Aged Care

Prophylactic antimicrobial prescribing in Australian residential aged-care facilities: Improvement is required

Improving management of urinary tract infections in residential aged care facilities Lyn-Li Lim, Noleen Bennett Abstract Antimicrobial resistance rates are higher in Australian residential aged care facilities (RACFs) than other community or hospital settings. This is driven by antibiotic overuse and misuse. Urinary tract infection (UTI) is consistently the most common infection treated with antibiotics in Australian RACFs. The aim of this article is to provide an overview of how general practitioners (GPs) can support appropriate UTI management in RACFs following antimicrobial stewardship (AMS) principles. GPs are well placed to improve UTI management in RACFs. In this article, criteria for suspected, proven, recurrent and relapsed UTI are outlined, in addition to key AMS practices for the assessment, prevention, treatment and review of UTIs. Included are recommendations for the judicious use of urine dipstick testing, a widespread and longstanding practice in RACFs, and first-line empirical antibiotic prescribing for suspected UTIs. Read the full paper here . Citation: Lim, L. L., & Bennett, N. (2022). Improving management of urinary tract infections in residential aged care facilities. Australian journal of general practice, 51(8), 551-557. DOI: https://doi.org/ 10.31128/AJGP-05-22-6413 .

Karin A Thursky, Laura Y Hardefeldt, Arjun Rajkhowa, Courtney Ierano, Jaclyn Bishop, Lesley Hawes, Ruby Biezen, Sajal K Saha, Leslie Dowson, Kirsten E Bailey, Ri Scarborough, Stephen B Little, Fiona Gotterson, Brian Hur, Anna Khanina, Karen Urbancic, Helen K Crabb, Suzanna Richards, Anna Sri, Rodney James, David C M Kong, Caroline Marshall, Danielle Mazza, Trisha Peel, Rhonda L Stuart, Jo-Anne Manski-Nankervis, N Deborah Friedman, Noleen Bennett, Thomas Schulz, Helen Billman-Jacobe, Evette Buono, Leon Worth, Ann Bull, Michael Richards, Darshini Ayton, James R Gilkerson, Glenn F Browning, Kirsty L Buising, National Centre for Antimicrobial Stewardship Abstract Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing ‘big data’ on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years. Read the full paper here . Citation : Thursky, K. A., Hardefeldt, L. Y., Rajkhowa, A., Ierano, C., Bishop, J., Hawes, L., Biezen, R., Saha, S. K., Dowson, L., Bailey, K. E., Scarborough, R., Little, S. B., Gotterson, F., Hur, B., Khanina, A., Urbancic, K., Crabb, H. K., Richards, S., Sri, A., James, R., Kong, D. C. M., Marshall, C., Mazza, D., Peel, T., Stuart, R. L., Manski-Nankervis, J.-A., Friedman, N. D., Bennett, N., Schulz, T., Billman-Jacobe, H., Buono, E., Worth, L., Bull, A., Richards, M., Ayton, D., Gilkerson, J. R., Browning, G. F., Buising, K. L., & National Centre for Antimicrobial, S. (2021). Antimicrobial stewardship in Australia: the role of qualitative research in programme development. JAC-Antimicrobial Resistance, 3(4), dlab166. DOI: https://doi.org/10.1093/jacamr/dlab166 .

