Understanding and improving antimicrobial prescribing in care homes: a multidisciplinary approach

Lead Research Organisation: University of Dundee
Department Name: Population Health and Genomics

Abstract

Bacteria that cause common infections are becoming increasingly resistant to currently available antibiotics. Antibiotics are essential in modern healthcare but their use drives the development of resistance as bacteria develop ways of surviving their effects. Previous research has found that antibiotics are often used when they are not needed, which increases the development of resistance in bacteria. Older people living in care homes are prescribed many more antibiotics than average and as a result often get antibiotic resistant infections later, which are then harder to treat. The amount of antibiotics used in different care homes varies a lot but we don't really know why. Most research on finding ways to safely reduce antibiotic use has been carried out in hospitals or GP surgeries rather than care homes. There is general agreement that antibiotic use in care homes could and should be safely reduced. However, to design effective approaches to reducing 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.

Researchers with different areas of expertise will work together in a four-stage project:

1. Measuring patterns of antibiotic use (epidemiology): We will analyse information on antibiotic prescribing and antibiotic resistance for all care home residents in two Scottish health board regions. As well examining the link between antibiotic prescribing and later antibiotic resistance, this will help us better understand how common antibiotic use is, which residents are prescribed, and variation in prescribing between care homes. This information will also be used to invite care homes with different patterns of antibiotic use to participate in the next stages of the project.

2. Understanding how and why antibiotic prescribing happens in different care homes (sociology and social anthropology): We will work with staff, GPs, residents and relatives in eight care homes. We will observe how staff and GPs work together and react to residents being unwell, and how this leads to antibiotic prescribing. We will also interview staff, GPs, residents and relatives to understand how the way the care home and general practices are organised influences the care different residents receive. This will help us identify new approaches to improving antibiotic prescribing decisions.

3. Identifying staff behaviours that could be changed to reduce antibiotic prescribing (health psychology): We will also carry out more focussed interviews and questionnaires to find out specific reasons why carers, nurses and GPs perform certain actions, and investigate what might encourage or discourage these actions. For example, what causes a nurse to phone a GP to request a prescription for a resident? Why might the GP sometimes write a prescription without reviewing the patient first? This will help us identify specific changes in behaviour which could improve antibiotic prescribing decisions.

4. Creating and testing new approaches to changing antibiotic prescribing (intervention development and testing): We will use all the information from the first three phases, and evidence from other situations (e.g. hospital or GP antibiotic studies) to create an intervention that we will try out in a small number of care homes to see if it is acceptable to staff and residents, and whether it is feasible to do alongside normal work. The intervention will include different elements, such as education for care home staff and GPs, and feedback about how many antibiotics are being used in each care home. At the end of the study, we will have created new and useful knowledge about antibiotic prescribing and its consequences in care homes, but we will also have pilot-tested a new intervention. The next stage of our research programme will be testing it in a large-scale trial to see if it 'works'.

Planned Impact

The proposed research is grounded in theory and informed by empirical research. As well as shorter-term significant contribution to theory and knowledge, there is a clear pathway to future real-world impact on antimicrobial use and resistance through the development of a complex intervention ready for evaluation in a randomised trial. In the shorter term, involvement in, and outputs from, the research proposed are of potential benefit care home residents and staff, general practitioners, the wider social care sector, the general public, the NHS, and other policy makers, as well as academia (see Academic Beneficiaries). To ensure these benefits are realised, key stakeholders have been consulted in the preparation of this proposal and have committed to participation in the fieldwork, the Study Team and the Study Advisory Group (see Letters of Support). Members of the Study Team also have relevant clinical positions (BG is a GP, CM is an ID Physician, CH & JS are pharmacists) which will enhance professional engagement. We have also planned a programme of engagement with stakeholders, policy makers and the public (see Pathways to Impact), and stakeholder and user participation, including co-creation of the intervention, is integral to the whole proposal (see Case for Support).

The following groups have potential benefits:

Care home residents: In the participating care homes, residents (with their relatives if appropriate) will have the opportunity to make positive contributions to informing and co-creating tools designed to improve quality, safety and equity of care for their peer group. In the future, the research programme aims to safely reduce unnecessary antimicrobial exposure specifically in this group, reducing side effects and the emergence of resistant difficult-to-treat infections.

Care home staff and general practitioners: Staff in, and GPs providing care for, the study care homes will have the opportunity to engage with and participate in research, while contributing to the co-creation of an intervention to help them deliver safer and more equitable care. In addition to the intrinsic benefits of this positive contribution, involvement can contribute to continuing professional development and revalidation for trained nurses and GPs.

Social care sector: Compared to other settings the social care sector has rarely been the focus for healthcare innovation. In addition to the benefits of participation and the knowledge gained, this research, with co-development of an intervention, should facilitate good working relationships between academia and the social care sector for future research and improvement activity. This will become increasingly relevant as the integration of health and social care proceeds.

General public: The ultimate aim is to reduce antimicrobial use and AMR to benefit broader public health, with impact achieved through a successful intervention. In the shorter term, the outputs will increase knowledge and understanding around AMR, with impact on other stewardship activity through our planned knowledge exchange activity (see Pathways to Impact).

NHS stakeholders: Care homes are not currently run by the NHS in the UK, but medical care and prescribing are provided by NHS GPs. This organisational model is similar across all four UK administrations, so the study outputs will be generalisable in informing NHS antimicrobial stewardship.

Policy stakeholders: Study findings will inform policy and strategy development for: the Scottish Antimicrobial Prescribing Group (JS is project lead), the Scottish Microbiology and Virology Network, NHS Education for Scotland, the NHS Scotland Infection Intelligence Platform, the British Society for Antimicrobial Chemotherapy, Health Protection Scotland, Public Health England, Public Health Wales, the Public Health Agency and the Farr Institute.
 
