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3 PHO s Urinary Tract Infection Program for long-term care homes: An innovative approach to program development and evaluation December 12, 2017 Public Health Ontario Grand Rounds

4 Learning Objectives Describe the public health impact associated with the overuse of antibiotics in long-term care. List five key target areas of PHO s Urinary Tract Infection (UTI) Program that can minimize unnecessary antibiotic prescribing and strategies that can support change. Explain a stepped approach to embed theory and evidence into program development in addition to practical frameworks and data sources that can assist with this process. Describe practical examples of how embedding evaluation into all phases of program development can contribute to better outcomes. 4

5 Getting to Know our Audience Which setting best describes where you work or study? What are the main reasons you joined the webinar today? 5

6 Antimicrobial Resistance is a Public Health Threat Source: Review on Antimicrobial Resistance. Tackling drug-resistant infections globally: final report and recommendations. London, UK: Wellcome Trust; Available from: 6

7 Antimicrobial Resistance Requires Global Action AMR is a slow-motion tsunami. It is a global crisis that must be managed with utmost urgency. AMR is the greatest and most urgent global risk. AMR is a serious and growing public health threat 7

8 Antimicrobial Use is a Driver of AMR Antimicrobial use is linked to antimicrobial resistance Patient Population Antimicrobial drugs are unique as they are the only pharmaceutical agents that have transmissible loss of efficacy over time Source: Antimicrobial Resistance: A Public Health Threat. Toronto, ON: Public Health Ontario; Available from: 8

9 Clostridium difficile Infection is Another Concern Source: Antibiotic Resistance Threats in the United States. Atlanta, GA: Centers for Disease Control and Prevention; Available from: 9

10 Opportunities to Improve Antibiotic Use in LTC 1. Loeb M, et al. Antibiotic use in Ontario facilities that provide chronic care. J Gen Intern Med. 2001;16: Daneman N, et al. Prolonged antibiotic treatment in long-term care: role of the prescriber. JAMA Intern Med. 2013;173(8): Daneman N, et al. Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents. JAMA Intern Med. 2015;175(8):

11 Antimicrobial Stewardship Coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial drug regimen, including dosing, duration of therapy, and route of administration. 1. Society for Healthcare Epidemiology of America, et al. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. 2012; 33(4):

12 Antibiotics are Often Prescribed for Asymptomatic Bacteriuria Treatment of asymptomatic bacteriuria (ASB) accounts for the majority of urinary antibiotic use in long-term care homes (LTCHs) 1 ASB is found in 15-30% of men and 25-50% of women in LTCHs 1,2 However, treating ASB is not recommended 3 Asymptomatic bacteriuria (ASB) is the presence of bacteria in the urine in the absence of urinary symptoms 1. Nicolle LE, et al. Urinary tract infections in long-term-care facilities. Infect Control Hosp Epidemiol. 2001;22(3): D Agata E, et al., Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections. J Am Geriatr Soc. 2013;61(1): Zalmanovici Trestioreanu A, et al. Antibiotics for asymptomatic bacteriuria. Cochrane Database of Systematic Reviews. 2015;4:

13 Journey to the UTI Program We were on a path for the innovation project, and then we paused and decided to take a different path (less traveled, some would say uphill) Innovation project Regional support and requests Needs assessment Educational resources UTI Program Image Credit: Glen Malley Flickr 13

14 An Evidence-informed and Theory-driven Program Evidence-informed theory-driven program Evidence Evidence-based practices that are being implemented Theory Implementation strategies used to enhance the adoption, implementation, and sustainability of the practices Evidence 1. Moore JE, et al. Developing an Evidence-Informed, Theory-Driven Program. Practicing Knowledge Translation. Course Pinnock et al., Standards for reporting implementation studies (StaRI) statement. BMJ. 2017;356:i

15 UTI Program: Evidence-based Practices 15

16 UTI Program: Strategies to Support Change Buy-in and support Identify an implementation lead, involve an influencer, confirm problem and agree on adopting best practices to address it, and align organizational policies and procedures. Knowledge and skill Deliver education and coach staff and provide information and education to residents and families. Monitor and feedback Review and improve how symptoms are documented and communicated, keep track of how you are doing with the changes and provide regular reminders. 16

17 A Five Step Process 1. Identify who needs to do what differently 2. Identify barriers and enablers that need to be addressed using the Theoretical Domains Framework 3. Identify implementation strategies to address modifiable barriers and enhance enablers 4. Define how behaviour change can be measured and understood 5. Identify supports for implementation 1. French SD, et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implementation Science. 2012;7:38. 17

18 Step 1: Identify Who Needs to do What Differently To specify the target behaviours you need to think about: What is best practice? Are there existing high quality guidelines to inform practice? What is going on? Which practices need improvement? Example Question: What should healthcare providers and support staff in long-term care be doing differently; and who needs to be involved in improving practice? 18

19 Step 2: Identify the Barriers and Enablers that Need to be Addressed using Theoretical Frameworks Collect information on barriers and enablers to practice change This step involves categorizing data into groups of behavioural constructs using the Theoretical Domains Framework 1 This process ensures strategies address the underlying issues that contribute to current practice 1. Michie S, et al. Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality and Safety in Health Care. 2005;14(1):

