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SAUL Project SBAR Tool

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SAUL Project SBAR Tool

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SAUL Project SBAR Tool

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SAUL Project SBAR Tool

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Research Activities

1. Literature Review

2. Usability testing of data collection instruments with NH staff

3. Small-Scale Trial (SST)of intervention with 4 homes

4. Field test (FT) with 12 homes

5. Debriefing interviews with NH staff

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Data Collection Process(Monthly)

Infection Log in home to identify all those with a Rx for a suspected UTI.

MDS data for these residents.

Medical records for orders and notes related to Rx and Dx.

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Research Design For Field Test

Higher intensity

O O O O O O X O O O O O O

Lower intensity

O O O O O O X O O O O O O

ComparisonHomes

O O O O O O O O O O O O

Mar. 2011 – Aug. 2011 Sept. 2011– Feb. 2012

Higher intensity Homes (4) —— training, technical assistance, re-training

Lower intensity Homes (4) —— training only

Comparison homes (4) —— data collection only

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Outcomes

• Shift in distribution of prescriptions between symptomatic and asymptomatic UTIs

• Number of prescriptions written

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Results: Implementation

Fidelity to implementation protocol varied.

Was not dependent upon the level of education and training provided.

Four homes were “implementers” (high level of fidelity) – three were from the high intensity education arm and one from the low intensity arm.

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Rx For UTIs (?) By Homes Classified According To Fidelity (per protocol)

Results Unadjusted by Covariates

SamplesPre-intervention Post-intervention

Asymptomatic Symptomatic Asymptomatic SymptomaticN (residents) 251 104 201 113

Level of fidelity

Implemented (n=4 homes)

N 79 29 38 39 % 73.15 26.85 49.35 50.65

Not Implemented (n=8 homes)

N 172 75 163 74

% 69.64 30.36 68.78 31.22

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% Change In Prescriptions Without Localized Symptoms

Series1

-35%

-30%

-25%

-20%

-15%

-10%

-5%

0%

5%

10%

High Intensity-8.7%

High Fidelity -23.8%

Low Intensity -13.6%

Low Fidelity -3.16%

Comparison,2.5%

Comparison2.59%

Fidelity(Per-Protocol)

Training Intensity (Intent to Treat)

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Rx For Suspected UTIs Dropped Significantly, And Then Rebounded

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Results: Barriers To Implementation

Turnover, particularly in leadership.

Competing demands from the corporate level.

Resistance from nurses and physicians.

Lack of champions/mandates.