Attachment C -- Qi Program Guide

ATTACHMENT C:
SAUL QI PROGRAM GUIDE
FOR LONG-TERM CARE FACILITIES

SAUL Quality Improvement Program Guide
for
Long-Term Care Facilities

1. Facility Protocol
2. Supplemental Materials

A program of research to promote the quality of life
and quality of care in residential care/ assisted living
and nursing homes

Standardizing Antibiotic Use
in
Long-Term Care
(SAUL)
A Quality Improvement Program for Nursing Homes

The Collaborative Studies of Long-Term Care
Program on Aging, Disability and Long-Term Care
Cecil G. Sheps Center for Health Services Research
University of North Carolina at Chapel Hill
725 Martin Luther King Jr. Boulevard
Chapel Hill, NC 27599-7590

In collaboration with:
Abt Associates
Supported by:
Agency for Healthcare Research and Quality (AHRQ)

INTRODUCTION
Inappropriate antibiotic prescribing practices by primary care clinicians caring for
residents in long-term care (LTC) facilities is becoming a major public health
concern as it is a risk factor for morbidity and mortality among LTC residents. In
an effort to reduce inappropriate prescribing of antibiotics, a panel of experts lead
by Dr. Mark Loeb set forth a set of guidelines for antibiotic prescribing in longterm care settings. These guidelines focus on the most common infections in
long-term care:
•
•
•

urinary tract
respiratory tract
skin and soft tissue infections

In addition, signs and symptoms related to unexplained fever are included.

The purpose of the Standardizing Antibiotic Prescribing in Long-Term Care
Quality Improvement Program (SAUL) is to reduce inappropriate antibiotic
prescribing in your community. To accomplish this goal, this program includes
materials that will allow you to:
• train your staff to provide the information that clinicians need to assess the
appropriateness of prescribing an antibiotic for a resident and
•

monitor your progress as you implement the program.

Also, as part of the program, you will communicate to the clinicians who care for
your residents your intention to initiate this program in your community.
Informational materials will be sent to them describing these guidelines and will
specify what information you will provide about a resident when an infection is
suspected.
In addition, a physician champion who cares for residents in your community will
work with you on your QI team and will be available to answer questions from
other clinicians. As part of this process, the UNC team of experts will provide
informational materials and training to your leadership staff, so they may train
your key nursing staff. Also, a training session will be offered by the UNC team
of experts to interested clinicians.

2

WHY IS THIS IMPORTANT FOR YOUR COMMUNITY?
 Antibiotics account for up to 40% of all systemic drugs prescribed in LTC
 Between 25 – 75% may be inappropriately prescribed
 Consequences of inappropriate use include
o Poor patient outcomes related to adverse effects
o Development of antibiotic resistant bacteria
o Increased healthcare costs


For long-term care residents, adverse effects of antibiotics are more likely
to occur and are often more severe. Adverse effects include

•
•
•
•
•

Diarrhea
Vomiting
Skin rash
C. difficile
Hospitalization

 Antibiotic resistance can cause significant danger and suffering for
residents in LTC
o longer-lasting illnesses
o more doctor visits
o extended hospital stays
o the need for more expensive and toxic medications
o death
 Increased costs result from
o More doctor visits
o More medications
o More hospitalizations

3

THE PROGRAM
1. SAUL QI PROGRAM KICK-OFF MEETING
The UNC team of experts will present information about the quality improvement
program and its implementation at a two-hour in-person meeting held at the
community. The UNC team will use a train-the-trainer model to provide guidance
on educating key staff on how to implement the QI program. In addition to the
physician champion, staff members from the community who will serve on the
SAUL QI Team (See Section 5) will attend this kick-off meeting. Training
materials will be provided by the UNC team and reviewed during this meeting.
(See Appendix D).
Steps:
1. Identify members of the QI Team (see below)
2. Schedule meeting with the UNC team for leadership team training

2. INFORMING RESIDENTS AND FAMILIES
Before beginning the SAUL QI program, it will be important to inform residents
and their families about this effort. Two information sessions will be held for
residents and families and will focus on the importance of reducing inappropriate
antibiotic prescribing and on what they can do to help. An invitational letter to the
families asking them to attend one of the sessions should be sent at the same
time the residents receive an invitational letter. Also, follow-up communication to
residents and families will provide helpful reminders. These may include
newsletter articles, bulletin board postings, or the availability of brochures in
public areas. The CDC informational brochure, CDC fast-facts sheet, or the FDA
antibiotic resistance sheet can be included in the initial letter sent to residents
and their families or as source material for subsequent communication. (See
Appendix) A reference to the CDC podcast on appropriate use of antibiotics can
be included in these materials.
(http://www2c.cdc.gov/podcasts/media/mp3/mmwr5_100109.mp3)
Steps:
1. Once you have established the date you will begin the SAUL QI
program, schedule a meeting for residents and families.
2. Send out letters to residents and families informing them about the
program and the informational sessions.

