Antibiotic Research in Care Homes (ARCH) WP2&3
Research type
Research Study
Full title
Antibiotic Research in Care Homes (ARCH); Understanding and improving antimicrobial prescribing in care homes: a multidisciplinary approach. Work Packages 2 & 3
IRAS ID
240826
Contact name
Suzanne Grant
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/1239, REC ref from previous review of this study
Duration of Study in the UK
2 years, 11 months, 30 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 antibiotic 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 improving antibiotic prescribing for care home residents we need to understand more about how, when and why they get prescribed from the perspectives of nurses, carers, GPs, and residents and their relatives.This study will systemically examine the social, cultural and behavioural determinants of antibiotic use in care homes. This will be achieved through novel multidisciplinary collaboration including epidemiology, sociology, social anthropology, behavioural health psychology, and implementation science. We will employ ethnographic observations, ethnographic interviews, behavioural psychology interviews and behavioural psychology questionnaires to obtain extensive and rich data. The results will be used to inform the development co-design and optimisation of an intervention to safely reduce antimicrobial use while continuing to ensure effective treatment.
Summary of Results
The overall aim of work package 2 was to develop an in-depth understanding of how the social and cultural characteristics of different care home organisational settings influenced inter-professional collaboration between care home staff and prescribers in relation to bacterial infection diagnosis and antibiotic decision-making, and to identify key moments for intervention. Multi-site ethnographic fieldwork was carried out across seven care home settings (including non-participant observation, semi-structured interviews with care home staff (including carers, senior carers, nurses, managers), care home residents and their families and GPs, and documentary analysis).Considerable variation was found between care homes in terms of how bacterial infections were identified and managed, with this variation reflecting factors such as care home type (e.g. residential vs nursing home), team structure, resident characteristics, existing relationships between the care home and linked GP practices, and their ethos and approach to resident care. Antibiotic prescribing was also found to not just be a single act undertaken by a prescriber (e.g. general practitioner), but a process which began much earlier involving complex ‘diagnostic work’ by care home staff including carers and senior carers. This diagnostic work involved creative, intelligent and experienced decision-making by all care home staff in the face of complex, context-dependent infection management challenges. For example, carers were often able to initially identify potential bacterial infections in residents using tacit knowledge of when a resident’s behaviour deviated from ‘their normal’ (e.g. becoming more vocal), or through awareness of subtle physical changes in a resident such as shortness of breath. While this initial work required a high degree of knowledge and skill, care home staff often did not recognise their role in this and described prescribing as a task that only GPs and ANPs (Advanced Nurse Practitioners), and aligned healthcare professionals, e.g. podiatrists, dentists, performed.
In this workpackage, we also found that prescribing antibiotics was highly influenced by the identification and escalation of potential infections within care homes and an over-assumption of infection. This often resulted in an antibiotic being prescribed without the GP seeing the resident, whereas a newer system involving escalation of unwell residents to an ANP more often resulted in monitoring or management not involving antibiotics. However, it was also recognised that UTI (urinary tract infection) diagnosis was sometimes difficult, as some residents may not meet the criteria for further investigation (e.g. urine culture test) because changes in a resident’s behaviour were not always recognised as ‘real’ symptoms. There was also a lack of consensus on infection management from GPs, with some using both urine dip tests and culture tests and others following more recent guidance and only using culture tests.
Several elements of these findings directly informed intervention development for WP4. For example, antibiotic prescribing in care homes was understood as being a wider process that started at the initial identification and management of a potential infection and involved carers and senior carers alongside clinically trained individuals. In addition, a series of issues relating to the relationship and communication between care homes and prescribers were identified. In terms of improving their own rates of antibiotic use, existing audits of antibiotic prescribing (by care home, GP practice or regulatory authority) were not sufficiently or effectively used.
A final set of interviews (n=13) conducted to evaluate the changes that COVID-19 had brought to the issue, revealed that staff believed chest infections had significantly decreased, but that UTIs were not affected. Digital technologies have made contacts with healthcare proferssionals easier and, overall, the sector is moving towards the use of digital devices to record routine care, medications and care plans.
Work Package 3The aim of work package 3 was to apply behavioural science theories and frameworks to identify: i) actors and behaviours relevant to antibiotic prescribing in care homes; ii) modifiable influences on those behaviours (i.e. barriers and enablers); and iii) clinically acceptable alternative behaviours to reduce AMR.
This was a mixed-methods study. We first conducted semi-structured qualitative interviews with 33 participants across the same seven care homes purposively sampled for participation in WP2. Participants represented the range of staff roles involved in antibiotic stewardship within care homes, including: care home managers, nurses, senior carers, care assistants; as well as staff in primary care (i.e. GP, advanced nurse practitioners and pharmacists). All interviews took place between February 2019 and July 2020.
