Implementing Antimicrobial Stewardship in Long-term Care Settings: An Integrative Review Using a Human Factors Approach

Abstract

Implementing effective antimicrobial stewardship in long-term care facilities (LTCFs) is associated with challenges distinct from those faced by hospitals. LTCFs generally care for elderly populations who are vulnerable to infection, have prescribers who are often off-site, and have limited access to timely diagnostic testing. Identification of feasible interventions in LTCFs is important, particularly given the new requirement for stewardship programs by the Centers for Medicare and Medicaid Services (CMS). In this integrative review, we analyzed published evidence in the context of a human factors engineering approach as well as educational interventions to understand aspects of multimodal interventions associated with the implementation of successful stewardship programs in LTCFs. The outcomes indicate that effective antimicrobial stewardship in long-term care is supported by incorporating multidisciplinary education, tools integrated into the workflow of nurses and prescribers that facilitate review of antibiotic use, and involvement of infectious disease consultants.

Keywords: antimicrobial stewardship; elderly; human factors; long-term care; nursing home.

Figure 1.

Adaptation of the work system from the Systems Engineering Initiative for Patient Safety (SEIPS) model to antimicrobial stewardship interventions in long-term care. Italicized text indicates the working definition used for each human factor. Bulleted text details specific interventions used in the studies reviewed here; bolded text indicates specific approaches that supported a quantifiable change in antibiotic use in accordance with principles of antibiotic stewardship. As detailed in the text, several of the interventions incorporated 2 or more human factors. Abbreviations: EMR, electronic medical record; ID, infectious disease; LTACH, long-term acute care hospital; VA, Veterans Affairs.