4

3. Prepare a brief presentation (See Appendix) with handouts from
CDC or FDA. The UNC team of experts will be available to
respond to questions from families and staff.
4. Include reminders about the program in newsletters and other
regular community level communication. Facts sheets should be
posted on community bulletin boards.

3. TRAINING NURSING STAFF
Nursing staff training will be provided in two in-service sessions. It is
recommended that the training materials include a variety of instructional
methods. The accompanying slides are provided for the staff in-service. (See
Appendix) Participants should hear the content and also read it in a handout; in
this way, the material is reinforced, and individual preferences for learning are
met. . The CDC 12-step brochure can be included in the materials given to staff.
(See Appendix)
The focus of the training is on what information needs to be communicated to a
physician when an infection is suspected and how to report the information on
the Suspected Infection Signs and Symptoms Form. Copies of the form should
be provided to all in-service attendees. At the end of the training, participants
should know specifically where or how to obtain the information needed
information to complete the Suspected Infection Signs and Symptoms Form and
how to complete the form.
Steps:
1. Schedule two in-service sessions for training key nursing staff
2. Arrange for adequate coverage so all key staff will be able to attend
the in-service
3. Prepare materials for the staff training
4. Send reminders to key staff and be sure there are no schedule
conflicts for these participants.
5. Conduct staff in-service
6. Provide copies of Suspected Infection Signs and Symptoms Forms
for staff to use when calling/faxing a clinician of a resident
suspected of having an infection. These should be in locations that
are easy to access. A master copy should be available at each
nursing station in case copies need to be made.

5

4. TRAINING PRIMARY CARE PROVIDERS
The community will notify all primary care providers of its quality improvement
program to reduce inappropriate antibiotic prescribing. A letter faxed or mailed to
physicians should be signed by the administrator (See Appendix) and followed by
a letter from the collaborating physician champion. Also, because some
physicians work in partnership with other health professionals, the community
may want to alert these individuals about the program. The CDC 12-step
brochure can be included in the materials sent to providers. Schedule a training
session for providers with the UNC team and physician champion.
Steps:
1. Identify possible dates for the training session with the UNC team
and physician champion.
2. Send notification letters and informational materials to clinician
regarding the implementation of the SAUL program in your
community. Include the training session dates in the notification
letter.
3. Be prepared to answer questions from clinicians about the QI
program
4. Refer questions about the clinical guidelines to the physician
champion. The UNC team will be available for questions if the
physician champion is unavailable.

5. THE SAUL QUALITY IMPROVEMENT LEADERSHIP TEAM
The quality improvement team will include:
•
•
•
•

the administrator
the director of nursing
a nurse educator and
the physician champion

The goal of this team is to effectively implement and monitor the progress of the
SAUL QI program. This team will meet on a regular basis (at least monthly) to
review the charts of residents receiving antibiotics to determine compliance with
the protocol. If necessary, a random sample of residents’ charts may be used for
the review.

6

At the end of the meeting, the number of charts reviewed, the number of these
charts containing the Suspected Infection Signs and Symptoms Form for the
current antibiotic(s), and the number of forms with complete information for the
suspected infection will be recorded on the SAUL QI Team Meeting Reporting
Form. Results of this review will be shared with nursing staff during regular staff
meetings and may be posted on break room bulletin boards. Issues related to
communication with clinicians will be shared with the physician champion.
Steps:

1. Schedule the first leadership team meeting.
2. At the first meeting, discuss roles and responsibilities, identify
regular meeting times, and set times for key personnel inservices.
3. The team leader should send a meeting reminder prior to each
meeting.

7

1. References
Warren J W; Palumbo F B; Fitterman L; Speedie S M. 1991. Incidence and
characteristics of antibiotic use in aged nursing home patients. Journal of the
American Geriatrics Society, 39(10):963-72.
Loeb, M., Bendey, D.W., Bradley, S., et al. (2001). Development of minimum criteria
for the initiation of antibiotics in residents of long-term care facilities: results of a
consensus conference. Infect Control Hosp Epidemiol 22, 120-124.

