DISCUSSION

Knowledge assessments of licensed and unlicensed personnel in nursing homes were conducted to assess their knowledge of CAUTI, ASB, antimicrobial stewardship, and other infection prevention topics. This information served as the basis for identifying the educational needs of participants in a national AHRQ Safety Program. Our most important findings are gaps in knowledge about the clinical symptoms of CAUTI, distinguishing CAUTI from ASB, and ways to apply the surveillance definitions of CAUTI to clinical scenarios. We also found limited knowledge of selected general infection prevention topics, including the specific procedures to follow for hand hygiene. These identified gaps were common among both licensed and unlicensed personnel and thus represent important targets for personnel education about infection prevention.

The questions requiring application of knowledge of CAUTI and ASB definitions to clinical scenarios elicited mostly incorrect responses. Possible explanations include a lack of familiarity with how to perform CAUTI surveillance, as most participating nursing home facilities were not performing National Healthcare Safety Network–based surveillance for CAUTI at the time of entry into the program cohorts. Other contributing factors may include limited training in infection prevention among nursing home personnel,Reference Herzig, Stone, Castle, Pogorzelska-Maziarz, Larson and Dick ¹² the complexity of the surveillance criteria themselves, and ingrained biases about what signs and symptoms should trigger an assessment for CAUTI.Reference Trautner, Petersen, Hysong, Horwitz, Kelly and Naik ¹³

The lack of knowledge about hand hygiene protocols was noteworthy, as 100% of facilities reported that specific training in hand hygiene is offered to personnel. Many factors may have led to this discrepancy, including logistical challenges to train part-time personnel, and limited uptake by the personnel being trained.Reference Travers, Herzig and Pogorzelska-Maziarz ⁸ This difference between personnel having knowledge of facts but having difficulty applying these facts to clinical scenarios inspired us to create case-based teaching modules reinforcing existing knowledge while enabling personnel to apply learned facts to clinical scenarios.Reference Knowles, Holton and Swanson ¹⁴ Thus, high priority was placed on teaching how to perform CAUTI surveillance through case examples in the clinical content webinars.

Our findings are in accord with those of several previous studies. A survey of Department of Veterans Affairs (VA) physicians, nurse practitioners, and physician assistants working in long-term care settings likewise reported significant gaps in knowledge about antibiotic stewardship and how to manage infections in older adults.Reference Jump, Heath and Crnich ^{15 ,} Reference Jump, Olds and Jury ¹⁶ Our knowledge assessment reveals similar knowledge gaps in non-VA facilities and includes clinical nurse assistants, who in nursing homes often generate the first request for urine testing or treatment for a possible UTI.Reference Fleming, Bradley, Cullinan and Bryne ¹⁷ The gaps in knowledge that we identified around inappropriate screening for ASB are also similar to those previously reported for acute care.Reference Trautner, Petersen, Hysong, Horwitz, Kelly and Naik ^{13 ,} Reference Grein, Kahn and Eells ^{18 –} Reference Drekonja, Abbo, Kuskowski, Gnadt, Shukla and Johnson ²⁰

Our study has several limitations. First, we do not have respondent-level demographic information, other than information about credentials, which limited our ability to examine the influence of respondent-level factors on various infection prevention knowledge domains. This knowledge assessment was exploratory and performed to prepare for a large-scale quality improvement program in nursing homes. Second, the sampling was not randomized, as facility leads were at liberty to select respondents at their facility. The knowledge assessment was not previously validated; but through this work we have created and refined a tool that can be used in other projects to measure baseline personnel knowledge relevant to CAUTI prevention. Although facilities participating in this program were not randomly selected, we have conducted separate analyses suggesting that participating facilities did not differ from nonparticipating facilities across a number of key characteristics.

This program represents the largest collaborative of long-term care facilities focused on infection prevention and CAUTI to date. As such, our findings on long-term care personnel knowledge have important implications for infection prevention policies and practices in nursing homes. First, we identified multiple gaps in knowledge of CAUTI, ASB, antimicrobial stewardship, hand hygiene, and standard precautions. Variable knowledge of diagnosis and prescribing guidelines for CAUTI and ASB is one of the challenges for antimicrobial stewardship in nursing homes.Reference Fleming, Bradley, Cullinan and Bryne ¹⁷ Second, we found a lack of knowledge about how to perform CAUTI surveillance. Finally, we found that the biases leading to inappropriate management of ASB previously identified in acute care are likewise present in nursing homes. Lessons learned here and the assessment tool are highly relevant to helping nursing homes meet the new Centers for Medicare and Medicaid Services requirements for having an active antimicrobial stewardship component within a robust infection prevention program. ⁷ As nursing homes expand and enhance their infection prevention programs, educational efforts can repair the gaps identified.