Theme 1. An ASP is resource intensive for nursing homes with limited resources

Despite support from the HBT (Table 3, T1 Qa), participants felt that an ASP was resource intensive with inadequate staff, time, and financial resources dedicated to stewardship functions. Champions were overwhelmed by the additional antibiotic stewardship duties and felt that “… it’s kind of a piece of everyone’s job, but nobody has the time for it.” Champions with clinical duties had to juggle their time between resident care and antibiotic stewardship. Staffing shortages (Table 3, T1, Qb) further decreased the time champions needed to devote to antibiotic stewardship activities, partially due to the need to provide antibiotic stewardship training to the constant influx of new staff (Table 3, T1 Qc). Financial constraints (Table 3, T1, Qd) made it difficult to reimburse consultant pharmacists for any additional time needed to analyze antibiotic use data as one pharmacist noted, “[the nursing homes] don’t want to pay me for what I [can] do.” With constrained resources of staff, time, and finances, the champions were concerned that without the HBT’s support there would be “no one to pick up the pieces.”

Theme 2. No matter how committed, a single person cannot sustain an ASP

Initially, based on the HBT’s recommendations, ASP teams comprised medical directors, directors of nursing, IPs, and pharmacists. Over time, due to competing priorities and staff turnover, nursing homes shifted the responsibility to the ASP champion. Although all champions were motivated and committed (Table 3, T3 Qa), the enormity of the task and the inability to maintain a cohesive team was overwhelming (Table 3, T3 Qb), resulting in “a lot of 10- to 12-hour days” and work on weekends. Sustaining the program single-handedly was challenging because “you give your 150% … but you’re one person.” This led to some leaving the job, further jeopardizing the program (Table 3, T3 Qc). ASP champions often had multiple responsibilities (eg, assistant director of nursing, infection preventionist, and nurse educator), and with staffing shortages, they also cared for residents (Table 3, T2 Qd). A champion who left her job said, “I feel like it’s making [me] a scapegoat. Because state [regulators] walk in, education’s lacking, I’m in charge of education. IP’s lacking, I’m in charge of IP. Staffing’s lacking, I’m the one (in charge).” Although motivated, with innumerable responsibilities, the champions felt that they could not sustain an ASP alone.

Theme 3. An ASP requires access to and interpretation of data not readily available at many nursing homes

During the implementation project, the HBT provided detailed antibiotic data summaries and interpretation and created tracking tools to enable nursing home staff to independently tabulate their data when the partnership ended. However, participants felt that the antibiotic stewardship was “data driven,” and that the lack of an in-house electronic health record (EHR) system limited their access to data. Gathering hand-written information from medical charts was time-consuming and labor intensive (Table 3, T3 Qa). For consulting pharmacists, lack of an EHR was challenging because they didn’t “have all the information … 99% of the time there’s a diagnosis” without any other indicators for an antibiotic. Access to records from other healthcare facilities where nursing home residents were treated was also limited (Table 3, T3 Qb). Champions created new forms for data collection that were later abandoned because providers did not have time to complete them (Table 3, T3 Qc). Some ASP champions struggled with the use of electronic data and maintained both electronic and paper systems to keep track of the data (Table 3, T3 Qd). Additionally, once data were collected, the ASP champion’s level of comfort with data analyses varied. One participant stated: “Nobody is doing a thing with it. They have no clue what to do with the information.” To sustain the ASP, champions needed access to real-time antibiotic use data and the technology and personnel to interpret and act on the data.

Theme 4. ASP sustainability requires external partnership, internal leadership support, and collaboration across longstanding disciplinary boundaries

Participants reported that internal and external partnerships as well as explicit leadership support were critical for sustainability. The partnership with the HBT was valued because the HBT understood the complex conditions of residents and provided clear and concise guidelines that could be used readily (Table 3, T4 Qa, Qb). ASP champions worried that without this partnership, the program would “very much struggle … because there is no help to do so,” and they would have to rely on internal collaborations and explicit leadership support for sustainability.

However, rigid internal interprofessional boundaries and the lack of communication (Table 3, T4 Qc) made collaboration challenging because “they’re very regimented: this is a nursing issue, this is a pharmacy issue, this is a medical issue.” For the champions to cross these boundaries without a good reason was unacceptable. Boundaries were seen as restrictive even by licensed practical nurses (LPNs) who felt that their clinical judgement was ignored and that they were not partners in promoting antibiotic stewardship (Table 3, T4 Qd). Nevertheless, these boundaries could be crossed with tangible and explicit leadership support. For example, a pharmacist said, “We can suggest … a pathway, but we really need the support of the medical director to actually support it.” All members of the nursing home leadership had signed letters of support for the ASP, but some champions felt there was not enough buy-in and that antibiotic stewardship could not be a “grassroots operation … the right thing has to be done from above” (Table 3, T4 Qe). Champions who perceived explicit leadership support felt that they were able to better execute their responsibilities (Table 3, T4 Qf).

