Original research
Impact of a Multidisciplinary Intervention on Antibiotic Use for Nursing Home–Acquired Pneumonia

Data from this study was presented as an Oral Paper Presentation at the 2009 American Geriatrics Society Annual Scientific Meeting, Chicago, Illinois, April 30, 2009.
https://doi.org/10.1016/j.amjopharm.2011.09.009Get rights and content

Abstract

Background

Academic detailing in nursing homes (NHs) has been shown to improve drug use patterns and adherence to guidelines.

Objective

The purpose of this study was to evaluate the impact of a multidisciplinary intervention that included academic detailing on adherence to national nursing home–acquired pneumonia (NHAP) guidelines related to use of antibiotics.

Methods

This quasi-experimental study evaluated the effects of a 2-year multifaceted and multidisciplinary intervention targeting implementation of national evidence-based guidelines for NHAP. Interventions took place in 8 NHs in Colorado; 8 NHs in Kansas and Missouri served as controls. Interventions included (1) educational sessions for nurses to improve recognition and timely treatment of NHAP symptoms and (2) academic detailing to clinicians by pharmacists regarding diagnostic and prescribing practices. Differences in antibiotic use between groups were compared after 2 intervention years relative to baseline.

Results

A total of 549 episodes of NHAP were evaluated in the intervention group and 574 in the control group. Compared with baseline, 1 facility in the intervention group significantly improved in guideline adherence for optimal antibiotic use (P = 0.007), whereas no facilities in the control group improved. The mean adherence score for optimal antibiotic use in intervention NHs increased from 60% to 66%, whereas the control NHs increased from 32% to 39% (P = 0.3). Mean adherence to guidelines recommending antibiotic use within 4 hours of NHAP diagnosis increased from 57% to 75% in intervention NHs but decreased from 38% to 31% in control NHs (P = 0.0003 for difference). There was no difference between intervention and control NHs for guideline adherence regarding optimal duration of antibiotic use.

Conclusions

The ability of this multifaceted study to repeatedly remind nursing staff of the importance of timely antibiotic administration contrasts with its limited academic detailing interaction with clinicians. This difference within the intervention may explain the differential impact of the intervention on antibiotic guideline adherence.

Introduction

Pneumonia is the most common, potentially serious acute illness that affects nursing home (NH) residents. Median reported incidence is 1 per 1000 patient-days, and mortality averages 25% annually.1 High-quality care, including appropriate antibiotic use, hospitalization when indicated, and rapid identification of and response to respiratory symptoms, has been shown to be associated with improved survival of residents who acquired pneumonia in a national sample of NH residents. Many of the 58 NHs in that study were providing less than adequate care (eg, only 31% of residents received antibiotics within one 8-hour shift of symptom onset and 25% of NH-acquired pneumonia [NHAP] episodes were not treated with an appropriate antibiotic).2 Loeb et al3 reported that only 28% of antibiotics prescribed for NHAP in 22 Canadian facilities met guideline criteria. Similarly, Jones et al4 and Nicolle et al,5 reported inappropriate antimicrobial use in long-term care facilities to be 50% and 25% to 75%, respectively.

Regardless of whether residents with NHAP are hospitalized or treated in the NH, evidence-based guidelines recommend providing empirical antibiotic coverage for the bacteria that most commonly cause pneumonia in the NH setting: Streptococcus pneumoniae, Haemophilus influenzae, common gram-negative rods, and Staphylococcus aureus.6, 7 When guidelines for NHAP were originally promulgated, the recommended antibiotic regimens included 10 to 14 days of either (1) an anti-pneumococcal fluoroquinolone (eg, levofloxacin, moxifloxacin, or gatifloxacin) or (2) an extended-spectrum β-lactam (eg, amoxicillin/clavulanate, some second- and all third-generation cephalosporins) in combination with a macrolide (eg, azithromycin or clarithromycin).6, 8, 9 The addition of a macrolide to a β-lactam–based regimen was designed to provide coverage for atypical organisms, which have also been recognized as potential causes of NHAP.10, 11 The guidelines also recommend that the antibiotic be provided within 4 hours of the physician's order and that residents being hospitalized or who have unstable vital signs receive antibiotics immediately.6 The rationale for rapid antibiotic treatment is that a survival benefit among hospitalized Medicare patients with pneumonia was demonstrated for those who received antibiotics within 4 hours of arriving in the emergency department,12 although this has never been studied in NH residents with NHAP who are not hospitalized.

Previous research in NHs, hospitals, and primary care settings has found that academic detailing (focused education of physicians and/or nursing staff about disease/drug therapy by other health care providers) can improve prescribing patterns of antibiotics and other drugs.13, 14, 15, 16, 17, 18, 19, 20 We hypothesized that multidisciplinary academic detailing regarding the above antibiotic recommendations would improve adherence to guideline recommendations for antibiotic choice, delivery, and duration of treatment in study NHs. This paper reports on the impact of the academic detailing facet of a multifaceted intervention whose objective was to test a multidisciplinary intervention implementing national evidence-based guidelines on care for NHAP.

Section snippets

Overview

This mixed-methods, quasi-experimental, unblinded study tested the impact of a multifaceted and multidisciplinary intervention implementing national evidence-based guidelines on care for NHAP. The multifaceted intervention included (1) institutional change to facilitate immunization and the availability of appropriate testing and treatment; (2) interactive educational sessions for NH nursing staff to improve vaccination rates and nursing assessment skills; (3) a study liaison nurse employed by

Results

The Table describes the baseline characteristics of the study participants and their facilities. The subjects in the control facilities were significantly more independent and had fewer “do not resuscitate” (DNR) orders than subjects at the intervention facilities. There was no correlation between presence of a DNR order and compliance with the antibiotic guidelines ([ρ] = 0.02). Additionally, the control facilities had significantly lower staffing ratios and higher nursing turnover than the

Discussion

In the present study, a multifaceted intervention, including (1) nursing staff education emphasizing rapid recognition and treatment of LRTI, (2) a within-facility change agent, (3) financial incentives, and (4) academic detailing, succeeded in significantly increasing the number of NHAP episodes receiving timely antibiotics compared with episodes in control facilities. This improvement in timely administration occurred despite significant baseline differences between intervention and control

Conclusions

The ability of this multifaceted study to repeatedly remind nursing staff of the importance of timely antibiotic administration contrasts with its limited academic detailing interaction with clinicians. This difference within the intervention may explain the differential impact of the intervention on antibiotic guideline compliance.

Acknowledgments

This study was supported by an investigator-initiated research grant from the Agency for Health Care Research and Quality (RO1 HS13618-01A1). The authors have indicated that they have no other conflicts of interest regarding the content of this article.

All authors contributed to the study design, methods, and the interpretation of findings. Drs. Linnebur, Hutt, and Fish contributed to writing and editing the manuscript. All authors approved the final version of the manuscript.

References (30)

  • Guidelines for the management of adults with community-acquired pneumonia

    Am J Respir Crit Care Med

    (2001)
  • K. Mills et al.

    Treatment of nursing home-acquired pneumonia

    Am Fam Physician

    (2009)
  • A.A. El Solh

    Nursing home-acquired pneumonia

    Sem Respir Crit Care Med

    (2009)
  • T.P. Meehan et al.

    Quality of care, process, and outcomes in elderly patients with pneumonia

    JAMA

    (1997)
  • B.J. Naughton et al.

    Antibiotic use, hospital admissions, and mortality before and after implementing guidelines for nursing home-acquired pneumonia

    J Am Geriatr Soc

    (2001)
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