Facilitated Implementation of Antibiotic Stewardship in Wisconsin Nursing Homes

The Wisconsin Healthcare-Associated Infections in Long-Term Care Coalition has developed a
toolkit of evidence-based best practices to improve the management of urinary tract infection
(UTI) in Wisconsin nursing homes (NHs). The theory and evidence supporting the individual
improvement strategies promoted in the "Wisconsin UTI Improvement Toolkit" are strong but
their combined impact on antibiotic prescribing in Wisconsin NHs is not known. Moreover, many
Wisconsin NHs lack the internal resources and expertise to successfully implement and sustain
the change interventions recommended in the toolkit. Consequently, there is a critical need
to identify effective strategies to support implementation of best practices in this setting.
The investigators hypothesize that an externally-facilitated implementation based on coaching
and peer-to-peer learning will result in superior toolkit adoption and reduced rates of
antibiotic utilization compared to a standard implementation.

To test these two hypotheses, the investigators are proposing a hybrid type 2
effectiveness-implementation randomized clinical trial in 20 Wisconsin NHs. Facilities
randomized to the standard implementation approach will participate in a kickoff meeting and
have access to a variety of online implementation resources. Facilities randomized to the
enhanced implementation approach will have access to the same resources but will also be
assigned a clinical coach and be invited to participate in ongoing collaborative learning
sessions. The clinical coach will meet regularly with NH staff to guide the facility through
implementation of the toolkit, including assembling a change team, performing an assessment
to identify baseline barriers and facilitators of change, and ongoing integration of the
toolkit practices into existing workflows. The learning collaborative will bring NH
participants together to share change and improvement strategies with each other. UTI
prescriptions per 1,000 resident-days in the study arms will be compared using generalized
linear mixed models. A mixed methods evaluation structured around the REAIM framework (Reach,
Effectiveness, Adoption, Implementation and Maintenance) will be employed to assess
differences in toolkit implementation among facilities in both arms of the study.