Table 2.

Themes and exemplar quotes of importance of communication, roles, within and across teams and challenges specific to UTI diagnosis and treatment

Theme	Exemplar quote
Importance of communication in transitions of care	Q1: The communication is very fragmented, not only at this nursing home, everywhere. And so the way that the change of condition is communicated, the way that who knows about it, right, in this case there was also a nurse supervisor onsite that should have known about that and should have, you know, been involved. And so there are a lot of opportunities, if you will, to make sure that, you know, we're right on top of these change of conditions as they happen. (LTCF Medical Director, 116)
Role of nurses in communicating patient status	Q2. Your physicians aren't coming in to see them. I mean, they're really basing their knowledge off of what the nurses are giving them. (LTCF Infection Preventionist, 104)
	Q3. The other piece is having the engagement of the nursing staff, right, because, again, it's coming down to that communication piece of collecting the data. They're really the first line, you know, of information for the providers on call and even onsite. (LTCF Medical Director, 116)
	Q4. When the UA comes back, if I see white blood cells, positive leukocytes, positive bacteria, sometimes blood in the urine, then I'll go up to the physician and say, oh, I notice UA is back, and they have quite a few white cells, you know what I mean. So I will never diagnosis it, but I will certainly let the physician know that I've seen it come back, and it looks suspicious.”(ED Nurse, 204)
Communication dynamics within health care settings	Q5. Most of the time they ask, ‘hey, do you want a UA’, before they order it for me. 95 percent of the time, they'll ask me before they do it. (ED Physician, 103)
	Q6. I think our charge nurse does a good job of letting us know if they feel we need to know about something in advance. The nurses will kind of prioritize appropriately. (ED Physician, 106)
	Q7. Emergency nurses, because of the nature of how we work and what we do, they're allowed to do certain things and get things going, which is often very helpful. (ED Physician, 104)
	Q8. And then before they want to get a UA, anything like that, they also have to call me… because I have been noticing like, well, these people don't have 3 symptoms, you know, and then they wanted to dip them, and I don't believe in that, and it's just, they're always going to have [a UTI]. They're always going to have one, So now, [the nurses] are getting pretty good about calling me to see if they need to get a UA. (Director of Nursing, 103)
	Q9. You know, if I called [the PCP], they're probably going to you know, order a urine. I try to encourage them [the nurse] if the resident is not acutely ill, but they have some change in their baseline, and it's a urine thing, to monitor 24 hours, push fluids give cranberry juice, all of those things that we can do here before we need to call a doctor. (Infection Preventionist, 109)
Communication dynamics across health care settings	Q10. And we get usually nothing. Every now and then, I'll get a great [ED] nurse, you know that calls me and says, this is what happened. This is what we did. And that's wonderful because then we know how to move forward because otherwise, it's just a guessing game. You know, I'll come in in the morning. Like they came back. Okay, What did they say? I don't know. We didn't get anything. Really? Nothing? So then I'll call. (Director of Nursing, 103)
	Q11. So you don't know who you're calling to report to. So if they don't give you the number of who to call back to, it's very difficult sometimes, especially with these bigger organizations to try to his somebody's who's actually going to follow up with them. (ED Nurse, 201)
	Q12. We don't have a lot of challenges with our hospital, because we're so close to all of the providers, the, you know, our medical director, and even having a meeting with the discharge planners of the hospital, they know us all by name... You work with the same providers. You know [physician] was a physician here for like 50 years, and he rounded at this facility for like 50 years. So they know everybody here, you know what I mean? And even our nurses, like I have a nurse that was a nurse for 54 years, 54 years. They all know her, you know what I mean?... But there's a certain level of trust and understanding and willingness to adapt what you usually do because you're in a small setting. Like this certainly would not work every place, because I am sure that not every place, you can literally walk into an ER and get care. (LTCF Director of Nursing 111)
	Q13. Occasionally, when you make that call [to send the patient back to the LTCF], [LTCF nurses are] surprised. Most of the time, they're fairly accepting. They'll say, ‘sure,’ and maybe that's that deference. They're just the random faceless person on the phone, and you're the physician, and so they're not going to argue with you. It would be nice sometimes if they did, if they really had a big concern, say, ‘this is not going to work,’ that they would push back. (ED Physician, 104)
	Q14. You get a new nurse in here that has to call a physician, and it's only the third time she's called a physician, and the last 2 times she called a physician, he yelled at her because she didn't have her assessment in line, she's going to be meek. And it's very difficult to be meek when you're calling a physician, because you're working as an advocate. (LTCF Director of Nursing, 111)
Communication challenges in the context of UTI diagnosis and treatment	Q15. I've talked across the state about this topic mostly to long-term care nurse audiences. Every place I talk, they ask this question. Why do [patients] always come back [from the ED] with an antibiotic for a diagnosis of urinary tract infection? (LTCF Medical Director, 113)
	Q16. I don't know that they understand as we now know, and I don't mean to belittle, but this whole idea of antibiotic use, how badly we want to avoid putting our people on antibiotics because they are so at risk for the side effects…So, you know, we want to make certain that the right diagnosis is given, and they're not treated for something partially for those reasons, but partially because then they miss the real diagnosis. (LTCF Director of Nursing, 111)
	Q17. So 2 days later, the culture comes back, 8,000 colonies of E. coli, which is an insignificant urine culture. The nurse calls back and says, “Doctor, the culture comes back negative. May we stop the antibiotic?” And he said, “How is the resident doing?” And the nurse said, “Well, he's doing fine.” He said, “Well, I'd like you to continue the antibiotic for ten days.” And she said, “Okay, but that does not satisfy our facility best practice criteria. Why do you want to do that? Why do you want to continue the antibiotic?” And he said, “Because I'm the doctor.” (LTCF Medical Director, 113)
	Q18. I talked to [the emergency department], and I did everything in my power. I sent them the evidence. I sent them the revised McGeer's Criteria. I sent them the FDA recommendations regarding fluoroquinolone use. I sent them her creatinine function that shows that she's a candidate for nitrofurantoin. I sent them the UA that showed E. coli with all the sensitivities. I sent them all of this stuff, and I'm still not successful. (LTCF Director of Nursing, 111)
	Q19. I feel like I present things a little bit differently than some people do, because I think that a lot of the time, the physician needs me to tell them it's okay that we don't send them over [to the ED]. And I will literally say those words. (LTCF Director of Nursing, 111)
	Q20. Because I think sometimes, we just say, oh I'm calling, and they have a fever and they're complaining of burning. And [the nurse] doesn't say anything else. And I think a lot of doctors will just jump on, let's start an antibiotic, versus, but they're still up and we can still encourage fluids. We could, you know, and things like that. So the conversation is a huge piece, that I'm trying to get my nurses is painting the picture for the physicians.” (Infection Preventionist, 109)