Managing family expectations in antibiotic reduction
I can't count how many times I've heard at conferences, “Sure, we know we need to do X, but the families always want us to do Y.” This could mean anything from the family wanting to send their loved one to the emergency room to taking someone off of an antipsychotic.
That's why it was different, and helpful, to hear Philip D. Sloane, M.D., MPH, a University of North Carolina Chapel Hill professor, discuss how to talk to families about antibiotic reduction during a McKnight's Super Tuesday webinar yesterday.
“Family expectations are overestimated, and families are starting to get the message a little bit,” he said. “It's all about communication and education.”
While there will be some family members who challenge nurses and staff about medication, Sloane offered a script to address concerns.
Families “want to know that we are helping them.” That includes reassuring them that staff understands the resident is ill and giving a realistic timeline.
“A cough may take three weeks to get better,” he said. After telling the family that, a nurse can reassuringly say, “We are on top of this. We are going to help him feel more comfortable so his body can fight this virus. We are watching him.”
If family specifically asks about antibiotics, Sloane recommends not using the word bronchitis, but instead to use the terms “chest cold” and “virus.”
He suggests lines such as, “Antibiotics won't help and can cause side effects. We will monitor him closely if there's a change in condition that might indicate a need for antibiotics.”
There's also a lot of room to grow in how nursing homes handle urinary tract infections. Sloane's research finds that urine cultures are over-ordered, and that there's too little attention to how residents feel.
For example, in one study 89% of those who had a positive culture were prescribed an antibiotic.
But “we didn't look to see if these people were sick. Almost none had a fever and most were doing fine. What happens is the result comes back, the nurse sees it is a positive culture, the doctor says they have to treat, and they don't ask, ‘Is this person OK?'” For example, 86% of the patients had a temperature less than 99 degrees and 74% lacked documentation of urinary tract-specific signs.
It's the last part of that that should make healthcare staff — especially women — prick their ears up. As one of my friends put it, having a UTI is like “peeing razor blades.” Granted, people our age — that is to say, well below retirement age — may be more likely to isolate the issue. Long-term care residents, as Sloane points out, have a variety of issues that can be causing dehydration, lack of appetite, fatigue and illness, ranging from a lack of sleep to chronic pain or constipation. The “knee-jerk” reaction, as Sloane noted, is to assume a resident has a urine issue.
My guess is some of that is history, some of it's fear and, quite frankly, some of it is laziness. It's a lot easier to order a urine culture than to arrange for someone to talk to the resident about why he or she might be depressed, to investigate diet or food preferences, or to see if there's an activity that might make the resident want to get out of bed.
It's hard to know how far the Centers for Medicare & Medicaid Services will continue to push antibiotic reduction — as Sloane noted, it's not the same situation as antipsychotic reduction. Antibiotics will always be needed.
But with the right data and guidance, leadership can push to make sure they are prescribed for the right patient at the right time.
You can listen to Sloane's webinar presentation by visiting www.mcknights.com/january23webinar.
Follow Senior Editor Elizabeth Newman @TigerELN.