Over 1.4 million people currently reside in a U.S. nursing home (NH) with 2 million new admissions each year. NHs are crucial for meeting short and long-term care needs of older adults. With the burgeoning post-acute care population, many of these individuals are recovering from serious events and are at high risk of complications, including healthcare-associated infections. In fact, nearly 25% of the post-acute population returns to a hospital with an infection, accounting for 325,000 hospital transfers and over $4 billion in additional healthcare costs per year in the U.S. Robust prevention programs in NHs are therefore critical to prevent infections, reduce unnecessary antimicrobial use, reduce transmission of multidrug-resistant organisms, and enhance patient safety. However, NHs face special challenges in implementing an effective infection prevention program, including limited resources, diagnostic challenges in a frail functionally disabled long-stay population, and an unacceptably high prevalence of multidrug-resistant organisms. A model that integrates NH infection prevention initiatives with hospital infection prevention programs within an Accountable Care Organization framework has the potential to improve continuity and quality of care, reduce infection, inappropriate transfers, and the spread of antimicrobial resistance. With this proposal, our goals are to first develop and evaluate an integrated model using 3 healthcare systems including 3 major hospitals and 15 community-based NHs. Then, using a stepped-wedge cluster randomized trial design, we propose to test the effectiveness of an integrated UTI prevention program in reducing catheter-associated and non-catheter- associated UTIs, inappropriate antibiotic use in patients with asymptomatic bacteriuria, and UTI-related hospitalizations. We will achieve these goals through the following aims.
Specific Aim 1 : Develop an integrated model of hospital and NH infection prevention using UTI (catheter and non-catheter-associated) prevention and management as an exemplar, and pilot this model in 15 NHs and 3 referral hospitals. We will adapt existing tools, materials, resources and finalize study protocols. In particular, we will emphasize targeted collaborations and knowledge transfer pertaining to asymptomatic bacteriuria, use of diagnostic testing to detect infection, defining UTI using standardized criteria, and treatment decisions.
Specific Aim 2 : Using a stepped-wedge cluster randomized trial design, we will test an integrated infection prevention model in preventing all catheter and non-catheter-associated UTIs in 60 NHs.
Specific Aim 2 a: Evaluate provider and leadership satisfaction with the integrated infection prevention model, using qualitative and quantitative methods.
Specific Aim 2 b: Evaluate the impact of the integrated infection prevention model on other NHSN reportable outcomes and process measures (e.g., positive cultures for methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, and other antimicrobial-resistant organisms; hand hygiene, glove and gown adherence).

Public Health Relevance

Infections, including urinary tract infection (UTI), remain a major cause of readmission from nursing homes to acute care hospitals. This project will develop an integrated infection prevention program model aligning nursing homes with their referral hospitals and test the effectiveness of this integrated UTI prevention program to reduce catheter-associated and non-catheter-associated UTIs, inappropriate antibiotic use in patients with asymptomatic bacteriuria, and UTI-related hospitalizations. This alignment can foster adoption of best practices including surveillance for common infections, joint antimicrobial stewardship programs, and training to reduce device utilization and infection-related hospitalizations leading to improved outcomes.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Project (R01)
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Healthcare Patient Safety and Quality Improvement Research (HSQR)
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Burwen, Dale R
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University of Michigan Ann Arbor
Internal Medicine/Medicine
Schools of Medicine
Ann Arbor
United States
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