Infections caused by multidrug resistant organisms [MDROs] are an urgent global threat. MDROs are highly prevalent in post-acute skilled nursing facilities [SNF] and long term care facilities [LTCF], and much of this is fueled by antibiotic overuse in these settings. A key influence on provider prescribing in SNF/LTCFs is family and/or facility resident (i.e., patient) pressure to prescribe antimicrobials, even when not clinically indicated. Our preliminary data suggest that >75% of SNF/LTCF providers have been influenced by this demand. To address this issue, we propose using a systematic approach to assessing and developing SNF/LTCF based educational interventions aimed at residents and family members that clearly delineate the risks associated with antibiotics and the need for their judicious use. This R21 is the initial effort of a phased approach, partnering with a Baltimore SNF/LTCF network. We will use two complementary models to inform formative research and to develop a survey instrument which will ultimately guide an intervention: (1) Knowledge, Attitudes and Behavior (KAB) which is individual-focused; and, (2) Systems Engineering Initiative for Patient Safety (SEIPS), a Human Factors and Systems Engineering model, which defines the interactions among humans and other elements in complex sociotechnical work systems. Integrating both models will identify both knowledge gaps for the educational intervention and facilitators and barriers within the work system that may require structural modification. This is an NIA-defined Stage 0 Behavioral Intervention. The formative research phase of Aim 1 will include in-depth qualitative research with resident, family, and staff stakeholders in SNF/LTCFs. This will include 30 in-depth interviews with residents and/or their family members, 10 interviews with facility staff, and 3 focus group interviews with patient/family advisory board members. The interview domains will address both KAB and human factors issues including intervention facilitators and barriers. This will inform development of a survey instrument in Aim 2, which combines the KAB and SEIPs approaches and which will be piloted in 50 residents/family and 20 staff members, to include post-hoc feasibility assessments. Data obtained from the formative research and pilot surveys will support the ultimate objective of developing an interactive intervention in Aim 3 based on behavioral science and human factors engineering principles, which will inform a subsequent R01 clinical trial intervention.

Public Health Relevance

Antibiotic resistance is an important and emerging public health problem and one of the most important factors is the overuse of antibiotics. In nursing homes, almost half of all antibiotic prescriptions are unnecessary. This project will interview patients, family members and staff to help us evaluate their knowledge and attitudes on antibiotic use and bacterial resistance, which will help in developing educational and behavioral interventions to reduce antibiotic overuse in these facilities.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Exploratory/Developmental Grants (R21)
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Dissemination and Implementation Research in Health Study Section (DIRH)
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Gerald, Melissa S
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Johns Hopkins University
Internal Medicine/Medicine
Schools of Medicine
United States
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