20 Theoretical Domains Framework (TDF) Social or Professional Role & Identity Skills Knowledge Behavioural Regulation Emotion Optimism Beliefs about Capabilities Theoretical Domains Framework Social Influences Environmental Context & Resources Beliefs About Consequences Memory, Attention & Decision Processes 1. Michie S, et al. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14(1): Reinforcement Intentions Goals 20 20

21 Example: Mapping Barriers to TDF Constructs Concerns about the consequences of not providing antibiotics to residents with nonspecific symptoms or ASB including fears that an infection will develop and be missed Beliefs about consequences Emotions 21

22 Step 3: Identify Implementation Strategies to Address Modifiable Barriers and Enhance Enablers Reviewed all strategies on the CADTH s RX for Change Interventions Database Can this implementation strategy be executed by a LTCH? Will LTCHs have the resources available to deliver this implementation strategy? How will the implementation strategy help address the barriers/enablers to practice change? 22

23 Step 5: Support for implementation An evidence-informed implementation planning process supports the UTI Program based on a published synthesis of critical steps in the implementation process 1 1. Meyers DC, et al. The quality implementation framework: A synthesis of critical steps in the implementation process. Am J Community Psychol. 2012;50(3-4):

24 Evaluation and the UTI Program A commitment to ongoing improvement in the iterations of the UTI Program Formal processes to work with LTCH staff in program development Processes in place to apply the findings from the evaluation Act Plan Study Do 24

25 Phase I Evaluation Piloting UTI Program implementation planning process and resources HOMES consulted 2 2 FOCUS GROUPS 9+ PEOPLE interviewed 3 MEETINGS per home to support planning 33+ PAGES notes/transcripts 64 RECOMMENDATIONS made A new resource on delirium was created in partnership with one of our nurse practitioners involved in the pilot. We eliminated a core implementation planning tool based on the pilot results and went in a different direction. The process had worked in other settings, but added too much complexity to the process. 25

26 Phase II Evaluation Outcome Evaluation To examine whether implementing the UTI Program results in a reduction in urine culturing and antibiotic prescribing for UTIs per 1000 residentdays To examine whether implementing the UTI Program reduces the number of inappropriate urine culture submissions and prescriptions for ASB. Process Evaluation To examine how LTCHs implement the UTI Program and what contextual factors influence the implementation experience. Formative Evaluation To describe the types of supports LTCH stakeholders request during the implementation of the UTI Program and to identify opportunities to improve the usability of the program resources. 26

27 Phase II Evaluation 12 HOMES consulted 3 MEETINGS per home to support planning Baseline Implementation Planning Intervention 7 months 5 months 6 months Interviews with implementation teams 27

28 Methods A regression model adjusting for time-trends and seasonality was used to compare rates at baseline and following the program installation phase based on laboratory and pharmacy data. The process and formative evaluation was based on interviews with PHO and LTCH staff. A classification guide was created to assess whether each strategy was complete or not complete. A thematic analysis of interview transcripts and documentation was used to explore implementation context and opportunities to improve the program. 28

29 The UTI Program had Impact In 10 long-term care homes that implemented aspects of the program, we have seen impact in the months following program implementation: 29% 42% 29

30 Feedback on the UTI Program The UTI Program can empower front-line staff to improve practice front-line staff are feeling more confident in their practice now that they have more concrete direction on how to manage decisions around urine collection, an approach to document and communicate relevant symptoms, and resources to support communication with families on the use of antibiotics. one of our homes shared how they have noted a change in how their Personal Support Workers are caring for residents they are paying attention to the whole picture and looking at residents using a holistic view. 30

31 Feedback on the UTI Program The UTI Program can demonstrate to families that a home is committed to innovative approaches to improving resident care one of our homes shared that following an orientation session at Family Council they had the highest attendance they have ever had on account of the interest in the program. They have received calls back from family members who attended on how impressed they were that the facility was taking steps to improve resident care. 31

32 There are Opportunities to Continue to Improve We learned there were still opportunities for ongoing improvement to align with the 5 practice changes among the pilot homes. There was variation in adherence and understanding of the implementation strategies. There are a number of considerations for improvement to the description of the implementation strategies, associated resources and supports for implementation. 32

33 Application of the Evaluation Results Simplifying the description and organization of implementation strategies Improving resources to support process surveillance Drawing on stakeholder feedback to inform implementation supports for scale-up Developing an evidence-package to increase buy-in to practice changes 33

34 Summary Supporting improvements to reduce inappropriate antibiotic prescribing requires a strategy that acknowledges barriers and enablers that influence current practice. There are a number of approaches from the implementation science literature that can assist with the development of antimicrobial stewardship programs. An ongoing improvement process is critical to maximize the utility of programs and supports offered by intermediary organizations. 34

35 Acknowledgements Lead: Sam MacFarlane Anne Augustin Helen Bedkowski Amanda Brizard Kevin Brown Sandra Callery Risa Cashmore Andrea Chaplin Esther Chan Sue Copper Mandy Deeves Danijela Draganic Gerald Evans Laura Fraser Gary Garber Julia Moore Liz McCreight Bradley Langford Valerie Leung Alekhya Mascarenhas Donna Moore Kevin Schwartz Eva Skiba Jacquelyn Quirk Virginia Tirilis Debbie Valickis Rosemary Zvonar 35

36 To learn more: 36