Jo-Anne Manski-Nankervis, Ruby Biezen, Karin Thursky, Douglas Boyle, Malcolm Clark, Sean Lo and Kirsty Buising Abstract Background : Inappropriate antibiotic prescribing can lead to antimicrobial resistance and drug side effects. Tools that assist general practitioners (GPs) in prescribing decisions may help to optimise prescribing. The aim of this study was to explore the use, acceptability, and feasibility of a clinical decision support (CDS) tool that incorporates evidence-based guidelines and consumer information that integrates with the electronic medical record (EMR). Methods : Eight GPs completed an interview and brief survey after participating in 2 simulated consultations. The survey consisted of demographic questions, perception of realism and representativeness of consultations, Post-Study System Usability Questionnaire, and System Usability Scale. Qualitative data were analysed using framework analysis. Video data were reviewed, with length of consultation and time spent using the CDS tool documented. Results : Survey responses indicated that all GPs thought the consultations were “real” and representative of real-life consultations; 7 of 8 GPs were satisfied with usability of the tool. Key qualitative findings included that the tool assisted with clinical decision making and informed appropriate antibiotic prescribing. Accessibility and ease of use, including content (guideline and patient education resources), layout, and format, were key factors that determined whether GPs said that they would access the tool in everyday practice. Integration of the tool at multiple sites within the EMR facilitated access to guidelines and assisted in ensuring that the tool fit the clinical workflow. Conclusion : Our CDS tool was acceptable to GPs. Key features required for the tool were easy navigation, clear and useful guideline content, ability to fit into the clinical workflow, and incorporation into the EMR. Piloting of the tool in general practices to assess the impact and feasibility of use in real-world consultations will now be undertaken. Keywords : antibiotics, clinical decision support, clinical information system, electronic medical record, general practice, guidelines, prescribing, primary care. Read the full paper here . Citation : Manski-Nankervis, J.-A., Biezen, R., Thursky, K., Boyle, D., Clark, M., Lo, S., & Buising, K. (2020). Developing a clinical decision support tool for appropriate antibiotic prescribing in Australian general practice: A simulation study. Medical Decision Making. DOI: https://doi.org/10.1177/0272989X20926136 .

Sajal Saha, David Kong, Karin Thursky and Danielle Mazza Abstract Implementing antimicrobial stewardship (AMS) programs is central to optimising antimicrobial use in primary care. This study aims to assess general practitioners’ (GPs’) awareness of AMS, uptake of AMS strategies, attitudes towards GP-pharmacist collaboration in AMS and future AMS improvement strategies. A paper-based survey of nationally representative GPs across Australia was conducted in 2019. Of 386 respondent GPs, 68.9% were familiar with AMS. Respondents most frequently used the Therapeutic Guidelines (TG) (83.2%, 321/385) and delayed antimicrobial prescribing (72.2%, 278/385) strategies, whereas few utilised point-of-care tests (18.4%, 71/382), patient information leaflets (20.2%, 78/384), peer prescribing reports (15.5%, 60/384) and audit and feedback (9.8%, 38/384). GPs were receptive to pharmacists’ recommendations on the choice (50.5%, 192/381) and dose (63%, 241/382) of antimicrobials, and more than 60% (235/381) supported a policy fostering increased GP-pharmacist collaboration. Most GPs agreed to have AMS training (72%, 278/386), integration of electronic TG (eTG) with prescribing software (88.3%, 341/386) and policies limiting the prescribing of selected antimicrobials (74.4%, 287/386) in the future. Conclusively, GPs are aware of the importance of judicious antimicrobial prescribing but indicated inadequate uptake of evidence-based AMS strategies. The majority of GPs support GP-pharmacist collaborative AMS approaches to optimising antimicrobial use. Developing a feasible GP-pharmacist collaborative AMS implementation model and facilitating AMS resources and training could foster AMS activities in primary care. Keywords : antimicrobial stewardship; general practitioners; GP-pharmacist collaboration; survey; primary care. Read the full paper here . Citation : Saha, S.K., Kong, D.C., Thursky, K., Mazza, D. (2020). A nationwide survey of Australian general practitioners on antimicrobial stewardship: Awareness, uptake, collaboration with pharmacists and improvement strategies. Antibiotics, 9, 310. DOI: https://doi.org/10.3390/antibiotics9060310 .

