1. Standardized Antibiotic Use in Long-Term Care Settings (SAUL Study) Steven Garfinkel American Institutes for Research AHRQ Annual Conference, Bethesda, MD, September 10, 2012 Project Cosponsored by the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality under AHRQ Contract# HHSA290200600019I,

2. 2 The Intervention Reduce inappropriate antibiotic use Communication and Order Form  SBAR format  Loeb criteria  For use by nurses and physicians

3. 3 SAUL Project SBAR Tool

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7. 7 Research Activities 1.Literature Review 2.Usability testing of data collection instruments with NH staff 3.Small-Scale Trial (SST)of intervention with 4 homes 4.Field test (FT) with 12 homes 5.Debriefing interviews with NH staff

8. 8 Data Collection Process (Monthly) Infection Log in home to identify all those with a Rx for a suspected UTI. MDS data for these residents. Medical records for orders and notes related to Rx and Dx.

9. 9 Research Design For Field Test Higher intensity OOOOOOXOOOOOO Lower intensity OOOOOOXOOOOOO Comparison Homes OOOOOOOOOOOO Mar. 2011 – Aug. 2011Sept. 2011– Feb. 2012 Higher intensity Homes (4) —— training, technical assistance, re-training Lower intensity Homes (4) —— training only Comparison homes (4) —— data collection only

10. 10 Outcomes Shift in distribution of prescriptions between symptomatic and asymptomatic UTIs Number of prescriptions written

11. 11 Results: Implementation Fidelity to implementation protocol varied. Was not dependent upon the level of education and training provided. Four homes were “implementers” (high level of fidelity) – three were from the high intensity education arm and one from the low intensity arm.

12. 12 Rx For UTIs (?) By Homes Classified According To Fidelity (per protocol) Results Unadjusted by Covariates Samples Pre-intervention Post-intervention AsymptomaticSymptomaticAsymptomaticSymptomatic N (residents)251104201113 Level of fidelity Implemented (n=4 homes) N79293839 %73.1526.8549.3550.65 Not Implemented (n=8 homes) N1727516374 %69.6430.3668.7831.22

13. 13 % Change In Prescriptions Without Localized Symptoms

14. 14 Rx For Suspected UTIs Dropped Significantly, And Then Rebounded

15. 15 Results: Barriers To Implementation Turnover, particularly in leadership. Competing demands from the corporate level. Resistance from nurses and physicians. Lack of champions/mandates.