Improving Antibiotic Stewardship for Long Term Care Facility Residents Treated in the Emergency Department

Given the dramatic reduction in antibiotic use observed, dissemination to other healthcare systems has the potential to significantly reduce antibiotic prescribing levels and reduce bacterial resistance levels in communities across the state and nation.

At a Glance

The inappropriate use of antibiotics in healthcare settings is a significant patient safety and public health threat. Older adults, particularly those living in long-term care facilities, often receive inappropriate antibiotic prescriptions in the emergency department and are at high risk for related complications.

The primary issue leading to inappropriate antibiotic prescribing for older adults identified by this project was urine testing patterns that resulted in overdiagnosis of urinary tract infections. To address this, the researchers developed and implemented a new way for emergency care providers to order urine testing in the electronic health record which was associated with a significant decrease in unnecessary antibiotic use in older adults being evaluated for urinary tract infections.

The Challenge

The inappropriate use of antibiotics in healthcare settings has been identified as a global public health threat because it is associated with increasing rates of antibiotic resistant bacterial infections: In the U.S., more than two people die hourly as a direct result of these infections. Misuse of antibiotics can also be dangerous for patients because it can cause allergic reactions and opportunistic infections. Thus, reducing the inappropriate use of antibiotics is paramount. The emergency department (ED) is a healthcare setting with high rates of inappropriate antibiotic prescribing, and older adults, particularly those residing in long-term care facilities (LTCFs), are a priority population for improving antibiotic prescribing in part because they are particularly vulnerable to harm related to adverse drug events. Each year, over 2.5 million LTCF residents receive care in the ED and they often have symptoms that could represent serious infections such as pneumonia, urinary tract infections, and sepsis. However, the amount of inappropriate antibiotic use among LTCF residents is estimated to be very high: from 25-75%.

Project Goals

The first aim of this project was to create a model of antibiotic use for long-term care facility (LTCF) residents treated in the emergency department (ED). To achieve this goal the researchers conducted semi-structured qualitative interviews, guided by a systems engineering framework, with ED and LTCF staff who work in communities across Wisconsin.

The second aim of the project was to develop an ED intervention to improve antibiotic use during the treatment of LTCF residents and measure its effectiveness. To achieve this goal, the team targeted the most salient barrier to appropriate antibiotic prescribing identified in the qualitative analysis: overuse of urine testing (urinalysis and urine culture) resulting in overdiagnosis of urinary tract infections (UTIs).

Results

For Aim 1, interviews were conducted with 32 participants—16 at LTCFs and 16 in the ED—representing a range of urban to rural settings, clinic sizes, professional roles, and levels of experience. The results of the qualitative analysis describe the range of work system factors that ultimately impact whether antibiotics are used.

• Patient Transfers: When patients are transferred from LTCFs to the ED, they leave familiar settings and receive care from practitioners who are less familiar with their baseline condition. This means that documentation of care and communication between facilities is very important: LTCF staff wanted a standardized transfer form and access to ED health records, and acknowledged that staff turnover exacerbates these challenges.
• Diagnostic Evaluation: LTCF staff thought that uncertainty about baseline condition, nonspecific symptoms, and a potential lack of understanding about normal rates of bacterial colonization in older patients lead to unnecessary UTI diagnoses in the ED.
• Antibiotic Use: LTCF staff perceive EDs as ordering unnecessary tests that lead to over-diagnosing of UTIs and over-prescribing of antibiotics, but have difficulty getting primary-care physicians to cancel antibiotics requested by other providers. ED staff acknowledge that it can be difficult to determine when an infection that warrants antibiotic use is present in the ED setting.
• Perceptions Across Settings: Misperceptions between LTCF staff and ED staff exist, and could be improved to facilitate patient management.
• Communication Dynamics: LTCF staff and ED staff have different understandings of geriatric health as it relates to UTIs. LTCF staff felt this was especially important given that about 20 to 50 percent of LTCF residents would test positive for bacteria regardless of symptoms. Thus, if providers are using a urinalysis test result as the only tool to diagnose a UTI, which some providers report doing, there is no doubt that the ED is overprescribing antibiotics for UTIs.

For Aim 2, education on UTI testing and diagnosis and redesigning the urinalysis culture order did not result in a significant change in urine culture rates for older adults. However, there was a significant reduction (15%) in overall antibiotic prescribing rates for older adults who had urine cultures obtained in the ED. This was predominantly driven by a 25% reduction in antibiotic prescribing for patients with negative or contaminated cultures who do not require antibiotic therapy. This indicates providers are more willing to hold on empiric prescribing for patients without a clear indication for a UTI pending the culture result.

Lasting Impact

This pilot, which redesigned the process by which ED physicians order a urinalysis culture, successfully led to reduced rates of antibiotic prescription for UTIs in older adults. The next step is to disseminate this order as part of a publicly available toolkit aimed at improving urine testing and UTI diagnosis for older adults being evaluated in the ED. Given the dramatic reduction in antibiotic use observed in the pilot, dissemination to other healthcare systems has the potential to significantly reduce antibiotic prescribing levels and reduce bacterial resistance levels in communities across the state and nation.

Apart from this success in meeting the project objectives, the findings are also significant in that they identified multiple areas that may serve as effective targets for future efforts to improve antibiotic prescribing for all major types of infection. This will make a difference in various fields of medicine, specifically those which care for older adults, including infectious diseases, nursing, emergency medicine, and geriatrics.