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Antibiotic Stewardship & Infection Prevention: What Nursing Homes Need to Know · The SHEA Podcast

• 0:06
  SPEAKER_01: Welcome to Shay's podcast discussing antimicrobial stewardship and infection prevention, what nursing homes need to know.
• 0:13
  SPEAKER_01: I am Christy Winschill, Executive Director of SHAY.
• 0:16
  SPEAKER_01: I'm excited to serve in the role of today's moderator.
• 0:19
  SPEAKER_01: Before we get started, I'd like to introduce you to today's speakers.
• 0:23
  SPEAKER_01: First is someone who needs no introduction, Dr.
• 0:25
  SPEAKER_01: Suzanne Bradley, Professor Emerata of Internal Medicine at University of Michigan Medical School and Ann Arbor Veterans Affairs Medical Center.
• 0:34
  SPEAKER_01: Dr.
• 0:34
  SPEAKER_01: Bradley was also editor-in-chief of Shay's Journal of Infection Control and Hospital Epidemiology, or Itchy, for 15 years.
• 0:41
  SPEAKER_01: We're also thrilled to have Dr.
• 0:43
  SPEAKER_01: Morgan Katz, Associate Professor of Medicine at the Johns Hopkins University School of Medicine, and Director of Antimicrobial Stewardship at Johns Hopkins Bayview Hospital.
• 0:53
  SPEAKER_01: Both of their areas of clinical expertise are infectious diseases, with research interests specifically in infection control and antimicrobial stewardship in long-term care facilities.
• 1:02
  SPEAKER_01: Welcome to the SHA podcast, Doctors Bradley and Katz.
• 1:05
  SPEAKER_01: I'm excited to hear your opinions on this important topic today.
• 1:09
  SPEAKER_01: To kick us off, you both just wrapped a project for SHAY where you served as program directors called Improving Antibiotic Stewardship and Infection Prevention in Nursing Homes.
• 1:19
  SPEAKER_01: Can you give us a high-level overview of what that program covers and who it's targeting?
• 1:24
  SPEAKER_01: Dr.
• 1:24
  SPEAKER_01: Bradley, I'll go ahead and let you start.
• 1:26
  SPEAKER_00: Okay, sure, Christy.
• 1:28
  SPEAKER_00: So we were charged with developing a half a dozen short modules for nursing home frontline staff.
• 1:36
  SPEAKER_00: And the question came up: who are the frontline staff?
• 1:40
  SPEAKER_00: Frequently we think of frontline staff as being physicians, advanced practice providers, and registered nurses based on our experience in hospitals.
• 1:53
  SPEAKER_00: But in nursing homes that's quite different.
• 1:56
  SPEAKER_00: So who is primarily seeing the patient and determining if there are problems that are new that are going on?
• 2:04
  SPEAKER_00: It's really the certified nursing assistant or perhaps a licensed practical nurse.
• 2:10
  SPEAKER_00: Our modules initially focused on recognizing findings that might signal an infection that would be helpful to the clinician, how to document and communicate those findings efficiently, and when to escalate areas of concern.
• 2:28
  SPEAKER_00: We also emphasize that while antibiotics can be important in suspected infection, their overuse can negatively impact residents.
• 2:39
  SPEAKER_00: While frontline staff are not prescribers, there are other important interventions they can do to reduce resident risk of infection.
• 2:48
  SPEAKER_00: In this way, we hope to empower members of the hot nursing home staff who often feel underappreciated.
• 2:56
  SPEAKER_00: Dr.
• 2:56
  SPEAKER_00: Katz, anything to add?
• 2:58
  SPEAKER_02: I think Dr.
• 2:59
  SPEAKER_02: Bradley really covered that nicely.
• 3:01
  SPEAKER_02: Again, um, we really want to include this very integral part of the healthcare team, the CNAs and LPNs, into the patient care, the infection prevention, and the antibiotic prescribing process.
