Antibiotic Prescribing in Care Homes: A Multidisciplinary Approach, 2022

ARCH was a multidisciplinary, four Work Package, project involving key stakeholders to improve understanding, and ultimately practice, around infection detection/management and antibiotic use in care homes for older people. WP1 used statistical analysis of anonymised quantitative data, finding wide variation in antibiotic prescribing rates, and informing selection of care homes for WP2/3. WP1 data are held by Health Informatics Centre (HIC), University of Dundee (https://www.dundee.ac.uk/hic/). WP2 and WP3 used anthropology, sociology and behavioural science to investigate individual, socio-cultural and contextual factors influencing antibiotic use, conducting ethnographic observations (61 periods, ~315hrs), interviews (n=101) and surveys (n=76) with care home managers, nurses, carers, senior carers, GPs, advanced nurse practitioners, pharmacists, residents and their relatives, across 7 care homes (survey broader). Observations and interviews highlighted variation in how suspected infections were identified and managed. Identified factors influencing antibiotic prescribing included: limited training around infections; lack of confidence in distinguishing infections from other conditions, and in ‘watchful waiting’; habitual/routine use of urine dip testing; the importance of communication internally and externally; limited handover documentation; duty of care linked to worry about ‘missing something’; antibiotic resistance a distant problem; pressure from family and residents, and; antibiotic stewardship not seen as care home staff’s role. WP4: Behavioural science intervention development frameworks were applied to integrated WP1-3 findings to identify candidate intervention strategies, prioritised by a co-design workshop (20 care home sector participants) into an intervention including: training (videos and online), appointment of Antibiotic Champions, an Assessment Flowchart, a Monitoring Tool, an SBAR (Situation-Background-Assessment-Recommendation) form for communication between care homes and GPs/ANPs, and reminder stickers. The feasibility trial was impacted by COVID-19 but some in-situ testing and online focus groups found that participants liked the intervention and were keen to engage. Implementation challenges included understaffing, protecting time for training, and balance between standardisation and individual contextual adaptation.