TY - JOUR
T1 - A Process Evaluation of an Antibiotic Stewardship Intervention for Urinary Tract Infections in Nursing Homes
AU - Rutten, Jeanine J. S.
AU - Smalbrugge, Martin
AU - van Buul, Laura W.
AU - van Eijk, Jorna
AU - Geerlings, Suzanne E.
AU - Natsch, Stephanie
AU - Sloane, Philip D.
AU - van der Wouden, Johannes C.
AU - Hertogh, Cees M. P. M.
AU - Gerritsen, Debby L.
N1 - Funding Information: Funding Sources: This work was supported by the Netherlands Organisation for Health Research and Development ( ZonMw , grant number 839120008 ). ZonMw had no role in study design, methods, subject recruitment, data collection, analysis and preparation of this paper. Publisher Copyright: © 2023 The Authors
PY - 2024/1
Y1 - 2024/1
N2 - OBJECTIVES: To assess the internal and external validity of a cluster randomized controlled trial (cRCT) evaluating a decision tool with supportive interventions for the empirical treatment of urinary tract infections (UTIs) in nursing homes (NHs), and to identify facilitators and barriers in implementing this antibiotic stewardship intervention.DESIGN: Mixed-methods process evaluation study.SETTING AND PARTICIPANTS: Physicians, nursing staff, client council members, and residents of Dutch NHs.METHODS: We used cRCT data of the ANNA study (Antibiotic Prescribing and Non-prescribing in Nursing Home Residents With Signs and Symptoms Ascribed to Urinary Tract Infection). In addition, we sent out an online evaluation questionnaire, conducted semistructured interviews with physicians and nursing staff, and consulted client council members.RESULTS: Internal validity was lowered: control group physicians participated in several non-study-related activities regarding UTI. External validity was good: almost all intervention components had a high fidelity (52%-74%) and were perceived as relevant (physicians: 7.2-8.6 of 10, nursing staff: 6.5-8.5 of 10) and feasible (physicians: 7.5 of 10, nursing staff 6.4 of 10), with feasibility for residents with dementia and urine incontinence needing attention. The most common reason for deviating from the advice generated by the decision tool was an unclear illness presentation. Identified facilitators to implementation were confidence in the intervention, repeated intervention encounter, and having "champions" in the NH. Barriers were limited involvement of nursing staff, unstable nursing teams, residents' and representatives' belief that antibiotics should be prescribed, and a low antibiotic prescribing threshold within the NH culture.CONCLUSIONS AND IMPLICATIONS: Lowered internal validity may have reduced the study effect. Attention should be paid to the feasibility of the intervention in residents with dementia and urinary incontinence. Improvement opportunities for implementation were higher nursing staff involvement and repeated intervention offering.
AB - OBJECTIVES: To assess the internal and external validity of a cluster randomized controlled trial (cRCT) evaluating a decision tool with supportive interventions for the empirical treatment of urinary tract infections (UTIs) in nursing homes (NHs), and to identify facilitators and barriers in implementing this antibiotic stewardship intervention.DESIGN: Mixed-methods process evaluation study.SETTING AND PARTICIPANTS: Physicians, nursing staff, client council members, and residents of Dutch NHs.METHODS: We used cRCT data of the ANNA study (Antibiotic Prescribing and Non-prescribing in Nursing Home Residents With Signs and Symptoms Ascribed to Urinary Tract Infection). In addition, we sent out an online evaluation questionnaire, conducted semistructured interviews with physicians and nursing staff, and consulted client council members.RESULTS: Internal validity was lowered: control group physicians participated in several non-study-related activities regarding UTI. External validity was good: almost all intervention components had a high fidelity (52%-74%) and were perceived as relevant (physicians: 7.2-8.6 of 10, nursing staff: 6.5-8.5 of 10) and feasible (physicians: 7.5 of 10, nursing staff 6.4 of 10), with feasibility for residents with dementia and urine incontinence needing attention. The most common reason for deviating from the advice generated by the decision tool was an unclear illness presentation. Identified facilitators to implementation were confidence in the intervention, repeated intervention encounter, and having "champions" in the NH. Barriers were limited involvement of nursing staff, unstable nursing teams, residents' and representatives' belief that antibiotics should be prescribed, and a low antibiotic prescribing threshold within the NH culture.CONCLUSIONS AND IMPLICATIONS: Lowered internal validity may have reduced the study effect. Attention should be paid to the feasibility of the intervention in residents with dementia and urinary incontinence. Improvement opportunities for implementation were higher nursing staff involvement and repeated intervention offering.
KW - Antimicrobial stewardship
KW - decision tool
KW - implementation science
KW - long term care facilities
UR - http://www.scopus.com/inward/record.url?scp=85175836020&partnerID=8YFLogxK
U2 - https://doi.org/10.1016/j.jamda.2023.09.016
DO - https://doi.org/10.1016/j.jamda.2023.09.016
M3 - Article
C2 - 38173264
SN - 1525-8610
VL - 25
SP - 146-154.e9
JO - Journal of the American Medical Directors Association
JF - Journal of the American Medical Directors Association
IS - 1
ER -