• 3:18
  SPEAKER_02: And this project is really dedicated to making them part of that process and helping them understand their role in improving the care of the resident.
• 3:29
  SPEAKER_02: Great.
• 3:30
  SPEAKER_01: The online education itself is meant to be shared as part of a five or 10-minute daily HUDL sessions that happen at nursing homes.
• 3:38
  SPEAKER_01: What makes this microlearning approach effective?
• 3:41
  SPEAKER_01: Dr.
• 3:41
  SPEAKER_01: Katz, can you share your thoughts on this learning methodology?
• 3:45
  SPEAKER_02: Sure.
• 3:46
  SPEAKER_02: So a lot of my work is on, you know, trying to make some of the tools that we share with long-term care facilities feasible.
• 3:56
  SPEAKER_02: And one of the things that many of the people on the team developing this recognize is that none of these frontline care workers have a lot of time.
• 4:07
  SPEAKER_02: They don't have dedicated, you know, out lunch hours or um, you know, learning opportunities to sit down and take a break and get a lot of this information.
• 4:19
  SPEAKER_02: And so the way to get this information quickly on the fly and integrate it into their daily tasks, integrate it into their workflow is to make it quick, digestible, um, and part of sort of this daily huddle process that often occurs between nursing, between the charge nurse.
• 4:41
  SPEAKER_02: And that's really how we design this project.
• 4:44
  SPEAKER_02: We want to make it feasible and something that they can have key takeaways that they can bring home with them, but not sort of get bogged down in the sort of hour-long learning opportunities that sometimes we present in in more academic settings or settings that um have dedicated time for this.
• 5:10
  SPEAKER_02: Um, so we're hoping that this makes it more feasible and um more widely accepted by uh the groups that this is directed towards in this project.
• 5:21
  SPEAKER_01: Great.
• 5:22
  SPEAKER_01: I think that it will have that effect.
• 5:24
  unknown: Dr.
• 5:24
  SPEAKER_01: Bradley, just checking.
• 5:25
  SPEAKER_00: Anything to share?
• 5:27
  SPEAKER_00: Sure.
• 5:28
  SPEAKER_00: Um I think uh Morgan pointed out that arranging didactic lectures every single shift is impossible in a clinical setting, to be honest.
• 5:40
  SPEAKER_00: And most of the guidelines and guidance documents, I believe to date, have not really targeted this audience that has very specific uh needs and educational background.
• 5:52
  SPEAKER_00: So I'm hoping this will be a novel product that will really help help the frontline workers understand, you know, why we're asking them to ask the questions that we are and communicate information in a timely manner.
• 6:11
  SPEAKER_01: As long as we're on the subject of sort of the frontline professionals that we're targeting, how can these CNAs and nurses influence antibiotic decisions, even though they aren't the prescribers themselves?
• 6:23
  SPEAKER_01: Dr.
• 6:23
  SPEAKER_01: Bradley, do you want to share your thoughts first?
• 6:26
  SPEAKER_00: Sure.
• 6:26
  SPEAKER_00: Um, as somebody who used to do geriatrics and had been on call in a nursing home, often I would have somebody call about the 30 odd patients I was covering.
• 6:40
  SPEAKER_00: Uh, and and they would say, I've never seen this patient before.
• 6:45
  SPEAKER_00: And then you're left uh with trying to make a decision.
• 6:49
  SPEAKER_00: Um, you know, do I start antibiotics, assuming that's uh the safest course, or uh do I dig dig in online and try to figure it out on my own?
• 7:01
  SPEAKER_00: Often the default was starting antibiotics.
• 7:06
  SPEAKER_00: So I think they can greatly uh influence what the clinician decides if they can target uh the information uh that the clinician needs to make a good decision.
• 7:22
  SPEAKER_00: Uh they also have measures that can help prevent infection, as Dr.