Theme 5. It is hard to “get to step two” and sustain an ASP because clinical “fires come first”

Urgent resident care needs always took precedence over ASP tasks (Table 3, T5 Qa). These “clinical fires” were routine because of inadequate staffing that was perceived as a 2-fold problem: too few staff (Table 3, T5 Qb) and too few newly hired frontline nurses with the skills to care for residents with complex needs. Temporary, “agency nurses” were perceived as lacking the skills to care for residents because “How do you teach people to care? Long-term care [is] not attractive to work in [and with poor pay] the turnover is constant.” At some nursing homes, turnover existed at all levels of the organization, making it difficult to promote antibiotic stewardship efforts (Table 3, T5 Qc). Many nursing home employees did not know about the ASP (Table 3, T5 Qd), nor did they remember the elements of antibiotic stewardship (Table 3, T5 Qe). Urgent medical needs and inadequate staffing made it hard for the champions to “ever get to step 2” of sustaining the program because, with high turnover, they needed to constantly re-educate staff. Additionally, caring for residents with complex medical conditions sometimes meant that antibiotics were started “a little bit more empirically … [because] we’ve seen people go septic so fast over and over and over again,” and sometimes antibiotic start dates were not documented on time (Table 3, T5 Qf).

Theme 6. Consistent and constant education on ASP is important for sustainability

Though the champions and medical directors at the nursing homes received antibiotic stewardship education and training from the HBT, the education of other nursing home personnel was fragmented. With high turnover, ASP teams were reconfigured frequently and the primary responsibility for antibiotic stewardship education often defaulted to the champions who were constantly “re-educating” new staff. In some nursing homes, education was fragmented because a variety of personnel (medical directors, champions, nurse educators, IPs, and nurse managers) provided antibiotic stewardship education in silos. A nurse educator at one nursing home stated, “The medical department I think does their own [antibiotic stewardship] education … but we have not been involved in their education.” The provider at the same facility said, “I’m not sure what’s done in orientation … the nursing orientation, I am from medical; we do it, you know, on a case-by-case basis.” At one nursing home, both the champion and the nurse educator created antibiotic stewardship education modules for staff in parallel and did not know what or when the other provided antibiotic stewardship education. Furthermore, formal antibiotic stewardship education formats varied from new hire orientation to in-service and online modules. Some participants felt that online training was ineffective because they only had to indicate that they completed the module (Table 3, T6 Qa). Champions felt that the education of frontline staff (LPNs and certified nursing assistant [CNAs]) was important because “they’re face to face with the residents” and knew them well. The more dramatically they presented a resident’s change in condition to their manager, the more likely a call was made to a provider who would then order an antibiotic. Despite this, frontline staff were rarely prioritized for formal antibiotic stewardship education and often learned about antibiotic stewardship through overheard conversations on the units. However, providing formal antibiotic stewardship education was also challenging because they usually could not leave their resident-care responsibilities to attend educational sessions (Table 3, T6 Qb) because, as a nurse educator stated, “Do you want them to care for the residents, or do you want them to do the education? They need to do both.”

Theme 7. Outer contextual factors impede stewardship efforts

Through the collaborative efforts of the HBT and the nursing home medical directors, the prescribing behaviors of in-house providers changed and led to reductions in the overall use of antibiotics and fluoroquinolones. However, outside entities, such as emergency departments (ED) and “on-call” providers, were perceived as impeding antibiotic stewardship efforts. A resident’s visit to the ED “resets everything you have tried to do. [Though] there’s no indication, [if] they go to the ED … [they] are diagnosed with a UTI and return with antibiotic prescriptions.” Some medical directors provided antibiotic stewardship education to external “on-call” providers who did not have antibiotic stewardship training. External specialists, like urologists or dentists, also posed challenges because they customarily prescribed prophylactic antibiotics. Similarly, families of residents exerted pressure for antibiotic prescriptions (Table 3, T7 Qa) because “[they] will not stop until they get a urine [analysis].” Lastly, the innumerable nursing-home regulations, including the mandated ASP, were burdensome because “setting up a regulation and then not putting resources behind it, is probably one of the biggest issues.” ASP champions spent much of their already depleted time and personnel in completing regulatory documentation and answering questions from regulators (Table 3, T7 Qb), and they felt that regulations fostered a “reactive culture” and undermined ASP sustainability.