Infection Control & Hospital Epidemiology


97


Fig. 1. The Systems Engineering Initiative for Patient Safety (SEIPS) model,18 showing how the 5 work-system components influence infection prevention processes and outcomes in the long-term care setting.


Table 1. Applying the Systems Engineering Initiative for Patient Safety Model18 to Forming Antibiotic Stewardship Interventions in Long-Term Care Barrier


Work System Component


Family or resident misconception about need or indication for antibiotics


Poor communication between nursing and prescriber regarding resident symptoms


Administration does not designate sufficient time/resources to developing antibiotic stewardship program


Prescriber forgets to document indication or duration for antibiotic course


Off-site microbiology lab leads to delay in culture processing and specimen contamination


Specimen culture and sensitivity not reviewed in timely manner due to lack of electronic medical record or fax delays


Potential Interventions


People-Knowledge gap Developing educational materials and engagement strategies for family and residents regarding risk of unnecessary antibiotic exposure


Organization- Communication


Organization-Lack of executive engagement


Task-Time constraints, human error


Environment-Physical delays


Tools/Technology


Implement communication tools or techniques such as SBAR (ie, situation, background, assessment, recommendations) in facility


Develop strategies to incentivize executive engagement, mandate stewardship policies for accreditation


Implement pharmacy alerts for prescriptions that do not have required information


Ensure refrigerator or appropriate storage mechanism in close proximity to resident care


Implement an automatic antibiotic “time-out” instituted by pharmacy at 48 h


guidelines. Both of these reasons may fall under the “persons” work factor component, and interventions can be explored based on the underlying social motivation. For example, if the nurse was prompted by family pressure, an appropriate intervention may include education and engagement of residents and family members regarding the risks of antibiotic use and the need for judicious use of antibiotics. If a lack of knowledge or training of the HCW was the reason for obtaining the culture, an appropriate intervention may include circulating a pocket card outlining


appropriate indications for urine culture collection, or in-service training for nurses providing up to date guidance to this effect. However, if the reason for HCW not complying with the guide- line is related to the pressure he/she gets from management regarding keeping residents and their families happy, then the underlying problem is probably due to wrongly incentivizing HCWs to collect the urine culture (organizational design). Defects may also occur later in the process. The urine itself may be contaminated at the time of collection, resulting in a


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