Title: An evaluation of a multifaceted intervention to reduce antimicrobial prescribing in care home residents [REducing Antimicrobials in Care Homes (REACH)]: a non-randomised feasibility study and process evaluation
Funder: Health and Social Care Research and Development Division (HSC R&D) of Public Health Agency, Northern Ireland

Abstract: Concerns have been raised about the level of prescribing of antimicrobials in care homes, with such facilities an important ‘reservoir’ of antimicrobial resistance. In this non-randomised pilot study, we will test the feasibility of a multifaceted intervention in six care homes (at least one with and one without nursing care) across Northern Ireland (NI) and England (West Midlands). We will adapt and refine an intervention previously shown to be effective in a Canadian study for use in the United Kingdom (UK). We will present the proposed intervention (see below) to stakeholders (focus groups with care home staff and family members and semi-structured interviews with general practitioners-GPs) who will be asked to comment on and amend the content of the intervention. The proposed intervention consists of education and training of care home staff and the GPs caring for pilot home residents, on appropriate management of common infections and antimicrobial stewardship. This will be achieved via visits to the care homes and practices, including training on the implementation of algorithms to guide recognition of signs and symptoms and treatment for infections by home staff and GPs. The intervention will be a complex whole home intervention targeting home staff and their linked general practices, focusing on use of antimicrobials in care homes with an implementation phase running for 6 months. A detailed process evaluation will run throughout the pilot study to assess whether care homes can be recruited to the study, implementation and acceptability of the intervention, and how home staff and general practices interact. We will also test our approaches to data collection from care homes and community pharmacies, the assessment of appropriateness of prescribing, and determination of event rates for sample size calculations.

Lay abstract: There have been concerns about the level of prescribing of antimicrobials (antibiotic, antifungal and antiviral medicines) in care homes for older people. The Chief Medical Officer (CMO) of England has highlighted that high use of antimicrobials can lead to resistance, meaning that these drugs may no longer be effective. The CMO’s report also suggested that older people, especially those living in care homes, may be at higher risk of infection. The report noted that education and training of doctors and nurses about infections and antimicrobials was very important to ensure that antimicrobials are used properly. A Canadian study found that education and training was useful in reducing the use of antimicrobials in Canadian care homes. We have based our study on this work. We will recruit 6 care homes to the study: 3 in Northern Ireland (NI) and 3 in the West Midlands. We will review the most up to-date scientific literature on how to manage infections in care home residents. We will develop training material and a training programme for care home staff and general practitioners (GPs). We will discuss the Canadian approach with staff, GPs and family members of residents, and adapt it for use in the UK. We will train care home staff and GPs in using this new approach. We will then test the new approach in the 6 homes to ensure that it is practical and feasible to implement. Members of the research team will interview the staff and GPs to explore how they have found the new approach, if there are any particular difficulties and if they have any suggestions for improvements. We will also test how we will collect information about residents from care homes, community pharmacies and large databases. The entire study will run for 2 years. We have considered the ethical issues in this study very carefully and have contacted the Health Research Authority, the Office of Research Ethics Committees N. Ireland and the Privacy Advisory Committee who advise that our general approach is likely to be acceptable. The new approach to be tested is low risk. All the necessary approvals will be in place for this approach before the project starts. We will involve residents, family members, care home staff and GPs at all stages of the project in helping us to refine and develop our ideas and project materials. The team overseeing this research are highly experienced in this type of work, have conducted research in care homes before, have clinical knowledge and expertise in infections, prescribing, ethical issues and are aware of the sensitivities which need to be considered. The costs for this project are based on the amount of time each team member will spend working on the project, the staff who will be needed to run the project on a day to-day basis, and the costs which have been incurred in other similar projects and based on the experience of the research team. We will produce a report of our findings for the funder, and will publish at least two papers in academic journals. We will also present our findings at relevant conferences.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: INFECTION