Infection Control & Hospital Epidemiology
Table 1. Targeted Evidence-Based Practice Recommendations to Minimize Treatment for Asymptomatic Bacteriuria Practice Recommendation
Description of the Practice Recommendation Screening for bacteriuria
Discontinue routine urine screening (eg, at admission and annually) unless residents have clinical signs and symptomsa of a UTI.8,10 Accepted clinical signs and symptoms of a UTI are defined as: new difficult or painful urination (acute dysuria) alone or 2 or more of the following: fever, new flank or suprapubic pain, new or increased urinary frequency/ urgency, gross hematuria, and acute onset of delirium in residents with advanced dementia.11,12,19
Diagnostic tools
Discontinue use of dipsticks to diagnose a UTI. Clinical symptoms of a UTI (defined above) and a positive culture are required for a UTI diagnosis.8,20
When to collect a urine sample for culture Obtain urine cultures only when residents have been determined to have accepted clinical signs and symptoms of a UTI.8
How to collect a urine sample
Obtain urine cultures using proper technique to avoid contamination. This includes the use of a clean catch or midstream collection or in/out catheterization and adherence to aseptic technique.
Store urine cultures under refrigeration if transport is not immediate. When to prescribe antibiotics
Prescribe antibiotics only when clinical criteria for UTI are present (as defined above). Review and reassess when urine culture and susceptibility results are received.
A bacterial count greater than or equal to 108 CFU/L with typical signs or symptoms of a UTI is considered diagnostic.8 If antibiotics are started empirically, the physician or nurse practitioner should reassess the need for, choice, and duration of antibiotic therapy based on the culture and susceptibility report.
Note. UTI, urinary tract infection. CFU, colony-forming units. aAccepted clinical signs and symptoms of a UTI were based on the Loeb 2005 criteria19 and additional considerations to reflect challenges in diagnosing residents who have advanced dementia.11,12
address similar determinants of behavior change or focus on a common barrier to practice change (eg, knowledge gaps). It is important to understand the mechanisms by which various strategies are intended to influence behavior change. The theoretical domains framework (TDF), which was devel-
oped to examine the factors that influence healthcare professional behaviors when implementing evidence-based practice recom- mendations, is based on a synthesis of 33 behavior-change theories.15,16 The TDF includes 14 domains: knowledge, skills, memory, attention and decision processes, behavioral regulation, social or professional role and identity, beliefs about capabilities, optimism, beliefs about consequences, intentions, goals, reinfor- cement, emotions, environmental context and resources, and social influences.16 The TDF helps the user categorize known barriers and facilitators to practice change and select imple- mentation strategies. The Infection Prevention and Control Department at Public
Health Ontario set out to develop a program using intervention mapping approaches to assist LTCFs to minimize antibiotic prescribing for asymptomatic bacteriuria, focusing on barriers and facilitators to practice change. This department at Public Health Ontario supports the dissemination and implementation of best practices in infection prevention and control and anti- microbial stewardship across healthcare settings in Ontario. This article describes the data sources and processes used to develop a program to reduce antibiotic overuse in long-term care.
Methods
A multidisciplinary team was established, composed of 2 physi- cians with specialization in infectious diseases, a pharmacist with specialization in antimicrobial stewardship, infection control specialists with backgrounds in nursing and medical laboratory sciences, and staff with expertise in evaluation, behavioral science, and implementation science. An intervention mapping approach was used to develop the program drawing on methods that incorporate the TDF.17 This
Analysis of barriers and facilitators
We used a descriptive coding process to summarize information from relevant excerpts in the online survey using descriptive codes and an open and inductive coding process. Three members of the team reviewed, discussed, and mapped each barrier or facilitator statement to the TDF.24,25 Some of the barrier and facilitator statements were mapped to >1 domain. The team also indicated whether each barrier or facilitator statement was related
stepped approach to developing evidence and theory-informed programs provides a guide to selecting strategies to address known barriers and facilitators to practice change. Several applications of this stepped approach have been described in the literature, with a focus on improving the implementation of clinical practice recommendations.18 An integrated knowledge translation approach was also incorporated to involve LTCF stakeholders in the program development process.
Identification of barriers and facilitators
Following the selection of the key areas for practice improvement (Table 1), barriers and facilitators to aligning with the practice recommendations were identified from the literature,14,21–23 and through an online survey. The survey was distributed to 643 infection control practitioners in long-term care in 2014 using a stakeholder relationship management database maintained by Public Health Ontario. Recipients were encouraged to forward the invitation to anyone in their LTCF involved in the prevention, identification, diagnosis, and/or treatment of UTIs. The survey included structured questions about current practices around the assessment and management of UTIs in addition to open-ended questions to obtain additional information on issues and other contextual information that influenced assessment and prescrib- ing practices. This article reports the analysis of excerpts from the open-ended questions related to barriers and facilitators to aligning with best practices to help the project team understand why antibiotics are overprescribed in this setting.
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