1895. Work System Influences on Antibiotic Prescribing in Nursing Homes
Session: Poster Abstract Session: Antibiotic Stewardship: Long Term Care
Saturday, October 29, 2016
Room: Poster Hall
Posters
  • IDweek 2016 Work System.pdf (1019.1 kB)
  • Background: While it is widely accepted that existing antibiotic prescribing practices in nursing homes diverge widely ideal prescribing targets, the reasons for this discrepancy remain poorly understood. Our research team performed a nursing staff work system analysis to identify system targets influencing antibiotic decisions that could benefit from redesign.

    Methods: Researchers performed site visits in six NHs (3 in Wisconsin and 3 in Pennsylvania). Interviews and observations with key stakeholders (management, nursing staff and providers) were performed and artifacts (policies, procedures, charting and data collection tools) were obtained during these visits. Archetypal process flow maps of pre- and post-antibiotic decision processes were generated through a triangulation process. Transcripts of interviews with nursing staff in study NHs were then analyzed using a hybrid inductive/deductive thematic approach based on the archetypal flow maps.

    Results: Our analyses uncovered several key findings: 1) the initial resident assessment, which is technically a RN duty, is a task shared by many staff with varying scopes of practice (CNA, LPN, nurse supervisor); 2) communication of resident change-in-condition to the provider was subject to frequent delays and interruptions both within and between shifts; 3) provider communication was often performed by surrogates uninvolved with the original resident assessment; 4) primary care providers were not consistently notified when their residents were started on an antibiotic by another provider; and 5) post-prescribing changes to antibiotic therapy was inconsistent and typically only occurred when discordant culture results were identified.

    Conclusion: The initial antibiotic decision in NHs is highly susceptible to information decay due to involvement of multiple agents and the asynchronous nature of communication in this setting. This likely increases already high levels of diagnostic uncertainty and may have a significant impact on prescribing thresholds. In addition, post-prescribing modification of antibiotics in NHs is a reactive process which promotes escalation rather than de-escalation of antibiotics. Interventions to counteract these prevailing system influences are a critical need in NHs.

    Edmond Ramly, PhD1, Jay Ford, PhD1, David Nace, MD, MPH2 and Christopher Crnich, MD, PhD3, (1)University of Wisconsin Center for Health Systems Research and Analysis, Madison, WI, (2)Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA, (3)Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, WI

    Disclosures:

    E. Ramly, None

    J. Ford, None

    D. Nace, None

    C. Crnich, None

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