Nurse Decision-making for Suspected Urinary Tract Infections in Nursing Homes: Potential Targets to Reduce Antibiotic Overuse

Abstract

Objectives:To determine what information is most important to registered nurses' (RNs) decisions to call clinicians about suspected urinary tract infections (UTIs) in nursing home residents. Design: Web-based discrete choice experiment with 19 clinical scenarios. Setting and Participants: Online survey with a convenience sample of RNs (N ¼ 881) recruited from a health care research panel. Methods: Clinical scenarios used information from 10 categories of resident characteristics: UTI risk, resident type, functional status, mental status, lower urinary tract status, body temperature, physical examination, urinalysis, antibiotic request, and goals of care. Participants were randomized into 2 deliberation conditions (self-paced, n ¼ 437 and forced deliberation, n ¼ 444). The degree to which evidence-and noneevidence-based information was important to decision-making was estimated using unconditional multinomial logistic regression. Results: For all nurses (22.8%) and the self-paced group (24.1%), lower urinary tract status had the highest importance scores for the decision to call a clinician about a suspected UTI. For the forced-deliberation group, body temperature was most important (23.7%), and lower urinary tract status was less important (21%, P ¼.001). The information associated with the highest odds of an RN calling about a suspected UTI was painful or difficult urination [odds ratio (OR) 4.85, 95% confidence interval (CI) 4.16e5.65], obvious blood in urine (OR 4.66, 95% CI 3.99e5.44), and temperature at 101.5 (OR 3.80, 95% CI 3.28e4.42). For the self-paced group, painful or difficult urination (OR 5.65, 95% CI 4.53e7.04) had the highest odds, whereas obvious blood in urine (OR 4.39, 95% CI 3.53e5.47) had highest odds for the forced-deliberation group. Conclusions and Implications: This study highlighted the importance of specific resident characteristics in nurse decision-making about suspected UTIs. Future antimicrobial stewardship efforts should aim to not only improve the previously studied overprescribing practices of clinicians, but to improve nurses' assessment of signs and symptoms of potential infections and how they weigh resident information.

Resident-Related Factors Influencing Antibiotic Treatment Decisions for Urinary Tract Infections in Dutch Nursing Homes

“…Thus, guideline recommendations alone do not prevent treatment of non-specific symptoms and additional approaches to improve antibiotic prescribing behaviour are warranted. Involvement, education, and coaching of both physician and nursing staff have already been presented as strategies to improve antibiotic stewardship [ 19 , 26 , 27 , 28 , 29 , 30 , 31 ]. Additional strategies include providing communication tools to nurses to improve effective communication among healthcare workers [ 32 ] and interventions directed at appropriate urine culturing [ 33 ].…”

Medications in Post-Acute and Long-Term Care: Challenges and Controversies

“…21,22 In this issue of JAMDA, 3 articles report research relevant to better understanding some of the issues related to antibiotic overprescribing. Beeber et al 23 present research documenting how nurses are more likely to make decisions that do not follow prescribing guidelines when they have limited time; Hendricksen and colleagues 24 identify facility factors that are associated with increased prescribing in persons with advanced dementia; and Hanlon et al 25 report encouraging results from an intervention study to improve prescribing for suspected cystitis. Additionally, an editorial provides guidance on how nursing home consultant pharmacists can be particularly helpful in advancing antibiotic stewardship efforts.…”

Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline

“…NH RNs appear to make different decisions about UTIs when under time pressure as compared to when they are forced to deliberate. 27 Given the challenges of diagnosing a UTI and the vital need to address antibiotic overuse for UTIs in NH residents, we sought to examine (1) the extent to which decision-making regarding UTIs of NH clinicians (primary care providers and RNs) correctly classifies clinical scenarios when compared with current evidence-based UTI guidelines, and (2) whether individual-level clinician characteristics are associated with correct classification.…”