8

Facility Letterhead

Date

Resident Name (or name of legal guardian for residents with cognitive impairment)
Address
City, ST Zipcode
Dear [Name]:
We are pleased to announce a new program that we are beginning here at [Name of facility].
We are working with a team of experts from the University of North Carolina at Chapel Hill to
standardize the way we report to physicians the signs andz symptoms of infection that our
residents may develop. The purpose of these new procedures is to ensure that your [your
relative’s] physician will have the information he or she needs to determine whether it is
appropriate to prescribe an antibiotic.
Why is this program important? While antibiotics play an important role in treating bacterial
infections, they do account for a significant number of adverse side effects for residents in longterm care settings. Also, the more antibiotics are prescribed the greater the likelihood that the
bacteria causing these infections will become resistant to antibiotics. Antibiotic resistance can
lead to longer-lasting illnesses, an increase in the number of doctor visits, and hospitalization.
We want to be sure that we provide the best information we can to your [your relative’s]
provider. In doing so, we believe we will reduce the number of antibiotics that are
unnecessarily prescribed and thus eliminate the possibility of serious side effects and
widespread resistance among our residents.
We have enclosed an information sheet from the Centers for Disease Control about antibiotic
resistance. However, if you have questions about specific medications prescribed for you [your
relative], it is best to discuss these with your [your relative’s] physician.
Please let us know if you have any questions.
Sincerely,

Executive Director

W

hen you feel sick, you want
to feel better fast. But
antibiotics aren’t the answer
for every illness. This brochure can
help you know when antibiotics work –
and when they won’t. For more
information, talk to your healthcare
provider or visit www.cdc.gov/getsmart.

The Risk:
Bacteria Become Resistant
What’s the harm in taking antibiotics
anytime? Using antibiotics when they are
not needed causes some bacteria to become
resistant to the antibiotic.
These resistant bacteria are stronger and
harder to kill. They can stay in your body and
can cause severe illnesses that cannot be cured
with antibiotics. A cure for resistant bacteria
may require stronger treatment – and possibly
a stay in the hospital.
To avoid the threat of antibiotic-resistant
infections, the Centers for Disease Control
and Prevention (CDC) recommends that
you avoid taking unnecessary
antibiotics.

Antibiotics Aren’t Always
the Answer
Most illnesses are caused by two kinds of
germs: bacteria or viruses. Antibiotics can
cure bacterial infections – not viral infections.
Bacteria cause strep throat, some pneumonia
and sinus infections. Antibiotics can work.
Viruses cause the common cold, most
coughs and the flu. Antibiotics don’t work.
Using antibiotics for a virus:
• Will NOT cure the infection
• Will NOT help you feel better
• Will NOT keep others from catching
your illness

Protect Yourself
With the Best Care

Y

ou should not use antibiotics to treat the
common cold or the flu.

If antibiotics are prescribed for you to treat
a bacterial infection – such as strep throat – be
sure to take all of the medicine. Only using
part of the prescription means that only part of
the infection has been treated. Not finishing
the medicine can cause resistant bacteria to
develop.
Talk to Your Healthcare
Provider to Learn More

?
Commonly Asked
Questions:
How Do I Know if I Have a
Viral or Bacterial Infection?

Ask your healthcare provider and follow his or
her advice on what to do about your illness.
Remember, colds are caused by viruses and
should not be treated with antibiotics.

Won’t an Antibiotic Help Me Feel
Better Quicker so That I Can Get
Back to Work When I Get a Cold
or the Flu?
No, antibiotics do nothing to help a viral
illness. They will not help you feel better
sooner. Ask your healthcare provider what
other treatments are available to treat your
symptoms.

If Mucus from the Nose
Changes from Clear to Yellow or
Green — Does This Mean
I Need an Antibiotic?
No. Yellow or green mucus does not mean that
you have a bacterial infection. It is normal for
mucus to get thick and change color during a
viral cold.

GET SMART…
• Antibiotics are strong medicines,
but they don’t cure everything.
• When not used correctly, antibiotics
can actually be harmful to your health.
• Antibiotics can cure most bacterial
infections. Antibiotics cannot cure
viral illnesses.
• Antibiotics kill bacteria – not viruses.
• When you are sick, antibiotics are
not always the answer.

USE ANTIBIOTICS WISELY

Talk with your healthcare provider
about the right medicines
for your health.

Cold or Flu.
Antibiotics Don’t
Work for You.

For more information, see the Centers for
Disease Control and Prevention website at:
www.cdc.gov/getsmart or call 1-800-CDC-INFO