Second, to explore generalisability of interview findings in a larger sample of participants, we conducted an online digital survey in December 2020, which was sent to all 148 care homes in the study region, as well as at least one GP practice associated with each care home. We asked for a response from at least one staff member in each care home and GP practice, with ideally multiple responses from participants representing the different aforementioned staff roles. We received responses from 21 GPs and 55 CH staff across 37 care homes (25% response rate).
Questions in both the interview topic guide and survey were structured around the domains of the Theoretical Domains Framework and COM-B Model (Capability. Opportunity, Motivation – Behaviour Model, Michie et al. 2014), in order to ensure we explored the wide range of potential individual, socio-cultural and environmental barriers and enablers to antibiotic prescribing in care homes. Initial themes from the interview analysis informed the design of the survey items. Data were analysed using a combined inductive thematic and deductive framework analysis approach.
The main themes and findings identified across both the interviews and surveys are summarised within the domains of COM-B.
Capability: Concerns knowledge and skills related to antibiotic stewardship, as well as attention, decision making, reflecting and problem-solving processes. We identified wide variation in participant’s levels of knowledge and understanding around what antibiotics can and cannot treat, and the threat and potential consequences of AMR. Many participants reported that they had received limited education and training on antibiotic stewardship, and what knowledge they did have on AMR sometimes came from other sources, such as the media. More specifically, participants reported having insufficient knowledge to confidently interpret signs and symptoms of infection and faced challenges distinguishing between potential infections and other conditions such as worsening dementia or dehydration. Care home staff reported a reliance on, and tendency to, automatically test for suspected infections, such as UTIs, using dip tests and often habitually or automatically escalated to GPs based on common signs and symptoms that may indicate infection. Participants also felt that they lacked clarity on safe alternatives to antibiotic prescribing, such as watchful waiting and monitoring. There was a reported lack of clear guidelines and protocols for managing infections without escalating to GPs and/or prescribing an antibiotic. Lastly, many staff reported that they did not know whether antibiotic overuse or misuse was a problem in their care home or locally, as they did not receive any data or feedback on current prescribing and antibiotic resistance rates in care homes.
Motivation: Concerns perceived consequences, pros/cons, risks, susceptibility relative and competing priorities, intentions, and emotions. Motivation was a key driver of antibiotic prescribing in care homes. Many participants reported antibiotic prescribing and escalation to GPs was often driven by a strong fear of ‘missing something’ and the potential adverse consequences to vulnerable residents of not prescribing. Care home staff felt a strong sense of duty of care for their residents, and ‘catching an infection early’ was sometime equated with satisfaction of providing good quality care. Participants reported that antibiotic resistance was not a high priority or immediate concern. The immediate threat to the resident took priority over the downstream/distant threat of antibiotic resistance. There were also variable views as to whether reducing or limiting use of antibiotics will lead to benefits in care homes. Furthermore, care home staff also reported at times being under pressure from resident’s family members to ‘do something,’ and prescribing was seen as a concrete action that was at times expected or requested. Combined, these concerns and pressures often led to escalation to a GP and/or an antibiotic being sought for a suspected potential infection.
Opportunity: Concerns barriers and enablers in the physical (i.e. time, available resources, staff) and social environments (i.e. culture, team work, communication, role clarity). Most barriers and enablers fell within social rather than physical opportunity, except for lack of time for care home staff to engage in quality improvement activities and reflect on current practice, including related to antibiotic resistance. A key theme within social opportunity was communication between healthcare staff both within the care home and between care homes and GP practices. Between care homes, key missed moments and opportunities for communication around antibiotic use were highlighted- such as handovers and associated lack of documentation and key information. Communication with GPs around prescribing was often done via telephone, sometimes without physically visiting or examining a resident. Rather, trust between care home staff and GPs was often mentioned. With GPs trusting the escalation and judgment of care home staff if they suspected an infection, and/or care home staff trusting and not questioning the prescribing decision of GPs. The use of SBARs and other structured communication tools was not frequent. The transient nature of care home staff (e.g. high staff turnover, agency staff) was a challenge to educating and training the workforce on antibiotic stewardship. Crucially, the potential role of care home staff in antibiotic stewardship was often not recognised- by others and care home staff themselves. Indeed, care home staff at times reported stewardship was not ‘part of their role’ or responsibilities. There was an emphasis on prescribing as the main behaviour, rather than other key behaviours performed by care home staff that contribute to antibiotic prescribing and are potentially modifiable (e.g. identifying changes in a resident, conducting observations and monitoring, documenting, communicating, and escalating).
Combined, these identified barriers and enablers and alternative behaviours within care homes represent potential targets for interventions to improve antibiotic stewardship in care homes. The design and testing of these interventions was the focus of work package 4.
REC name
London - Camberwell St Giles Research Ethics Committee
REC reference
18/LO/1645
Date of REC Opinion
31 Oct 2018
REC opinion
Favourable Opinion