Antibiotic Research in Care Homes (ARCH) Work Package 4:
Research type
Research Study
Full title
Antibiotic Research in Care Homes (ARCH) Work Package 4: Intervention feasibility testing – “ARCHeS”
IRAS ID
288751
Contact name
Charis Marwick
Contact email
Sponsor organisation
University of Dundee
Clinicaltrials.gov Identifier
14/ES/0015, REC ref for Work Package 1; 2016MC03, Tayside ref for Work Package 1; 18/LO/1645 , REC ref for Work Packages 2&3; 2018MC03, Tayside ref for Work Packages 2&3
Duration of Study in the UK
1 years, 3 months, 31 days
Research summary
Summary of Research
Antibiotics are essential in modern healthcare to treat infections but bacteria develop ways of surviving their effects and develop resistance to them. Previous research has found that antibiotics are often used when they are not needed, which increases this effect. Research shows that antibiotic use among care home residents is high, as is antimicrobial resistance and other adverse effects of antibiotic use. Care home residents are vulnerable to infections so prescribing decisions are not straightforward and the amount of antibiotics used in different care homes varies significantly. There is general agreement that antibiotic use in care homes could and should be safely reduced but there is limited evidence about how this can be achieved in this complex, multi-stakeholder context, as most research on finding ways to safely reduce antibiotic use has been carried out in hospitals or GP surgeries rather than care homes.To design effective approaches to reducing antibiotic prescribing for care home residents we have carried out extensive research involving epidemiology, sociology, social anthropology and behavioural health psychology. This has increased our understanding about how, when and why antibiotics get prescribed in care homes, including from the perspectives of nurses, carers, GPs, and residents and their relatives.
The findings of our research are being used in Work Package 4 (the subject of this application) to inform the feasibility testing and optimisation of an intervention to safely reduce antibiotic use in this context while continuing to ensure effective treatment.
Summary of Results
Context:
The ongoing impact of the COVID-19 pandemic on the social care sector during the study period was more severe than anticipated by the study team and stakeholders from the sector. Staffing difficulties were the most critical, but not the only factor limiting the ability for care homes and their staff to participate. Observations within care homes during this period were not feasible but this possibility was anticipated, with alternative methods planned and used. Virtual focus groups were added, with sponsor approval, to generate additional feedback on the ARCHeS support system elements.Participants:
16 participants undertook consented research data collection activities. Other staff members used elements of the ARCHeS support system, but these numbers were not recorded. The 16 participants included three Care Home Managers, three Senior Carers who were also Antibiotic Champions, one Senior Carer, six Carers, and three Advanced Nurse Practitioners (ANPs).Recruitment and retention:
The recruitment target of four care homes was achieved, with a total of 35 care homes contacted. One of four recruited care homes completed the 6-month feasibility study (28 weeks), one care home completed 18 weeks, and the remaining two care homes did not provide any data (essentially dropped out post-recruitment).
There was no fixed target number for the recruitment of individual participants, but COVID-19 had a significant detrimental effect on recruitment and retention. The ten interviews from participating care homes and seven focus group participants (one interviewee also participated in a focus group) is lower than anticipated. There were an additional four interviews planned that the participant withdrew from before initiation.Implementation:
Short-staffing and internal IT limitations affected the ability for all staff to undertake online training (which was part of the intervention) but some staff in both care homes participated. The tools were used as intended in the submitted documents, and as reported in phone calls. There were no adaptations made to the support system elements during use in the study. The main adaptation suggested for future work was to make the tools electronic and compatible with IT systems used by some care homes for resident daily care (beyond the scope of this study).
Staff reported in interviews and phone calls that the tools were used almost every time there was an appropriate situation. There were occasional reports that they had not been used if the staff member involved had not undergone training. The extent of dissemination to all members of staff was limited by workload, staff availability, and perceived limitations of some staff roles.
Reports and feedback from interviews and focus groups were overall very positive about the tools, and the whole support system. There was no negative feedback in the weekly logs. There were reports during phone calls that the additional paperwork (particularly for study participation) was onerous, and there was some perceived overlap between ARCHeS tools and existing recording that staff routinely undertake.
Other than IT issues noted above, the support system was felt to be suitable for use, as reported in interviews, Antibiotic Champion training sessions, phone calls and focus groups. However, key challenges to implementation included understaffing, protecting time for training, balance between increased autonomy and fear of “missing something”/blame, alongside balancing standardisation across the sector with adaptation to individual care home contexts.Design of outcome measures for future trial:
Routine data accessed via the Health Informatics Centre, University of Dundee, can be used to generate efficacy (including antibiotic prescribing rates) and safety (including unplanned hospital admission rates) measures, but for a small number of care homes the numbers of events are low, and the time delay inherent in administrative data processing limits the utility over a short timeframe study. The number of care homes and events in the feasibility study were too low for comparison between routine data sources and reporting by care home staff.
Due to the limitations in data collection already noted, exploration of additional potential outcome measures, and definitive selection for a future trial, were limited but participants agreed that antibiotic prescribing rates were useful (both as feedback and outcome measurement) and safety outcomes were important to include.Reports are available here: https://eur03.safelinks.protection.outlook.com/?url=https%3A%2F%2Fu2790089.ct.sendgrid.net%2Fls%2Fclick%3Fupn%3DXv3JSvJ-2B3M71ppf7N9agbd7S9vB4WK40-2Bcz4c0Nu1k-2FnpInFA4BnouQcL-2FkENggntlgB_E1aO2-2BZlVOSJJV-2FajQqskegTd6IRomHYTi-2Fbt8SH3YJsFxsLLdEOnOHlRQ6tK3bUpONgr8o7R4qeIcdNP-2FMF0P5-2F-2FX-2FbEe696bnCv67jhQ6yX8iM-2FTkwSvAIsyIW1Gv-2Fz16KFpaYchHg5yWYZr1GkUJIqeQH5oqhCr3RB545Wb9JrYfhF9pLSbXr1DouMbJ8QV8HD6SMXTbcC2UiAIwPvg-3D-3D&data=05%7C01%7Capprovals%40hra.nhs.uk%7C3f1705fbc3574be14e2908db40e421ab%7C8e1f0acad87d4f20939e36243d574267%7C0%7C0%7C638175120779408806%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=IC9lz9542o5Kz8kgTP2IjgeeUa5Yex7tn8%2Fl33DTRkw%3D&reserved=0
REC name
East of Scotland Research Ethics Service REC 1
REC reference
21/ES/0058
Date of REC Opinion
28 May 2021
REC opinion
Favourable Opinion