CDC - Get Smart: Fast Facts About Antibiotic Resistance

Page 1 of 2

Fast Facts
Facts About Antibiotic Resistance
• Antibiotic resistance has been called one of the world’s most pressing public health
problems.
• The number of bacteria resistant to antibiotics has increased in the last decade. Many
bacterial infections are becoming resistant to the most commonly prescribed antibiotic
treatments.
• Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may
be left to grow and multiply. Repeated and improper uses of antibiotics are primary causes
of the increase in drug-resistant bacteria.
• Misuse of antibiotics jeopardizes the usefulness of essential drugs. Decreasing
inappropriate antibiotic use is the best way to control resistance.
• Children are of particular concern because they have the highest rates of antibiotic use.
They also have one of the highest rates of infections caused by antibiotic-resistant
pathogens.
• Parent pressure makes a difference. For pediatric care, a study showed that doctors
prescribe antibiotics 65% of the time if they perceive parents expect them and 12% of the
time if they feel parents do not expect them.
• Antibiotic resistance can cause significant danger and suffering for people who have
common infections that once were easily treatable with antibiotics. When antibiotics fail to
work, the consequences are longer-lasting illnesses, more doctor visits or extended
hospital stays, and the need for more expensive and toxic medications. Some resistant
infections can even cause death.
(#top)

How You Can Help Prevent Antibiotic Resistance
• Do not take an antibiotic for a viral infection like a cold, a cough or the flu. Antibiotics
should be used only to treat bacterial infections.
• Take an antibiotic exactly as your healthcare provider tells you. Do not skip doses.
Complete the prescribed course of treatment, even if you are feeling better.
• Do not save any antibiotics for the next time you get sick. Discard any leftover medication
once you have completed your prescribed course of treatment. Visit the EPA website for
how to properly dispose of antibiotics (http://www.smarxtdisposal.net/) .
• Do not take antibiotics prescribed for someone else, not even those from friends and
family members. The antibiotic may not be appropriate for your illness. Taking the wrong
medicine may delay correct treatment and allow bacteria to multiply.
• Antibiotic prescriptions in outpatient settings can be reduced dramatically – without
adversely affecting patient health – by not prescribing antibiotics for viral illnesses, such
as colds, most sore throats, coughs, bronchitis, and the flu.
• Do not demand antibiotics when a healthcare provider has determined they are not
needed.
• Talk with a healthcare provider about antibiotic resistance.

http://www.cdc.gov/getsmart/antibiotic-use/fast-facts.html

2/9/2010

CDC - Get Smart: Fast Facts About Antibiotic Resistance

Page 2 of 2

Related Materials
• Antibiotic Resistance Questions & Answers (anitbiotic-resistance-faqs.html)
• FOOD AND DRUG ADMINISTRATION VIDEO ABOUT ANTIMICROBIAL RESISTANCE
(http://www.fda.gov/AnimalVeterinary/SafetyHealth/AntimicrobialResistance/ucm134359.htm)
(#top)

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Page last reviewed: June 30, 2009
Page last updated: June 30, 2009
Content source: National Center for Immunization and Respiratory Diseases, Division of Bacterial Diseases

Centers for Disease Control and Prevention 1600 Clifton Rd. Atlanta, GA
30333, USA
800-CDC-INFO (800-232-4636) TTY: (888) 232-6348, 24 Hours/Every Day cdcinfo@cdc.gov

http://www.cdc.gov/getsmart/antibiotic-use/fast-facts.html

2/9/2010

Antibiotic Resistance
Antibiotic drugs can save lives. But
some germs get so strong that they
can resist the drugs. This is called
resistance. The drugs don’t work
as well. Germs can even pass on
resistance to other germs.
Antibiotics normally work by killing
germs called bacteria. Or they
stop the bacteria from growing.
But sometimes not all of them are
stopped or killed. The strongest
ones are left to grow and spread. A
person can get sick again. This time
the germs are harder to kill.
The more often a person uses an
antibiotic, the more likely it is that
the germs will resist it. This can
make some diseases very hard to
control. It can make you sick longer
and require more doctor visits. You
may need to take drugs that are
even stronger.
Two main types of germs
Bacteria and viruses are the two
main types of germs. They cause
most illness. Antibiotics can kill
bacteria, but they do not work
against viruses.
Viruses cause:
• Colds

• Coughs

• Sore throats

• Flu

• Bronchitis

• Sinus problems

Bacteria live in drinking water, food,
and soil. They live in plants, animals,
and people. Most of them do not
hurt people. Some even help us
to digest food. But other bacteria
cause bad diseases like tuberculosis
(TB) and lyme disease.
Does this affect me?
If you have a virus, taking antibiotics
is not a good idea. Antibiotics
don’t work against viruses. The
medicine will not help you. It might
even harm you. Each time you take
one, you add to the chances that
bacteria in your body will be able to
resist them. Later that could make
you very sick. Finding the right
treatment could be a problem.
What common mistakes do
patients make?
• Patients ask for antibiotics they
don’t need. For example, they ask
for antibiotics to treat a cold.
• They don’t take antibiotics the
way the doctor says. For example,
they stop taking the drug before
all the pills are used. That can
leave the strongest germs to grow.
• They save antibiotics and take
them on their own later.

