With the increase in patients being discharged from the hospital to settings other than their homes, collaborative approaches are now being used to enhance care in extended care facilities, such as nursing homes, which provide care for over 1.5 million short-stay patients and long-term residents daily.
Our study used qualitative methods to evaluate implementation of The Agency for Healthcare Research and Quality Safety Program for Long-term Care: Health Care-Associated Infections/Catheter-Associated Urinary Tract Infection, a national collaborative aimed at reducing CAUTI in nursing homes. We were especially interested in nursing home personnel experiences during program implementation and any practice changes that may have occurred. Our findings suggest that participants valued the resources that were provided and the collaborative was generally viewed positively (not to mention the reduction in CAUTI rates observed among the participating community-based nursing homes1). Additionally, many participants stated that by participating in the program, some staff felt empowered to make changes to their urinary catheter insertion, care, and/or maintenance practices and that they hoped these changes would lead to other quality improvement initiatives.
Nonetheless, we note several practical challenges that impacted program implementation. For example, education, which is often the main focus in practice change, was disseminated electronically. However, several nursing homes were not equipped to support electronic education and improvised by printing out hard copies for staff. This was both time-consuming and resource intensive for nursing homes that were already understaffed. Although the education focused on the appropriate use and maintenance of urinary catheters, we heard from nursing homes that it also helped to empower some nurses to speak with physicians about changing their practice but that more instruction on how to have those conversations would have been helpful.
Staff turn-over is extensive and impacts both program implementation and long-term sustainment. Unlike hospitals that may have the resources to hire additional staff, we heard that what often happens is that one person will be responsible for program implementation along with all their other day-to-day responsibilities. Thus, the time afforded to these types of programs is often limited. Some nursing homes were able to involve everyone, including food service and cleaning staff, thus engaging them in the collaborative. However, guidance and additional education on how to engage reluctant staff and physicians would have been helpful.
Although program evaluation is a focus of quality improvement, through our work we found that it is just as necessary to perform a context assessment prior to implementing quality initiatives. Context assessments would document the resources a facility currently has, what resources they feel are most needed, and would look for ways to modify the program’s resources and requirements to fit the context. These assessments should be developed by national collaboratives and done in cooperation with local facilities, whether they are nursing homes, rehabilitation centers, hospitals etc., to not only understand the context but also as a means of engaging facilities in the process. This may be especially important for national collaboratives that are being implemented in settings that have a diverse array of resources so as not to further burden local facilities but rather, enhance and build-off of what they have and to provide what they need.
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Written By: Sarah L Krein, Molly Harrod, Lona Mody
1. Mody L, Greene MT, Meddings J, Krein SL, McNamara SE, Trautner BW, Ratz D, Stone ND, Min L, Schweon SJ, Rolle AJ, Olmsted RN, Burwen DR, Battles J, Edson B, Saint S. A National Implementation Project to Prevent Catheter-Associated Urinary Tract Infection in Nursing Home Residents. JAMA Internal Medicine. 2017;177(8):1154–1162. doi:10.1001/jamainternmed.2017.1689