• 7:28
  SPEAKER_00: Katz already alluded to, uh like optimizing health, um hand washing, uh skin care, uh, aspiration precautions, and device use.
• 7:42
  SPEAKER_00: Uh so as long as we can emphasize that information, I think it will make a difference.
• 7:48
  SPEAKER_00: Finally, they often interact with families, and if we can have them understand that antibiotics aren't always uh the best option, that perhaps they can mitigate the family's expectations that their family member is always going to get an antibiotic.
• 8:08
  SPEAKER_02: Yeah, so I would add to this, I mean, I completely agree, Dr.
• 8:12
  SPEAKER_02: Bradley, that you know, we just we need to recognize that these CNAs and the nurses are really at the at the bedside of these residents on a daily basis.
• 8:22
  SPEAKER_02: They're spending the most time with them.
• 8:24
  SPEAKER_02: They really know them best.
• 8:26
  SPEAKER_02: And so they are the, they really have an important role in identifying changes in the trajectory of the resident's course.
• 8:37
  SPEAKER_02: And this is something that we really emphasize throughout the course: being able to identify even subtle changes that may represent infection or other changes that need to be addressed and improving the monitoring processes so that we can prevent downstream complications or missepsis in these patients, which is something that providers are often fear and leads to unnecessary or an antibiotic use.
• 9:06
  SPEAKER_02: On top of that, you know, I really can't emphasize enough, as you said, the importance of this interaction with family members.
• 9:15
  SPEAKER_02: One of the most uh likely causes of antibiotic starts in the nursing home is family pressure.
• 9:23
  SPEAKER_02: Um so having these bedside frontline staff educated on, you know, concepts as really basic as cloudy or foul-smelling urine does not indicate the need for a urine culture.
• 9:39
  SPEAKER_02: This is sort of basic material that if frontline staff are armed with dialogue to talk to family members about that information, we can really prevent a lot of downstream issues like unnecessary urine cultures, the provider feeling like they need to treat that urine culture when they haven't assessed symptoms and various issues that we can really prevent if we have the groups that are at the bedside educated on these sort of core principles.
• 10:08
  SPEAKER_01: So continuing on that vein, can you explain how unnecessary antibiotic use really contributes to MDROs in nursing homes and what frontline staff specifically could be charged with to reduce that risk?
• 10:21
  SPEAKER_01: Dr.
• 10:22
  SPEAKER_01: Katz, I know this is a specific area of interest for you.
• 10:24
  SPEAKER_01: So any thoughts?
• 10:26
  SPEAKER_02: Yeah, absolutely.
• 10:27
  SPEAKER_02: So, you know, we we know that antibiotic use is a problem in nursing homes.
• 10:33
  SPEAKER_02: Um, you know, some of the early studies have shown up to 75% of antibiotic courses prescribed in nursing homes are considered unnecessary.
• 10:43
  SPEAKER_02: And nursing homes are often tasked as serving as reservoirs for multidrug-resistant organisms because this is a high-risk population.
• 10:51
  SPEAKER_02: They're going to and from the acute care facilities, and they are getting repeated rounds of antibiotics and healthcare exposure.
• 11:00
  SPEAKER_02: Much of this is due to the provider having a fear of missing sepsis because these patients can decompensate very quickly.
• 11:09
  SPEAKER_02: Um, and also that added family pressure.
• 11:12
  SPEAKER_02: Those are really common-sided reasons for inappropriate antibiotic use.
• 11:17
  SPEAKER_02: So, by educating the frontline staff who are at the resident's bedside, we can make providers feel more comfortable, even about holding off on starting antibiotics, implementing active monitoring, relying on the uh frontline staff who are at the bedside to assess changes in the resident and communicate clearly these changes so that we are able to identify infection earlier or reasons that are not infection.
• 11:51
  SPEAKER_02: Um, and that's really the basic of this core, the basics of these courses, right?
