Implementing Standardized Practices in Long-Term Care

Individual variation in clinical decision-making and practices can contribute to poor-quality patient care. This is especially true in the field of geriatrics; because representation of older adult patients is often lacking in high-quality clinical research, clinical care is often the result of individual physician decision-making. Continued efforts to adopt standardized practices based on high-quality evidence can result in higher quality for older adults.

One method of standardizing care is through the use of standing orders (SOs). SOs are written, physician instructions or procedures, designed for a patient population with specific diseases, disorders, health problems, or symptoms. Such instructions delineate under what conditions and circumstances action or treatment should be instituted. These orders allow nurses and other qualified staff to carry out medical orders per a practice-approved protocol without the authorized clinician’s examination or requirement for individual approval.

SOs are widely used in long-term care facilities to improve the efficiency of nursing care. However, SO content varies and frequently lacks an evidence-based approach, often reflecting the individual medical director’s experience and desires. Because it is common for clinicians working in long-term care to practice in many different facilities, variations in individual facility SOs can create confusion. 

In this issue of Annals of Long-Term Care: Clinical Care and Aging, Jaclyn Guetzko, DNP, APRN, C-AGNP, and colleagues report on their quality improvement project to create a standardized SO protocol, based on high-quality evidence, clinical practice guidelines, and expert opinions, for use in long-term care settings. A Minnesota-state based interdisciplinary group of geriatric primary care providers, who serve LTC residents, transitional care, assisted-living, and other senior living communities, developed consensus on best clinical practice for patient care in geriatric care settings. The goal was to decrease unwarranted practice variation whenever possible and, by doing so, decrease the burden, inefficiencies, and risk of multiple different requirements and approaches to care by the various clinical practices.

Standardization of practices in long-term care facilities is also needed to counter one of the major concerns in these health care settings: the steadily increasing rate of antimicrobial resistance. Antimicrobial agents comprise a large proportion of prescribed medications in long-term care facilities, typically prescribed for the treatment of urinary tract infection, skin and soft tissue infection, and respiratory tract infection. However, most systemic antimicrobial use is reportedly inappropriate. In order to combat this threat, hospitals across the nation have successfully implemented antibiotic stewardship teams (ASTs). These teams implement antibiotic stewardship programs in long-term care facilities to decrease the overuse and misuse of antimicrobial agents, which result in antibiotic resistance and adverse effects.

Although many long-term care facilities do not have their own antimicrobial stewardship programs, those implemented in hospitals have shown great success for standardizing antibiotic prescribing practices and improving patient outcomes. For example, fluoroquinolones are a class of broad-spectrum antimicrobials that has been associated with an increased risk of Clostridium difficile infection (CDI) and multidrug resistant organisms (MDRO). One commonly employed initiative to decrease CDI rates in hospitals is to restrict the use of the fluoroquinolones class of antimicrobials. Many hospitals have implemented antimicrobial stewardship teams for the purpose of reducing prescribing of fluoroquinolones, and these have had great success. Long-term care facilities that do not have their own antimicrobial stewardship programs may benefit from collaboration with local hospital-based antimicrobial stewardship teams.

In a study by Christine L Rahme, PharmD, et al, the effectiveness of a hospital-based antimicrobial stewardship team for reducing the use of fluoroquinolones, overall antibiotic consumption, and CDI rates at a neighboring, unaffiliated long-term care facility was assessed. The team created a multi-faceted intervention that included antibiogram development, provider and family education, and a telephone hotline. The results showed that implementing greater standardization relating to prescribing of antibiotic medications led to decreased antibiotic consumption and reduced rates of CDI.

Practitioners in long-term care should continue to look for opportunities to standardize their practices in order to improve the quality of care provided to residents.