The reports of the 2018 Hospital NAPS, Surgical NAPS and Aged Care NAPS

Leslie Dowson, N. Deborah Friedman, Caroline Marshall, Rhonda Stuart, Kirsty Buising, Arjun Rajkhowa, Fiona Gotterson, David C. M. Kong Abstract Background : The excessive use of antimicrobials in aged-care homes is a widely recognised phenomenon. This is problematic because it can harm residents, and is detrimental to public health. Residents in the final month of life are increasingly likely to be prescribed an antimicrobial, commonly without having signs and symptoms of infection that support antimicrobial use. Objectives : We aimed to describe the perspectives of health professionals on antimicrobial use near the end of life in aged-care homes and investigate the potential opportunities for nurses to undertake antimicrobial stewardship activities near the end of life in aged-care homes. Design : One-on-one, semi-structured, qualitative interviews. Settings and participants : Twelve nurses, six general practitioners and two pharmacists providing routine care to residents of aged-care homes in Victoria, Australia, were interviewed. Diversity in terms of years of experience, aged-care funding type (government, private-for-profits and not-for-profits) and location (metropolitan and regional) was sought. Methods : Interviews were transcribed and open coded in a descriptive manner using validated frameworks for understanding behaviour change. The descriptive code was then used to build an interpretive code structure based on questions founded in grounded theory. Results : Thematic saturation was reached after fourteen interviews, and an additional six interviews were conducted to ensure emergent themes were consistent and definitive. There are opportunities for aged-care home nurses to undertake antimicrobial stewardship activities near the end of life in the provision of routine care. Aged-care home nurses are influential in antimicrobial decisions near the end of life in routine care because of their leadership in advance care planning, care co-ordination and care provision in an environment with stopgap and visiting medical resources. Nurses also have social influence among residents, families and medical professionals during critical conversations near the end of life. Past negative social interactions within the aged-care home environment between nurses and families can result in ‘fear-based’ social influences on antimicrobial prescribing. Conclusions : The work of facilitating advance care planning, care coordination, care delivery, and communicating with families and medical professionals provide important opportunities for aged-care home nurses to lead appropriate antimicrobial stewardship activities near the end of life. Read the full paper here . Citation : Dowson, L., Friedman, N.D., Marshall, C., Stuart, R.L., Buising, K., Rajkhowa, A., Gotterson, F. and Kong, D.C. (2020). The role of nurses in antimicrobial stewardship near the end of life in aged-care homes: A qualitative study. International Journal of Nursing Studies, p.103502. DOI: https://doi.org/10.1016/j.ijnurstu.2019.103502 .

Leslie Dowson, N. Deborah Friedman, Caroline Marshall, Rhonda L. Stuart, Kirsty Buising, Arjun Rajkhowa, Fiona Gotterson, David C. M. Kong Abstract Highlights : Antimicrobial stewardship should clearly be part of an aged care home nurse's role. Addressing family confidence in resident wellbeing is critical. Promoting the understanding that antimicrobial stewardship improves resident care is important. Accreditation standards are important motivators for behaviour change in aged care. Background : The objective of this study was to understand how aged care home health professionals perceive antimicrobial use near the end of life and how they perceive potential antimicrobial stewardship activities near the end of life in aged care homes. Methods : Qualitative semi-structured interviews were undertaken with general practitioners, nurses, and pharmacists who provide routine care in aged care homes in Victoria, Australia. Interviews were coded using frameworks for understanding behaviour change. Results : Themes were established within 14 interviews, and an additional 6 interviews were undertaken to ensure thematic saturation. Two major themes emerged: (i) Antimicrobial stewardship activities near the end of life in aged care homes need to enable aged care home nurses to make decisions substantiated by evidence-based clinical knowledge. Antimicrobial stewardship should clearly be part of an aged care home nurse's role, and accreditation standards provide powerful motivation for behaviour change. (ii) Antimicrobial stewardship activities near the end of life in aged care homes must address family confidence in resident wellbeing. Antimicrobial stewardship activities should be inclusive of family involvement, and messages should highlight the point that antimicrobial stewardship improves care. Conclusions : Antimicrobial stewardship activities that reinforce evidence-based clinical decision-making by aged care home nurses and address family confidence in resident wellbeing are required near the end of life in aged care homes. Accreditation standards are important motivators for behaviour change in aged care homes. Read the full paper here .  Citation : Dowson, L., Friedman, N. D., Marshall, C., Stuart, R. L., Buising, K., Rajkhowa, A., Gotterson, F., Kong, D. C. (2019). Antimicrobial stewardship near the end of life in aged care homes. American Journal of Infection Control. DOI: https://doi.org/10.1016/j.ajic.2019.10.010 .