Care homes
Care homes have a strong focus on preventing and controlling infections, but their antimicrobial stewardship efforts are less developed, compared to to other healthcare settings. Care homes are thus a strategic care setting for researchers to work on optimising antibiotic use.
What we already know
- Around one in seven people aged over 85 years live in approximately 20,000 care homes in the UK.
- Infections are common in care homes and can often lead to outbreaks. Antibiotics are therefore used frequently and there is potential for development of antibiotic resistance.
- Care home residents are particularly susceptible to side effects of antibiotics. They are also often admitted to hospital and move back to care homes, which can lead to spread of antibiotic resistant infections between these two settings.
- To safely reduce antibiotic use in care homes, better information is needed on how antibiotics are currently used in this setting.
What questions did we ask?
Electronic health records
We analysed electronic records from 135 care homes across the UK for calendar years 2016–2017. These records contained information on
- resident characteristics such as age, sex, length of stay, residential or nursing care
- care home characteristics such as the number of beds, number of clinical and care staff, the Care Quality Commission (CQC) rating (in England only)
- medicines dispensed to residents.
Using these data, we investigated the following research questions:
- What is the rate of antibiotic prescribing for care home residents in the UK?
- How does prescribing vary by resident and care home characteristics?
- What infections are antibiotics most used for, and how does the type of antibiotic used compare with guidelines?
Interviews
The aim of the interviews was to understand who performs antibiotic stewardship and when and how it is managed in care homes. The interview questions were developed using a theoretical informed behaviour change framework (Atkins et al 2017) to identify the likely enablers and barriers of antibiotic stewardship (e.g. escalation of suspected infections within and beyond the care home). Recruitment was through a national care home provider using their prescribing data to include both ‘high prescribers’ and ‘low prescribers’ of antibiotics in the interviews. Interviews were conducted with managers, nurses and care assistants in 4 care homes in the Midlands and the South-East of England.
Observations
An ethnographer conducted direct non-participant observations in communal areas of the practice and consultations within 4 care homes, totalling 51 hours of observation. The care homes were selected from a list of provided by our partner Four Seasons Healthcare in two regions (East Midlands and London).
The researcher recorded detailed handwritten field notes while at the research site. The researcher reflected on these notes and audio recorded the field notes, reflections and interpretations. These audio recordings were then transcribed and analysed alongside pictures and policies/guidelines collected from the research site.
Data were analysed using a thematic analysis approach assisted by NVivo software to identify influences on antibiotic stewardship. Analysis was informed by a framework of six universal challenges to improving quality commonly faced by healthcare organisation (Bate et al. 2008).
The six universal challenges to improving quality in healthcare (Bate et al. 2008)
- structural challenges: organising, planning and coordinating quality efforts
- political challenges: addressing and dealing with the politics of change surrounding any quality improvement effort
- cultural challenges: giving ‘quality’ a shared, collective meaning, value and significance within the organisation
- educational challenges: creating a learning process that supports improvement
- emotional challenges: engaging and motivating people by linking quality improvement efforts to inner sentiments and deeper commitments and beliefs
- physical and technological challenges: the designing of physical systems and technological infrastructure that supports and sustains quality efforts.
Design workshops
We held three design workshops in 3 of the 5 UK care homes we had completed interviews and observations. 3 to 9 staff joined each workshop, lasting roughly 2 hours. Staff included care home managers, senior care and nursing staff, and day-to-day care staff.
Workshop activities aimed to find out more about the pressures and anxieties experienced by care staff on a daily basis that might impact how well care homes are able to support antibiotic stewardship. Staff completed worksheets and undertook activities that invited them to describe, reflect, evaluate their experiences or generate new ideas, both as individuals or in small groups. These fed into whole-group discussions.
What did we find?
Electronic health records
In 2016–2017, data from 135 care homes showed that:
- the rate of antibiotic prescribing for care home residents was about twice the rate for older adults in the general population.
- residents who had recently moved into the care home, were nearer to the end of life, and had more long-term medical conditions were most likely to be prescribed antibiotics.
- almost a third of antibiotics were repeat prescriptions, likely for prevention of infection.
- urinary tract infections and chest infections led to the most antibiotic prescriptions. Most of the time, the type of prescription was in line with guidelines for treatment of infections in primary care. However, there are no care home-specific guidelines for antibiotic prescription.
- there was wide variation in the rate of antibiotic prescriptions in different care homes. More research is needed to understand what causes this variation.
Detailed results are available from Smith et al. (2020).
Interviews
Multiple behaviours were performed to prevent and manage infections in care homes. Some frequent behaviours were observing changes in residents and sharing observations with other staff, increasing the residents’ fluid intake for suspected infections, using diagnostic tests (e.g. dipsticks), monitoring and recording clinical signs and symptoms and documenting infection cases on IT system.
