Falls are a significant issue for older adults, and many older adults who once received care in nursing homes now reside in assisted living communities (ALCs). ALC staff needs to address resident falls prevention; however, federal or state requirements or oversight are limited. This research explores falls prevention in Wisconsin ALCs in the context of the Kotter Change Model to identify strategies and inform efforts to establish a more consistent, proactive falls prevention process for ALCs. A mixed methods approach demonstrated inconsistency and variability in the use of falls risk assessments and prevention programs, which led to the development of standardized, proactive falls prevention process flowcharts. This process, as delineated, provides ALCs with an approach to organize a comprehensive falls reduction strategy. Findings highlight the importance of educating staff regarding assessments, resident motivation, falls prevention programs, and feedback, all key components of the falls prevention process.
Key PointsQuestionDoes external facilitation improve adoption and effects of a complex antibiotic stewardship intervention in nursing homes?FindingsThis trial protocol describes a cluster-randomized hybrid type 2 effectiveness-implementation clinical trial of implementation of a multicomponent toolkit focused on improving the recognition and management of suspected urinary tract infection (UTI) in nursing homes. The trial seeks to evaluate whether delivery of external facilitation—coaching, collaborative learning, and peer comparison feedback—to implement this toolkit results in higher rates of toolkit adoption and reduced rates of urine testing and initiation of antibiotics for treatment of suspected UTI.MeaningIf successful, external facilitation could become an effective approach for improving spread and adoption of antibiotic stewardship interventions, as well as other quality improvement initiatives, in the nursing home setting.
Background Half of all urinary tract infections (UTI) are probably unnecessary. We conducted a cluster-randomized trial in which a toolkit to enhance the diagnosis and treatment of UTIs was introduced in study NHs via usual implementation versus an enhanced implementation approach based on external facilitation and peer comparison reporting. Methods Thirty Wisconsin NHs were randomized to each treatment arm in a 1.5:1 ratio. NHs used an online portal to report urine culture and antibiotic treatment data over a 6-month pre-intervention period (Jan-June 2019), a pre-COVID 8-month post intervention period (July 2019-Feb 2020) and an 8-month post-COVID intervention period (Mar-Oct 2020). Study outcomes included urine culture (UC), antibiotic start (AS), and antibiotic days of therapy (DOT) rates per 1,000 resident days. A generalized estimating equation model for panel data was used to assess differences in study outcomes between treatment arms before and after onset of the COVID-19 pandemic. STATA 16.1 was used for all analyses. Results A total of 802 UCs (457 pre-COVID, 345 post-COVID), 724 AS (401 pre-COVID, 323 post-COVID), and 6,454 DOT (3553 pre-COVID and 2901 post-COVID) were reported over the 16-month intervention period. No significant differences in the study outcomes were observed during the pre-COVID intervention period, however, UC rates in NHs assigned to the usual care arm of the study increased while those in the enhanced arm declined following onset of COVID-19 (Figure 1). AS and DOT rates followed a similar pattern although the differences between the study arms were not statistically significant. Figure 1. Post Implementation Periods Conclusion Our findings suggest that NHs assigned to usual implementation regressed in their diagnosis and treatment of UTIs during the COVID-19 pandemic while those receiving external facilitation and peer comparison reports were more resilient to the effects of COVID-19. Disclosures All Authors: No reported disclosures
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