• Ear infections

OVER
2007

Antibiotic Resistance
Why do doctors give antibiotics
when these drugs are not needed?
• Doctors are not sure what is
causing an illness.
• They are pressed for time.
• They give in to what patients ask
for.
What is the FDA doing about the
problem?
The FDA wants doctors to be more
careful about giving antibiotics
when they are not needed.

What should I do?
• Don’t demand an antibiotic when
your doctor says you don’t need it.
• Don’t take an antibiotic for a virus
(cold, cough, or flu).
• Take your medicine exactly the
way the doctor says. Don’t skip
doses.
• Don’t stop taking your medicine
when you feel better. Take all the
doses.
• Don’t take leftover medicine.

• The FDA will require new labeling
for doctors.

• Don’t take someone else’s
medicine.

• One of the new labels must say
that these drugs should be used
only for infections caused by
bacteria.

• Don’t rely on antibacterial
products (soaps, detergents, and
lotions). There is no proof that
these products really help.

• Another label will ask doctors to
explain the right way to use the
drugs to their patients.

FDA Office of Women’s Health http://www.fda.gov/womens

To Learn More:
Food and Drug Administration (FDA)
http://www.fda.gov

Centers for Disease Control and Prevention (CDC)
http://www.cdc.gov
TAKE TIME TO CARE... For yourself, for those who need you.

Facility Letterhead

Date

Physician Name
Physician Address
Physician City State Zip
Re: Optimizing Antibiotic Use in Long-Term Care Settings
Dear Dr. __________:
As a primary care provider to one or more patients in our nursing home, we wanted you to be aware that
[Name of Facility] is starting a new quality improvement (QI) program aimed at optimizing the use of
antibiotics among our residents. Our hope is to be able to provide you with the information you need to
make the best antibiotic prescribing decisions for your patients who reside in our community.
Purpose of the Program: This QI program is designed to help our staff provide you with information
about a resident’s condition that is consistent with the clinical guidelines developed by an expert panel
lead by Dr. Mark Loeb. The Loeb criteria and other related guidelines are described in the attached
document that we hope you will carefully review. Also, we have included the standardized format that
we will use to report the signs and symptoms of suspected infections. If you have questions about this
effort, you may contact [Name of facility QI team leader] who is our QI team leader at [phone or email].
The QI Team: The QI team includes key facility administrative and nursing staff, and Dr. [Name of
lead physician], a community physician. In addition to Dr. [Lead MD last name], a team of experts
from the University of North Carolina at Chapel Hill (UNC), Philip Sloane, MD, MPH, a nationally
recognized geriatrician, David Weber, MD, an infectious disease specialist, Sheryl Zimmerman, PhD, a
social gerontologist, and Anna Beeber, PhD, RN, a geriatric nursing specialist, will advise our team
throughout the process. Also, the UNC team will evaluate the effectiveness of the program at the end of
six months. The QI program evaluation is sponsored and funded by the Agency for Healthcare
Research and Quality and is supported by the American Medical Directors Association.
CME Opportunity: The University of North Carolina at Chapel Hill is offering CME credit for
attending an educational session on optimal prescribing of antibiotics in the long-term care setting. We
will be hosting [# of sessions] of these sessions at the following date(s) and time(s).
[Dates and times]
If you are interested in attending, please complete the attached registration form.
Our leadership is committed to this program and to working with you to provide the best care for our
residents. We look forward to our continued partnership.
Sincerely,

Executive Director

At A Glance

CDC Campaign to Prevent Antimicrobial
Resistance in Healthcare Settings
12 Steps to Prevent Antimicrobial Resistance Among
Long-term Care Residents
Prevent Infection
Step 1. Vaccinate
– Give influenza and pneumococcal vaccinations to residents
– Promote vaccination among all staff
Step 2. Prevent conditions that lead to infection
– Prevent aspiration
– Prevent pressure ulcers
– Maintain hydration

Step 3. Get the unnecessary devices out
– Insert catheters and devices only when essential and minimize duration of
exposure
– Use proper insertion and catheter-care protocols
– Reassess catheters regularly
– Remove catheters and other devices when no longer essential

Diagnose and Treat Infection Effectively
Step 4. Use established criteria for diagnosis of infection
– Target empiric therapy to likely pathogens
– Target definitive therapy to known pathogens
– Obtain appropriate cultures and interpret results with care
– Consider C. difficile in patients with diarrhea and antibiotic exposure
Step 5. Use local resources
– Consult the infectious disease experts for complicated infections and

potential outbreaks
– Know your local and/or regional data
– Get previous microbiology data for transfer residents

Department of Health and Human Services
Centers for Disease Control and Prevention