Description Additional award from ESRC for - "ENHANCING THE IMPACT OF ESRC FUNDED RESEARCH ON ANTIMICROBIAL PRESCRIBING IN CARE HOMES"
Amount £8,060 (GBP)
Organisation Economic and Social Research Council 
Sector Public
Country United Kingdom
Start 04/2018 
End 04/2019
 
Description COVID-19 in care-homes in Tayside and Fife
Amount £32,000 (GBP)
Organisation University of Dundee 
Sector Academic/University
Country United Kingdom
Start 03/2021 
End 09/2021
 
Description Dundee Centre for AMR - Antimicrobial Resistance Capital award
Amount £2,126,998 (GBP)
Funding ID NIHR200639 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 08/2019 
End 03/2022
 
Description MEDICAL RESEARCH FOUNDATION NATIONAL PHD TRAINING PROGRAMME IN ANTIMICROBIAL RESISTANCE RESEARCH
Amount £4,035,701 (GBP)
Funding ID MPG-145-0004-TPG-AVISO 
Organisation Medical Research Council (MRC) 
Department Medical Research Foundation
Sector Charity/Non Profit
Country United Kingdom
Start 09/2017 
End 09/2025
 
Description MEDICAL RESEARCH FOUNDATION NATIONAL PHD TRAINING PROGRAMME IN ANTIMICROBIAL RESISTANCE RESEARCH
Amount £856,000 (GBP)
Funding ID MRF-145-0004-TPG-AVISO 
Organisation Medical Research Council (MRC) 
Department Medical Research Foundation
Sector Charity/Non Profit
Country United Kingdom
Start 09/2020 
End 09/2024
 
Title WP3 ARCH Questionnaire 
Description Questionnaire to be completed by healthcare staff in care homes (managers, nurses and carers) and prescribers (GPs and Advance Nurse Practitioners) who provide care to care home residents. Data collected concerns infection management and antibiotic use in care homes and includes questions on the impact of COVID-19. The findings are of interest in antimicrobial stewardship generally and for the design of the intervention to be feasibility-tested in work package 4 of this programme. NB - there is no ideal "type of tool or method" in the drop down list above although questionnaire is listed as an appropriate entry in this section. 
Type Of Material Model of mechanisms or symptoms - human 
Year Produced 2020 
Provided To Others? No  
Impact No impact yet but it will influence improvement interventions in this context. 
 
Title HIC Care Home Cohort 
Description Dataset identifying (pseudonymised) all residents of care homes for older people, and which care home they live in, within a complete geographic region of the UK. As far as we know, this is a unique dataset to date (see below). The dataset is temporally dynamic -starting in 2016 - allowing changes over time to be examined and multiple cross-sectional analyses. Individual level data on the population in the dataset includes epidemiological data, hospital admissions, community prescriptions and microbiology data. Care home level data includes: publicly available Information on the care homes from Care Inspectorate reports and their own websites - e.g. size, ownership, ratings from inspections, complaints and requirements, and; data generated from resident level data - e.g. relationships with general practices, rates of prescribing and microbiological sampling. 
Type Of Material Database/Collection of data 
Year Produced 2018 
Provided To Others? No  
Impact There are manuscripts in preparation describing the use of multilevel models to quantify resident and care home factors associated with antibiotic prescribing and antibiotic resistance. The dataset is being used in a study of COVID-19 (complete wave 1 and 2 data) in care homes in the region (see additional funding). There is work ongoing in collaboration with other organisations (Public Health Scotland) and research institutions (QMUL) to develop automated algorithms to identify care homes and their residents in administrative datasets. Our dataset (which required manual adjudication) represents a gold standard to validate automated algorithms against. The dataset is not able to be published as it contains individual level NHS data but approved researchers with appropriate data governance training can apply to access the data within the Health Informatics Centre, University of Dundee, Safe Haven (https://www.dundee.ac.uk/hic/). 
 
Description Antimicrobial Stewardship in Care Homes 
Organisation University College London
Country United Kingdom 
Sector Academic/University 
PI Contribution Methodological and theoretical approaches to multidisciplinary data analysis and intervention design
Collaborator Contribution Methodological and theoretical approaches to multidisciplinary data analysis and intervention design
Impact Additional funding from ESRC for collaborative meeting - successful event in summer 2018 The disciplines include: epidemiology, sociology, anthropology, behavioural psychology and implementation science
Start Year 2018
 
Description Co-design workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Twenty professional and lay care home stakeholders participated in a workshop to contribute to the co-design of an antibiotic stewardship intervention. Participants included - care home managers, nurses, carers and a resident and a resident's relative; pharmacist and prescriber with a role in care homes; representatives from organisations which own (Balhousie Care Group) and support (Scottish Care) care homes. This was held remotely (Microsoft Teams) due to COVID-19 restrictions.
There was facilitated discussion of proposed intervention strategies and components (developed using empirical evidence from earlier work packages) and the opportunity to suggest additional approaches. Participants were engaged, enthusiastic and honest (both positive and negative) and their input is critical to selection and prioritisation of intervention components and the implementation strategy.
Year(s) Of Engagement Activity 2021
 
Description Study website 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Engaging public-facing website giving an overview of our research plans, the team and organisations involved.
Year(s) Of Engagement Activity 2018,2019
URL http://arch-antibiotics.org.uk/
 
Description Twitter account @arch_antibiotic 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Active twitter account with lots of activity from a broad range of stakeholders. Nearly 300 followers. Currently used to engage with general public and those interested in care homes and/or antibiotic use and resistance. We will use the account to share research outputs as well as stakeholder events planned for later in the award.
Year(s) Of Engagement Activity 2018,2019