• 11:55
  SPEAKER_02: It's it's helping the staff understand that all of the part of all of these decisions that we're making in terms of starting antibiotics and also monitoring the resident to prevent bad outcomes.
• 12:11
  SPEAKER_00: So, no, I totally agree, uh uh Dr.
• 12:14
  SPEAKER_00: Katz.
• 12:15
  SPEAKER_00: Um I think the other point of um of the M MDRO issue is I think it helps the frontline staff understand why basic infection control, um infection control procedures are so important, uh, adherence to PPE, uh, and knowing what the risk factors are for patients who may not be sick with MDRO that might harbor them.
• 12:47
  SPEAKER_00: Uh all these uh issues uh can be helpful in preventing transmission.
• 12:55
  SPEAKER_01: I think that's helpful.
• 12:57
  SPEAKER_01: Several modules of the education really emphasize early recognition and communication of changes in condition of the patients or the residents in nursing homes.
• 13:07
  SPEAKER_01: You covered this a little bit with some of the other questions, but what are some early subtle signs of infection that staff, particularly French line staff, should not ignore?
• 13:16
  SPEAKER_01: Dr.
• 13:16
  SPEAKER_01: Bradley, I know you have a lot of experience with this care to start with.
• 13:20
  SPEAKER_01: Can you share your thoughts?
• 13:22
  SPEAKER_00: Sure.
• 13:22
  SPEAKER_00: Um, so I think any evidence of hemodynamic instability uh is important.
• 13:30
  SPEAKER_00: And there are lots of different algorithms out there, but we rely on the 100-100-100 approach, which is easily remembered.
• 13:41
  SPEAKER_00: So new hypotension, blood pressure less than 100, pulse greater than 100, or fever greater than 100.
• 13:51
  SPEAKER_00: Those signs and symptoms should be reported promptly.
• 13:55
  SPEAKER_00: In addition, if the patient has new onset to kidnea, um acute hypoxemia as measured by pulse ox, which is available in nursing homes today, and confusion.
• 14:09
  SPEAKER_00: They should not be ignored.
• 14:11
  SPEAKER_00: These changes in signs and symptoms may not be due to infection, but the point is they warned evaluation by a nurse, by an RN, and then communicated very promptly to uh the provider for further instructions.
• 14:29
  SPEAKER_00: We're not out to make the frontline staff diagnosticians or prescribers.
• 14:37
  SPEAKER_01: That was a great answer.
• 14:38
  SPEAKER_01: Dr.
• 14:38
  SPEAKER_01: Katz, anything to add?
• 14:40
  SPEAKER_02: Yeah, the only thing I would add to that is we also, I guess, um incorporate in this the importance of sort of again, not catching these signs before we reach that that level of hemodynamic instability.
• 14:58
  SPEAKER_02: Um, so really noticing even just a change in the regular pattern of residents should uh sort of signal at least a stop and watch and an increased monitoring from the CNA to the nurse, some communication about that.
• 15:15
  SPEAKER_02: Because even a resident um sort of refusing breakfast may be a sign that something else is going on and they need to be looked at more closely over the next several hours.
• 15:27
  SPEAKER_02: Um, so we actually have incorporated in the program a lot of different levels for that.
• 15:32
  SPEAKER_02: So hopefully we can actually prevent the level of hemodynamic instability and increase the communication process before we even get to that point.
• 15:44
  SPEAKER_01: From the stewardship perspective, Dr.
• 15:46
  SPEAKER_01: Katz, UTIs and respiratory infections are common reasons antibiotics are prescribed in nursing homes.
• 15:53
  SPEAKER_01: What are some misconceptions about these infections that this course really works to try to address?
• 15:59
  SPEAKER_02: Yeah, so I mean, uh we do focus this course, we do um we focus on the most common infections in that we see in long-term care.
• 16:09
  SPEAKER_02: So really UTIs, respiratory infections, and skin and soft tissue infections.