At A Glance

CDC Campaign to Prevent Antimicrobial
Resistance in Healthcare Settings
Use Antimicrobials Wisely
Step 6. Know when to say “no”
– Minimize use of broad-spectrum antibiotics
– Avoid chronic or long-term antimicrobial prophylaxis
– Develop a system to monitor antibiotic use and provide feedback to
appropriate personnel
Step 7. Treat infection, not colonization or contamination
– Perform proper antisepsis with culture collection
– Re-evaluate the need for continued therapy after 48-72 hours
– Do not treat asymptomatic bacteriuria

Step 8. Stop antimicrobial treatment
– When cultures are negative and infection in unlikely
– When infection has resolved

Prevent Transmission
Step 9. Isolate the pathogen
– Use Standard Precautions
– Contain infectious body fluids (use approved Droplet and Contact
isolation precautions)
Step 10. Break the chain of contagion
– Follow CDC recommendations for work restrictions and stay home
when sick
– Cover your mouth when you cough or sneeze
– Educate staff, residents, and families
– Promote wellness in staff and residents
Step 11. Perform hand hygiene
– Use alcohol-based handrubs or wash your hands
– Encourage staff and visitors
Step 12. Identify residents with multi-drug resistant organisms (MDROs)
– Identify both new admissions and existing residents with MDROs
– Follow standard recommendations for MDRO case management
The Campaign to Prevent Antimicrobial Resistance in Healthcare Settings is funded by the CDC Foundation
with support from Pharmacia Corporation, the Sally S. Potter Endowment Fund, and Premier.

Department of Health and Human Services
Centers for Disease Control and Prevention

March 2004

A Quality Improvement Program

Antibiotic Use in Long-Term Care
 Up to 40% of all systemic drugs prescribed in LTC 
 Between 25 – 75% may be inappropriately prescribed 
 Consequences of inappropriate use 




Poor patient outcomes related to adverse effects
Antibiotic resistant bacteria
Increased healthcare costs

 Benoit, et al., 2008

 Increased costs result from




More doctor visits
More medications
More hospitalizations

 For long-term care residents, adverse effects of
antibiotics:



more likely
more severe

• Diarrhea
• Vomiting
• Skin rash
• C. difficile
• Hospitalization

 Antibiotic resistance can cause significant
danger and suffering for residents in LTC







longer-lasting illnesses
more doctor visits
extended hospital stays
the need for more expensive and toxic
medications
death

Source: CDC - Get Smart: Fast Facts About Antibiotic Resistance
http://www.cdc.gov/getsmart/antibiotic-use/fast-facts.html

Prevention
 Conditions that lead to infection
 aspiration
 pressure ulcers
 dehydration
 ineffective infection control

 Most common infections in LTC


Urinary tract



Respiratory tract



Skin, soft tissue

Partnership for Change
 Prescribing Physicians
 You and your staff

Prescribing Physicians


Physician champion – part of your QI team



Prescribing guidelines for providers



Need to know specific signs and symptoms
related to guidelines

Your QI team
 Recommended members
 Administrator
 Director(s) of nursing
 Nurse educators (staff trainers)
 Physician champion

QI Program
 Signs and Symptoms of Infection form
 Complete before calling/faxing provider
 File each report in the resident’s chart
 Use for any suspected infection

QI Program
 QI team meets on a regular basis (at least monthly)
 Reviews charts of residents currently receiving

antibiotics (or at least a random selection of charts)
 record on QI Team Review form





# of charts reviewed
# of missing “Suspected Signs and Symptoms of
Infection Form”
# of forms with incomplete but available data

QI Program
 Create/revise plan for staff reminders
 Plan a short report for nursing staff meetings
 Send guideline reminder to frequent prescribers
(signed by physician champion)

Suspected Infection Signs and Symptoms
 Respiratory infection report
 Temperature
 Age
 Respiratory rate
 Pulse rate
 New or increased cough
 Delirium
 Rigors (shaking chills)
 Productive cough


describe sputum (Clear, green, yellow, white and creamy,
blood-tinged, dark red blood, bright red blood)

Suspected Infection Signs and Symptoms
 Urinary tract infection report
 Temperature
 Chronic indwelling catheter
 New or increased urgency, frequency, suprapubic pain,
or gross hematuriaPulse rate
 Urinary incontinence
 Costovertebral tenderness
 Rigors (shaking chills) with or without cause
 New onset delirium

Suspected Infection Signs and Symptoms
 Skin/soft tissue infection report
 Site of suspected infection
 Temperature
 New or increasing purulent drainage
 Redness
 Tenderness
 Warmth
 Swelling (new or increasing at the affected site)

Suspected Infection Signs and Symptoms
 Unexplained fever
 Temperature
 Duration
 New onset of delirium
 Rigors (shaking chills)

Suspected Infection Signs and Symptoms
 Other suspected infection
 Temperature
 Describe pertinent signs and symptoms
 Symptom onset

Questions?

