Pilot study to evaluate the need and implementation of a multifaceted nurse-led antimicrobial stewardship intervention in residential aged care

Natali Jokanovic; Sue J Lee; Terry Haines; Sarah N Hilmer; Yun-Hee Jeon; Laura Travis; Darshini Ayton; Eliza Watson; Tess Tsindos; Andrew J Stewardson; Rhonda L Stuart; Allen C Cheng; Trisha N Peel; Anton Y Peleg; START Trial Group

doi:10.1093/jacamr/dlae016

Pilot study to evaluate the need and implementation of a multifaceted nurse-led antimicrobial stewardship intervention in residential aged care

JAC Antimicrob Resist. 2024 Feb 14;6(1):dlae016. doi: 10.1093/jacamr/dlae016. eCollection 2024 Feb.

Authors

Collaborators

START Trial Group:
Anton Peleg, Terry Haines, Allen Cheng, Trisha Peel, Kathryn Holt, Sarah Hilmer, Yun-Hee Jeon, Andrew Stewardson, Rhonda Stuart, Sue J Lee, Daniel Wilson, James Trauer, Marilyn Cruickshank, Nicola De Maio, Natali Jokanovic, Janine Roney, Jessica Wisniewski

Affiliations

¹ Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia.
² School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.
³ Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.
⁴ Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.
⁵ Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Clayton Victoria, Australia.
⁶ Public Health and Infection Prevention, Monash Health, Monash Medical Centre, Clayton, Victoria, Australia.
⁷ Monash Infectious Diseases, Monash Health, Monash Medical Centre, Clayton, Victoria, Australia.
⁸ Monash Biomedicine Discovery Institute, Infection and Immunity Theme, Department of Microbiology, Monash University, Clayton, Victoria, Australia.

Abstract

Objectives: To evaluate the need and feasibility of a nurse-led antimicrobial stewardship (AMS) programme in two Australian residential aged care homes (RACHs) to inform a stepped-wedged, cluster randomized controlled trial (SW-cRCT).

Methods: A mixed-methods pilot study of a nurse-led AMS programme was performed in two RACHs in Victoria, Australia (July-December 2019). The AMS programme comprised education, infection assessment and management guidelines, and documentation to support appropriate antimicrobial use in urinary, lower respiratory and skin/soft tissue infections. The programme was implemented over three phases: (i) pre-implementation education and integration (1 month); (ii) implementation of the intervention (3 months); and (iii) post-intervention evaluation (1 month). Baseline RACH and resident data and weekly infection and antimicrobial usage were collected and analysed descriptively to evaluate the need for AMS strategies. Feedback on intervention resources and implementation barriers were identified from semi-structured interviews, an online staff questionnaire and researcher field notes.

Results: Six key barriers to implementation of the intervention were identified and used to refine the intervention: aged care staffing and capacity; access to education; resistance to practice change; role of staff in AMS; leadership and ownership of the intervention at the RACH and organization level; and family expectations. A total of 61 antimicrobials were prescribed for 40 residents over the 3 month intervention. Overall, 48% of antibiotics did not meet minimum criteria for appropriate initiation (respiratory: 73%; urinary: 54%; skin/soft tissue: 0%).

Conclusions: Several barriers and opportunities to improve implementation of AMS in RACHs were identified. Findings were used to inform a revised intervention to be evaluated in a larger SW-cRCT.