Workflow Barriers and Strategies to Reduce Antibiotic Overuse in Nursing Homes

J Am Geriatr Soc. 2020 Oct;68(10):2222-2231. doi: 10.1111/jgs.16632. Epub 2020 Jul 28.


Objectives: Antibiotic overuse is a significant problem in nursing homes (NHs). Strategies to improve antibiotic prescribing practices in NHs are a critical need. In this study, we analyzed antibiotic prescribing workflows to identify strategies for improving antibiotic prescribing in NHs.

Design: Qualitative descriptive study using prospective field-based assessment of workflows.

Setting: Six NHs in Wisconsin (n = 3) and Pennsylvania (n = 3).

Participants: A total of 44 interviews with 68 NH professionals, including leadership, nurses, and prescribers.

Measurements: During a 1-day field visit in each NH, we conducted semistructured interviews with NH professionals, collected artifacts (policies, procedures, and documentation and communication tools), and observed clinical meetings. Study participants were interviewed (30-60 minutes) about antibiotic prescribing workflows in their facility. Information collected during site visits was used to create a representative workflow map of NH antibiotic prescribing. The workflow map guided thematic analysis to identify barriers corresponding to workflow steps across multiple NHs.

Results: The representative antibiotic preprescribing workflow map included 17 steps, beginning with resident change in condition and ending with the decision to prescribe an antibiotic. Thematic analysis identified common step-specific barriers to antibiotic stewardship centering on three themes: (A) information barriers, comprising (A1) inconsistent nurse assessment report and (A2) misalignment between the work and tools of information sharing within the facility, (B) communication barriers, comprising (B1) mismatched perception of prescriber information needs and (B2) difficulty reaching prescribers for direct interaction, and (C) professional barriers, comprising (C1) low prescriber confidence in nurse assessment report and (C2) nurse reluctance to express their professional opinions.

Conclusion: Strategies addressing workflow barriers are important targets for antibiotic stewardship. Such strategies include structured information tools, nurse and prescriber education, and organizational improvement. Future research can build on combinations of existing and new strategies to measure their effects in improving antibiotic prescribing. J Am Geriatr Soc 68:2222-2231, 2020.

Keywords: antibiotic prescribing; antibiotic stewardship; nursing homes; qualitative research; workflow redesign.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Anti-Bacterial Agents / therapeutic use
  • Antimicrobial Stewardship*
  • Female
  • Homes for the Aged*
  • Humans
  • Inappropriate Prescribing*
  • Male
  • Middle Aged
  • Nursing Homes*
  • Pennsylvania
  • Practice Patterns, Nurses'
  • Practice Patterns, Physicians'
  • Prospective Studies
  • Qualitative Research
  • Wisconsin
  • Workflow*


  • Anti-Bacterial Agents