Resident Name: _______________________________________ Date: ___________________________
Primary Care Provider: ____________________________ Phone: _____________ FAX: ____________

Signs and Symptoms of Suspected Infections
Instructions: Prior to contacting the resident’s primary care provider, record the signs/symptoms for the
suspected infection below. Report the presence or absence of each sign/symptom to the provider.

I.

1

Respiratory Infection?

Yes

0No

1. Temperature :
2. Age:
3. Respiratory rate:
4. Pulse rate:
5. New or increased cough

1

Yes 0No

6. Delirium

1

Yes 0No

7. Rigors (shaking chills)

1

Yes 0No

8. Productive cough: If yes, describe sputum (Clear, green, yellow,

1

Yes 0No

2. Chronic indwelling catheter
3. New or increased urgency, frequency, suprapubic pain, or
gross hematuria, specify:

1

Yes 0No

1

Yes 0No

4. Urinary incontinence

1

Yes 0No

5. Costovertebral tenderness

1

Yes 0No

6. Rigors (shaking chills) with or without cause

1

Yes 0No

7. New onset delirium

1

Yes 0No

white and creamy, blood-tinged, dark red blood, bright red blood)

II.

1

Urinary Tract Infection

Yes

0No

1. Temperature:

III.

Skin or Soft Tissue Infection

1

Yes

0No

Infection Site:

1. Temperature:

IV.

2. New or increasing purulent drainage

1

Yes 0No

3. Redness, describe:

1

Yes 0No

4. Tenderness, describe:

1

Yes 0No

5. Warmth, describe:

1

Yes 0No

6. Swelling (new or increasing at the affected site)

1

Yes 0No

2. New onset of delirium

1

Yes 0No

3. Rigors (shaking chills)

1

Yes 0No

Unexplained Fever

1

Yes

0No

When did it begin:

1. Temperature:

V.

Other Infection

1

Yes

0No

When did it begin:

1. Temperature:
Describe other signs and or symptoms (use back if needed):

SAUL Quality Improvement Program Guide
for
Long-Term Care Clinicians

1. Training Slides
2. Supplemental Materials

A Quality Improvement Program

Guidelines for Clinicians

Antibiotic Use in Long-Term Care
 Up to 40% of all systemic drugs prescribed in LTC 
 Between 25 – 75% may be inappropriately prescribed 
 Consequences of inappropriate use 




Poor patient outcomes related to adverse effects
Antibiotic resistant bacteria
Increased healthcare costs

 Benoit, et al., 2008

 Increased costs result from




More doctor visits
More medications
More hospitalizations

 For long-term care residents, adverse effects of
antibiotics:



more likely
more severe

• Diarrhea
• Vomiting
• Skin rash
• C. difficile
• Hospitalization

 Antibiotic resistance can cause significant
danger and suffering for residents in LTC







longer-lasting illnesses
more doctor visits
extended hospital stays
the need for more expensive and toxic
medications
death

Source: CDC - Get Smart: Fast Facts About Antibiotic Resistance
http://www.cdc.gov/getsmart/antibiotic-use/fast-facts.html

Prevention
 Conditions that lead to infection
 aspiration
 pressure ulcers
 dehydration
 ineffective infection control

 Most common infections in LTC


Urinary tract



Respiratory tract



Skin, soft tissue

Partnership for Change
 Prescribing Physicians
 Facility staff

Prescribing Physicians


Physician champion – part of the QI team



Prescribing guidelines for providers



Providers need to know specific signs and
symptoms related to guidelines

Minimum Prescribing Criteria


Guidelines set forth by Loeb, et al



Developed to minimize inappropriate
prescribing

Respiratory Tract Infections
A. With fever
1. Fever >38.9ºC [102ºF] and at
least one of the following:
a) respiratory rate >25
breaths per minute
b) productive cough

A. Without fever
1. With COPD AND age >65 and at
least one of the following:

OR
2. Fever >37.9ºC [100ºF] or a
1.5ºC [2.4ºF] increase above
baseline temperature AND <
38.9ºC [102ºF] and at least
one of the following:

OR
2. Without COPD, a new cough
with purulent sputum production
AND at least one of the
following:

a) pulse >100
b) delirium
c) rigors (shaking chills)
d) respiratory rate >25

a) new or increased cough
b) with purulent sputum production

a) respiratory rate >25 breaths per
minute
b) delirium

Urinary Tract Infections
A. With chronic indwelling catheter

B. Without an indwelling catheter

1. Fever >37.9ºC [100ºF] or a 1.5ºC
[2.4ºF] increase above baseline
temperature AND < 38.9ºC [102ºF]
and at least one of the following:

