Choosing the Right Toolkit

The Guide is intended to allow nursing homes to pick and choose among toolkits, and even choose among individual tools. Each nursing home will have different needs and resources resulting in different choices. To help decide which tools may be most appropriate for a particular nursing home, it may be helpful to consider the following questions:

1. Has the nursing home identified a particular problem?
   For example, if the nursing home is already monitoring antibiotic use, staff may have identified that prescribing clinicians are using antibiotics for bacteria that are not usually sensitive to that antibiotic. In that case, a nursing home may want to select one of the tools designed to help prescribing clinicians choose the right antibiotic for treating an infection. Other common problems that nursing homes may wish to address are high rates of prescribing for specific infections or residents referred from hospitals with an antibiotic prescription for an asymptomatic UTI.
   
   If the nursing home has not identified a problem, it may want to start monitoring antimicrobial use with the Monitor and Sustain Stewardship toolkit. This may help the antimicrobial stewardship team identify a problem on which to focus.
    
2. What level of resources can the nursing home devote to the intervention?
   
   Table 1 below lists the toolkits organized by the level of resources needed (first column) and potential goals of the antimicrobial stewardship program. Resource use levels are based primarily on the amount of staff time or training required, but also reflects costs of materials. “Low” indicates that the toolkit can be implemented with a few hours of administrator time, less than an hour of initial training for staff, limited ongoing time for monitoring and retraining, and costs for printing/photocopying. These toolkits may take more effort if the nursing home wants to make substantial changes to the tools themselves. “Medium” indicates that more time and effort is required by all involved staff, ongoing time for monitoring and retraining will be higher, and the toolkit may require computer access or costs other than printing costs. These toolkits may require staff to take time to consider how to adapt workflows or adapt the tool to fit existing workflows. “High” indicates that implementing the toolkit will require a significant investment of staff time, requires the development of specialized expertise, and may involve higher costs for materials.

   Table 1. Toolkit Goals and Level of Resources Needed

   Potential Antimicrobial Stewardship Program Goals
   Level of Resources Needed	Identify Potential Problems	Help Prescribing Clinicians Identify an Infection	Help Prescribing Clinicians Choose the Right Antibiotic	Educate Residents and Family Members
   Low		Suspected UTI SBAR	Working with a Lab to Improve Antibiotic Prescribing	Educate and Engage Residents and Family Members
   Medium	Monitor and Sustain Stewardship	Communication and Decisionmaking for Four Infections Minimum Criteria for Three Infections	Concise Antibiogram
   High			Comprehensive Antibiogram



3. Do these tools support QAPI program and/or State survey requirements?
   The Quality Assurance and Performance Improvement (QAPI) program is a set of standards designed to improve the quality of life, care, and services in nursing homes. QAPI was developed by the Centers for Medicare & Medicaid Services as a result of provisions within the Affordable Care Act. Although QAPI programs are similar across the country, each State may have different requirements, so each nursing home should check the requirements in its State. As part of their QAPI programs, nursing homes are expected to identify problems or opportunities for improvement, that represent high risk, high volume, or problem-prone issues. The toolkits in this Guide can potentially support a nursing home’s QAPI program, depending on the area of improvement wanted. The Start an Antimicrobial Stewardship Program toolkit includes draft policies and procedures that can be used across all toolkits in the Guide, and two toolkits also have their own specific policies and procedures. Table 2 below outlines relevant aspects of each toolkit as they relate to the QAPI program and State requirements.
    

   Table 2. How Toolkits Apply to QAPI or State Survey Requirements

   Toolkits	Focus on Quality Improvement	Outlines Policies and Procedures	Monitoring and Feedback	Performance Improvement Projects	Evidence- Or Best Practice-Based	Resident Engagement
   Start an Antimicrobial Stewardship Program	X	X			X
   Monitor and Sustain Stewardship	X		X		X
   Suspected UTI SBAR Form	X			X	X
   Communicating and Decisionmaking for Four Infections	X			X	X
   Minimum Criteria for Three Infections	X	X			X
   Concise Antibiogram	X	X		X	X
   Working with a Lab to Improve Antibiotic Prescribing	X		X		X
   Comprehensive Antibiogram	X	X		X	X
   Residents and Family Member Education	X		X		X	X