Antimicrobial Stewardship in Residential Aged Care Facilities

Need and Readiness Assessment

Ching Jou Lim; Megan Kwong; Rhonda L Stuart; Kirsty L Buising; N Deborah Friedman; Noleen Bennett; Allen C Cheng; Anton Y Peleg; Caroline Marshall; David CM Kong


BMC Infect Dis. 2014;14(410) 

In This Article


Study Population and Setting

This is part of a larger study exploring key healthcare providers' views about improving antibiotic use in the RACF setting. The study targeted primarily high-level care RACFs (i.e. nursing homes) affiliated with four major public healthcare service networks within metropolitan and regional Victoria, Australia. These residential care facilities deliver 24-hour nursing care to elderly residents requiring significant assistance in their activities of daily living. There was no institutional policy for antibiotic prescribing in any of the RACFs; however, intravenous antibiotic therapy when required is normally delivered via specialized support from hospitals.

Three major groups of healthcare providers servicing the participating RACFs were invited to participate, namely general practitioners (GPs), nurses and pharmacists. At these RACFs, the medical care is provided by off-site GPs (equivalent to family physicians in the US) from different practices, who visit residents periodically or upon request. There are significant roles for nursing staff in daily care of residents, including ringing GPs to request medical assessment. Prescription medicines, including antibiotics, require an order from the GPs and are supplied by external community pharmacies. Medication review for individual residents [known as Residential Medication Management Review (RMMR)] is normally performed on an annual basis by consultant pharmacists, however this does not involve audit of short-term antibiotic use.

Participant Recruitment and Data Collection

Institutional ethics approvals from the human research ethics committees of all participating healthcare service networks and Monash University were obtained prior to participant recruitment. A combination of purposive and snowball sampling strategies were used for recruitment of different healthcare providers.[16] The aforementioned healthcare professionals with routine involvement in the antibiotic prescribing process were intentionally approached (i.e. purposive sampling), and some other participants were also recruited through recommendation by initial informants (i.e. snowball sampling). Informed consent was obtained from individual participants, and participation was voluntary.

Nursing staff in different clinical positions [senior executive nurses, nurse unit managers (NUMs), registered nurses (RNs)] were involved in either one-on-one interviews or focus groups. All NUMs and RNs were involved in daily care of residents, whilst the executive nursing staff were responsible at the policy-making level for quality improvement of resident care. Face-to-face or phone interviews were conducted with the GPs and pharmacists, depending on their preference. We used several triangulation strategies; we sought information from different stakeholders' perspectives (i.e. data triangulation), performed onsite observation on the organizational workflow and documentations related to antibiotic prescribing (i.e. methodological triangulation), and explored views of participants from RACFs in different locations (i.e. environmental triangulation).

All interviews were conducted using a semi-structured interview guide, which was tailored to different healthcare providers (Additional files 1, 2 and 3 The interview guide was divided into three main domains (antibiotic prescribing, antibiotic resistance and AMS) whilst allowing flexibility to pursue particular issues by more in-depth discussion as they emerged from the interviews. All discussions were moderated by one or two interviewers (CJL and MK). Recruitment of key stakeholders from the four healthcare networks continued until data saturation (i.e. when no new relevant themes emerged). Participant recruitment and interviews were conducted between January and July 2013. All interviews were audio-recorded and transcribed verbatim by an independent, professional transcribing service.

Data Analysis

Data were analyzed for emergent themes using the framework approach, as described elsewhere.[17,18] This approach involved five stages: (i) familiarization with the data collected by detailing the interview recording and transcripts; (ii) identifying key issues and themes that construct a thematic framework; (iii) indexing (coding the data) into themes; (iv) charting by rearranging indexed data according to the thematic framework; and (v) mapping and interpreting the data. Data management of interview transcripts and recording was facilitated using Nvivo® 9.0 (QSR, Melbourne). All transcripts were verified against audio recordings by CJL and MK. Data analyses were carried out independently by the two researchers (CJL and MK) for cross-validation purpose, with peer-debriefing at regular intervals. Themes and codes were discussed at regular meetings involving all co-authors, where discrepancies were resolved and themes were finalized.