Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System, Cleveland, OH, USA; Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Population & Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
J Am Med Dir Assoc. 2022 Jun;23(6):1025-1030. doi: 10.1016/j.jamda.2021.08.019. Epub 2021 Sep 7.
To evaluate a bundled electronic intervention to improve antibiotic prescribing practices in US nursing homes.
Prospective mixed-methods quality improvement intervention.
Nursing staff and residents in 13 nursing homes, and residents in 8 matched-control facilities (n = 21 facilities total, from 2 corporations).
This study involved a 2-month design period (n = 5 facilities) focused on the acceptability and feasibility of a bundled electronic intervention consisting of 3 tools, followed by a 15-month implementation period (n = 8 facilities) during which we used rapid-cycle quality improvement methods to refine and add to the bundle. We used mixed-methods data from providers, intervention tools, and health records to assess feasibility and conduct a difference-in-difference analysis among the 8 intervention sites and 8 pair-matched controls.
Nurses at 5 pilot sites reported that initial versions of the electronic tools were acceptable and feasible, but barriers emerged when 8 different facilities began implementing the tools, prompting iterative revisions to the training and bundle. The final bundle consisted of 3 electronic tools and training that standardized digital documentation to document and track a change in resident condition, infections, antibiotic prescribing, and antibiotic follow-up. By the end of the implementation phase, all 8 facilities were using at least 1 of the 3 tools. Early antibiotic discontinuation increased 10.5% among intervention sites, but decreased 10.8% among control sites.
The 3 tools in our bundled electronic intervention capture clinical and prescribing data necessary to assess changes in antibiotic use and were feasible for nurses to adopt. Achieving this required modifying the tools and training before the intervention reached its final form. Comparisons of rates of antibiotic use at intervention and control facilities showed promising improvement in antibiotic discontinuation, demonstrating that the intervention could be evaluated using secondary electronic health record data.
评估捆绑式电子干预措施在美国养老院改善抗生素处方实践的效果。
前瞻性混合方法质量改进干预。
13 家养老院的护理人员和居民，以及 8 家匹配对照设施的居民（共 21 家设施，来自 2 家公司）。
本研究包括 2 个月的设计期（n=5 家设施），重点评估由 3 种工具组成的捆绑式电子干预措施的可接受性和可行性，随后是 15 个月的实施期（n=8 家设施），在此期间，我们使用快速循环质量改进方法对捆绑包进行改进和补充。我们使用来自提供者、干预工具和健康记录的混合方法数据，评估可行性，并对 8 个干预地点和 8 个配对对照进行差异分析。
5 个试点地点的护士报告说，最初版本的电子工具是可以接受和可行的，但当 8 个不同的设施开始实施这些工具时，出现了障碍，这促使对培训和捆绑包进行迭代修订。最终的捆绑包包括 3 种电子工具和培训，这些工具和培训使数字化文档标准化，以记录和跟踪居民病情、感染、抗生素处方和抗生素随访的变化。到实施阶段结束时，所有 8 家设施都至少使用了 3 种工具中的 1 种。干预地点的早期抗生素停药率增加了 10.5%，而对照地点的停药率则降低了 10.8%。
我们捆绑式电子干预措施中的 3 种工具捕获了评估抗生素使用变化所需的临床和处方数据，并且对护士来说是可行的。实现这一目标需要在干预措施达到最终形式之前对工具和培训进行修改。干预和对照设施抗生素使用率的比较显示，抗生素停药率有了显著改善，这表明可以使用二级电子健康记录数据来评估该干预措施。
