Toolkit 2. Common Suspected Infections: Communication and Decisionmaking for Four Infections

Toolkit Effectiveness

When tested in six nursing homes in an intervention group and six in a comparison group, this toolkit demonstrated a small reduction in prescribing in the intervention group relative to the comparison group.¹

Overview of the Toolkit

What are the Four Infections and Why Should a Nursing Home Use this Toolkit?

At least 25 percent of antibiotic prescriptions in nursing homes do not meet clinical guidelines for prescribing. This use and overuse of antibiotics results in side effects and drug-resistant bacteria. The Communication and Decisionmaking for Four Infections toolkit aims to reduce inappropriate prescribing for the four infections for which antibiotics are most frequently prescribed in nursing homes: (1) urinary tract infections (UTIs), (2) lower respiratory tract infections, (3) skin and soft tissue infections, and (4) gastrointestinal infections.

What is the Communication and Decisionmaking for Four Infections Toolkit?

The toolkit is intended to help prescribing clinicians and nurses work together to determine when antibiotics are truly needed. This toolkit includes the following tools:

• A Medical Care Referral Form to document information for prescribing clinicians (tool 1) (PDF | Word)
• Pocket Cards for nurses that present 12 common situations where systemic antibiotics are generally not indicated and provides infection control guidelines (tool 2) (PDF)
• Quality Improvement (QI) Tip Sheet that presents discussion points for a QI meeting (tool 3) (PDF | Word)
• Training slides for prescribing clinicians and nursing staff (tool 4) (PPT | Word)

How Do I Implement the Toolkit?

Implementing the toolkit involves five steps:

1. Identify Champions. Champions help drive successful implementation by increasing staff awareness of tools and building support among leadership and nursing home staff. It is important to identify at least two champions for small- to medium-sized nursing homes (under 100 beds), and three to four for larger nursing homes (100 or more beds). These champions can be the director of nursing, assistant director of nursing, administrator, charge nurses, the medical director and/or other onsite prescribing clinicians.
    
2. Introduce the tools to appropriate staff. Training increases staff understanding of inappropriate antibiotic use and of the tools available to them. Conducting this training is important because staff are more likely to use tools they understand and know how to use. Training should include information about inappropriate antibiotic use, a description of the tools and how to use them, and a discussion about scientific evidence for the recommended best practices.
    
3. Use the Medical Care Referral form. When considering a referral, clinicians need easy access to information required for evidence-based prescribing, instead of relying on handwritten notes that may be in multiple locations. The Medical Care Referral form facilitates communication between nurses and clinicians when a resident has a suspected infection or is being transferred to an emergency department or hospital. The form documents information clinicians need for prescribing decisions and reflects evidence-based guidelines for the four types of infections². Nurses should be trained on how to complete the form, and prescribing clinicians should be familiarized with its content and use it to make decisions about treatment.
    
4. Refer to the Pocket Card. Staff should understand common situations when antibiotics are unnecessary and must remain attentive to infection control guidelines. The pocket cards summarize situations in which systemic antibiotics are generally not indicated and provide infection control guidelines for Vancomycin-resistant enterococci (VRE), Clostridium difficile (C. diff), and Methicillin-resistant Staphylococcus aureus (MRSA). Nurses should be trained to use the pocket cards whenever an infection is suspected. Prescribing clinicians should also be trained to use order forms for treatment other than antibiotics when appropriate.
    
5. Hold QI meetings. Quality improvement meetings can be used to plan how to implement the intervention and to evaluate its success. The QI meetings tip sheet (tool 3) provides suggestions for how to organize these meetings.

¹Abt Associates and UNC Chapel Hill. Standardizing antibiotic use in long-term care settings (SAUL study). Final report prepared for Agency for Healthcare Research and Quality, Contract HHSA290200600019i, Task Order 11; 2012.

² Loeb M, Bentley DW, Bradley S, et al. Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference. Infect Control Hosp Epidemiol 2001 Feb;22(2):120-4. PMID: 11232875.

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