Effect of a Standard vs Enhanced Implementation Strategy to Improve Antibiotic Prescribing in Nursing Homes: A Trial Protocol of the Improving Management of Urinary Tract Infections in Nursing Institutions Through Facilitated Implementation (IMUNIFI) Study

James H Ford 2nd, Lillian Vranas, DaRae Coughlin, Kathi M Selle, Susan Nordman-Oliveira, Brenda Ryther, Tola Ewers, Victoria L Griffin, Anna Eslinger, Joe Boero, Paula Hardgrove, Christopher J Crnich, James H Ford 2nd, Lillian Vranas, DaRae Coughlin, Kathi M Selle, Susan Nordman-Oliveira, Brenda Ryther, Tola Ewers, Victoria L Griffin, Anna Eslinger, Joe Boero, Paula Hardgrove, Christopher J Crnich

Abstract

Importance: Suspicion of urinary tract infection (UTI) is the major driver of overuse and misuse of antibiotics in nursing homes (NHs). Effects of interventions to improve the recognition and management of UTI in NHs have been mixed, potentially owing to differences in how interventions were implemented in different studies. An improved understanding of how implementation approach influences intervention adoption is needed to achieve wider dissemination of antibiotic stewardship interventions in NHs.

Objective: To compare the effects of 2 implementation strategies on the adoption and effects of a quality improvement toolkit to enhance recognition and management of UTIs in NHs.

Design, setting, and participants: This cluster-randomized hybrid type 2 effectiveness-implementation clinical trial will be performed over a 6-month baseline (January to June 2019) and 12-month postimplementation period (July 2019 to June 2020). A minimum of 20 Wisconsin NHs with 50 or more beds will be recruited and randomized in block sizes of 2 stratified by rurality (rural vs urban). All residents who are tested and/or treated for UTI in study NHs will be included in the analysis. All study NHs will implement a quality improvement toolkit focused on enhancing the recognition and management of UTIs. Facilities will be randomized to either a usual or enhanced implementation approach based on external facilitation (coaching), collaborative peer learning, and peer comparison feedback. Enhanced implementation is hypothesized to be associated with improvements in adoption of the quality improvement toolkit and clinical outcomes. Primary outcomes of the study will include number of (1) urine cultures per 1000 resident days and (2) antibiotic prescriptions for treatment of suspected UTI per 1000 resident-days. Secondary outcomes of the study will include appropriateness of UTI treatments, treatment length, use of fluoroquinolones, and resident transfers and mortality. A mixed-methods evaluation approach will be used to assess extent and determinants of adoption of the UTI quality improvement toolkit in study NHs.

Discussion: Knowledge gained during this study could help inform future efforts to implement antibiotic stewardship and quality improvement interventions in NHs.

Trial registration: ClinicalTrials.gov identifier: NCT03520010.

Conflict of interest statement

Conflict of Interest Disclosures: Ms Nordman-Oliveira reported grants from the University of Wisconsin (UW) Madison and the UW School of Medicine and Public Health and contracts from the Wisconsin Department of Health Services during the conduct of the study. Dr Crnich reported grants from the UW School of Medicine and Public Health, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and the Veterans Administration Health Services Research and Development during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.. Study Overview
Figure 1.. Study Overview
aStratified by rurality in block sizes of 2.
Figure 2.. Wisconsin UTI Improvement Toolkit Logic…
Figure 2.. Wisconsin UTI Improvement Toolkit Logic Model
UTI indicates urinary tract infection.

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