1. Fever >37.9ºC [100ºF] or a 1.5ºC
[2.4ºF] increase above baseline
temperature AND < 38.9ºC [102ºF]
and at least one of the following:

a) new or increased urgency,
frequency,suprapubic pain,
gross hematuria,
costovertebral angle
tenderness

a) new costovertebral
tenderness

b) urinary incontinence

b) rigors (shaking chills)
c) new onset delirium

Skin and Soft Tissue Infections
1. New or increasing purulent drainage at a wound, skin, or softtissue site
OR
2. Two of the following
a) Fever >37.9ºC [100ºF] or a 1.5ºC [2.4ºF] increase above
baseline temperature AND < 38.9ºC [102ºF]
a) Redness
a) Tenderness
a) Warmth
a) Swelling that was new or increasing at the affected site

Unexplained Fever
1. Fever >37.9ºC [100ºF] or a 1.5ºC [2.4ºF] increase above
baseline temperature AND < 38.9ºC [102ºF] and one of the
following:

a) New onset of delirium

b) Rigors (shaking chills)

QI Program
 Signs and Symptoms of Infection form
 Will be completed by staff before calling/faxing

provider

 Each report filed in the resident’s chart
 Used for any suspected infection

QI Program
 What specific information will nursing home
staff provide to clinicians?

Suspected Infection Signs and Symptoms
 Respiratory infection report
 Temperature
 Age
 Respiratory rate
 Pulse rate
 New or increased cough
 Delirium
 Rigors (shaking chills)
 Productive cough


describe sputum (Clear, green, yellow, white and creamy,
blood-tinged, dark red blood, bright red blood)

Suspected Infection Signs and Symptoms
 Urinary tract infection report
 Temperature
 Chronic indwelling catheter
 New or increased urgency, frequency, suprapubic pain,
or gross hematuriaPulse rate
 Urinary incontinence
 Costovertebral tenderness
 Rigors (shaking chills) with or without cause
 New onset delirium

Suspected Infection Signs and Symptoms
 Skin/soft tissue infection report
 Site of suspected infection
 Temperature
 New or increasing purulent drainage
 Redness
 Tenderness
 Warmth
 Swelling (new or increasing at the affected site)

Suspected Infection Signs and Symptoms
 Unexplained fever
 Temperature
 Duration
 New onset of delirium
 Rigors (shaking chills)

Suspected Infection Signs and Symptoms
 Other suspected infection
 Temperature
 Describe pertinent signs and symptoms
 Symptom onset

Questions?

Consensus Minimum Criteria For Prescribing Antibiotics
I.

Respiratory Infection
1. With fever

2. Without fever
1. With COPD AND age >65 and at least one of
the following:

1. Fever >38.9ºC [102ºF] and at least one of
the following:
a) respiratory rate >25 breaths per
minute
b) productive cough

OR

a)

new or increased cough

b)

with purulent sputum production

OR

2. Fever >37.9ºC [100ºF] or a 1.5ºC [2.4ºF]
increase above baseline temperature AND <
38.9ºC [102ºF] and at least one of the
following:

2. Without COPD, a new cough with purulent
sputum production AND at least one of the
following:

a) pulse >100

a) respiratory rate >25 breaths per minute

b) delirium

b) delirium

c) rigors (shaking chills)
d) respiratory rate >25

II.

Urinary Tract Infection
1. With chronic indwelling catheter

2. Without an indwelling catheter

1. Fever >37.9ºC [100ºF] or a 1.5ºC [2.4ºF]
increase above baseline temperature AND <
38.9ºC [102ºF] and at least one of the
following:
a) new or increased urgency, frequency,
suprapubic pain, gross hematuria,
costovertebral angle tenderness
b) urinary incontinence

1. Fever >37.9ºC [100ºF] or a 1.5ºC [2.4ºF]
increase above baseline temperature AND <
38.9ºC [102ºF] and at least one of the
following:
a) new costovertebral tenderness
b) rigors (shaking chills)
c) new onset delirium

III.

Skin or Soft Tissue Infection
1. New or increasing purulent drainage at a wound, skin, or soft-tissue site
OR
2. Two of the following
a) Fever >37.9ºC [100ºF] or a 1.5ºC [2.4ºF] increase above baseline
temperature AND < 38.9ºC [102ºF]
b) Redness
c) Tenderness
d) Warmth
e) Swelling that was new or increasing at the affected site

IV.

Unexplained Fever
1. Fever >37.9ºC [100ºF] or a 1.5ºC [2.4ºF] increase above baseline temperature
AND < 38.9ºC [102ºF] and one of the following:
a) New onset of delirium
b) Rigors (shaking chills)