• 16:14
  SPEAKER_02: Um, I would say from a UTI standpoint, you know, obviously sort of the low-hanging fruit that we're all trying to address across the stewardship world is this over-treatment of asymptomatic bacterial and this um sort of first feeling that um you need to get a culture if there's a change in urine consistency, um, which we really tried to dispel there if there's no symptoms associated.
• 16:41
  SPEAKER_02: And second, you know, that new delirium without other signs of infection is is always signs of a UTI in nursing home residents.
• 16:50
  SPEAKER_02: Um, we really try to dispel that in some of this education.
• 16:55
  SPEAKER_02: Uh, from a respiratory standpoint, you know, many respiratory um changes in residents are due to viruses or respiratory infections are due to viruses and do not require antibiotic therapy.
• 17:09
  SPEAKER_02: And then, you know, really emphasizing the importance of prevention in terms of respiratory infections, um, not only infection prevention and the importance of early transmission-based precautions at the onset of new signs or symptoms of a respiratory infection, um, but also the importance of vaccination, which is really our best way to protect the residents in nursing homes because they are certainly at risk for uh rapid spread of uh respiratory viruses in this setting.
• 17:43
  SPEAKER_01: Great.
• 17:44
  SPEAKER_01: Um if a long-term care facility implements this program, like they really use it as part of their training in these early morning huddles, how do you think this training will ultimately improve resident safety and quality of care?
• 17:57
  SPEAKER_01: Dr.
• 17:58
  SPEAKER_01: Bradley, I'll let you start with this last question.
• 18:01
  SPEAKER_00: Sure.
• 18:01
  SPEAKER_00: So I think uh it will be important uh for this course to uh work in concert with infection control and antimicrobial stewardship.
• 18:12
  SPEAKER_00: What are the measures they are following?
• 18:15
  SPEAKER_00: Um I think that will be be critical to see how we improve quality of care and patient safety.
• 18:23
  SPEAKER_00: So, for example, if we improve the information given to clinicians who are often off-site, will that improve the detection and documentation of real infections, not just colonization?
• 18:40
  SPEAKER_00: Uh will that result in reduction in overall antibiotic prescribing, unnecessary antibiotic use, and its complications like C.
• 18:52
  SPEAKER_00: difficile infection, allergies and the like.
• 18:56
  SPEAKER_00: And then other measures that could be looked at would be adherence to hand washing, PPE use, and adherence to isolation procedures, and finally uh unnecessary attention to unnecessary device use.
• 19:15
  SPEAKER_00: Again, these are the people who see the patient every day and can be very valuable if empowered to help with these issues.
• 19:27
  SPEAKER_00: Dr.
• 19:27
  SPEAKER_00: Katz, that's anything to share?
• 19:31
  SPEAKER_02: No, I mean I am just a huge believer in the importance of multidisciplinary um education and and and working with the entire healthcare team to um to make these quality improvement efforts successful.
• 19:50
  SPEAKER_02: Um, and so really the goal again is to empower all levels of staff to help them work together and make sure that everyone that's um you know caring for these vulnerable residents feels like they're part of a team and that they understand the reasons for prescriber decisions as well.
• 20:10
  SPEAKER_02: So I'm excited to have been a part of this project and we're really thankful too.
• 20:16
  SPEAKER_02: There were many other um experts involved that created the content here.
• 20:23
  SPEAKER_02: So um we are so grateful to all of them for their time as well.
• 20:30
  SPEAKER_01: Thank you both so much.
• 20:31
  SPEAKER_01: This conversation really helped give some important perspectives and background for this online education and really provided some key highlights for different learners.
• 20:40
  SPEAKER_01: I really appreciate Dr.
• 20:42
  SPEAKER_01: Bradley and Katz sharing their perspectives and experiences, as well as leading this effort on this important learning area.
• 20:48
  SPEAKER_01: Shea appreciates your efforts to help us move the needle on making nursing home patient care better.