Care assistants primarily took responsibility for observing changes in the residents’ demeanour during the daily routine, before sharing any concerns to other senior staff. Nurses decided when to increase fluid intake and what signs and symptoms to monitor and when to escalate to GP practice or Out-of-hour services. It was the responsibility of GPs to decide when to prescribe or not prescribe an antibiotic.
The identified key themes fell within 8 theoretical behavioural domains: Environmental context & resources, Social influence, Behaviour regulation, Beliefs about consequences, Memory attention & decision-making, Skills, Social/professional role & identity, and Knowledge.
Key enablers of stewardship were collective responsibilities among staff, staffs’ familiarity with residents, following procedures for investigating suspected infections and continuity of care from same GP. Key barriers were pressure from resident’s family, nature of co-comorbidities of residents and lack of awareness about antibiotic resistance. Few care homes were prepared to ‘watch and wait’ whilst most preferred to escalate immediately to the GP practice.
Observations
Roles and responsibilities Staff recognised their role in infection prevention but approaches and focus varied across the care homes. Care homes had a range of policies, routines or systems in place for optimising infection prevention and control. This included in relation to promoting good hygiene but also patient management (e.g. avoiding aspiration, maintaining hydration to reduce risks of urinary tract infections).
In contrast staff did not see themselves as having a particular role in antibiotic stewardship and did not have training or feedback on antibiotic use.
Escalation and avoiding escalation Preventing negative outcomes from deterioration was a high priority; staff were focused on monitoring residents and responding to any sign of deterioration. Any escalation, e.g. calling in the GP, significantly increased the likelihood a resident would be prescribed antibiotics. Familiarity with the resident, staff experience and confidence, relative expectations, and concerns about litigation, all influenced escalation decisions.
Continuity and consistency of medical services Continuity of GP and relationship with care home staff facilitated flexible conversations about antibiotic use. Inconsistency in antibiotic prescribing between GPs and out of hours services was problematic.
Medicines management Issues around medication management, including prescribing and dispensing problems, were seen to contribute to the risk of resident deterioration and subsequent escalation.
Design workshops
We found the following factors made it harder for care homes to support good stewardship:
- external staff and services using different criteria to assess a resident’s health and make treatment decisions
- frustrated communication with local GPs or pharmacies around prescriptions appropriateness and timely dispensing
- barriers to good communication between care home staff
- insufficient 1-to-1 time to observe and monitor residents closely
- lack of digitisation of tasks
- insufficient opportunities to co-work with families and relatives to plan the best infection care for residents
- insufficient training for all staff around common care home infections.
Intervention development
We are using what we have learnt and to develop interventions that will address antibiotic resistance in healthcare. This involves:
- reviewing barriers and facilitators of stewardship
- identifying mechanisms of change and behaviour change techniques
- collaborating with practitioners to decide how best to deliver behaviour change techniques in terms of feasibility and acceptability.
PASS Interventions
PASS Interventions Presentation
(PDF, 2.5Mb)
References
Atkins, L., Francis, J., Islam, R., ..., Michie, S. (2017). 'A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems', Implementation Science, 12, 77. DOI: 10.1186/s13012-017-0605-9
Bate, P., Mendel, P., & Robert, G. (2008). Organizing for Quality: The Improvement Journeys of Leading Hospitals in Europe and the United States. Research report. London: Nuffield Trust. Available online
Crayton, E., Richardson, M., Fuller, C., Smith, C., Liu, S., Forbes, G., Anderson, N., Shallcross, L., Michie, S., Hayward, A., & Lorencatto, F. (2020). Interventions to improve appropriate antibiotic prescribing in long-term care facilities: A systematic review. BMC Geriatrics, 20(1), 237. DOI: 10.1186/s12877-020-01564-1
Smith, C. M., Conolly, A., Fuller, C., Hill, S., Lorencatto, F., Marcheselli, F., … Fragaszy, E. B. (2019). Symptom reporting, healthcare-seeking behaviour and antibiotic use for common infections: protocol for Bug Watch, a prospective community cohort study. BMJ Open, 9(5), e028676. DOI: 10.1136/bmjopen-2018-028676
Smith, C. M., Williams, H., Jhass, A., Patel, S., Crayton, E., Lorencatto, F., Michie, S., Hayward, A. C., & Shallcross, L. J. (2020). Antibiotic prescribing in UK care homes 2016–2017: Retrospective cohort study of linked data. BMC Health Services Research, 20(1), 555. DOI: 10.1186/s12913-020-05422-z
