A Seat at the Table: Delivering Effective Infectious Diseases and Antimicrobial Stewardship Education to Advanced Practice Providers at an Academic Medical Center

Abstract

Introduction:Antimicrobial Stewardship programs promote appropriate antimicrobial use through different avenues, including education. Advanced Practice Providers (APPs) provide inpatient care in a wide-range of settings. Little is known about the educational needs of APPs at academic medical centers or the effect of educational interventions directed at inpatient APPs on clinical care. Our study looked at the effect of an educational intervention on antimicrobial prescribing by APPs for asymptomatic bacteriuria (ASB) and candiduria (ASC). We also conducted a needs assessment on the opportunities and barriers to continuing medical education.Methods:The educational intervention consisted of in-person interactive learning accompanied by an online video. Pre-intervention and postintervention surveys included an educational needs assessment and knowledge acquisition assessment. A retrospective chart review of adult inpatients admitted to the APP services with bacteriuria or candiduria during the 3 months pre-intervention and postintervention was performed.Results:Our needs assessment revealed several barriers to APP-focused education including no protected time for learning, and curricula predominantly directed at the Graduate Medical Education level. Engaged APPs had improved knowledge scores, but the proportion of treated ASB or ASC episodes did not differ between the pre-intervention and postintervention.Discussion:Although our educational intervention did not change prescribing patterns, the intervention increased knowledge around ASB and ASC. The potential hierarchical structure of interprofessional care teams may be a barrier to changing antimicrobial prescribing. Our study identified the possibility of a hidden curriculum at academic medical centers that does not prioritize APP educational needs.

One size does not fit all: advanced practice provider considerations for the antimicrobial steward

“… 24 In addition, APPs practicing at one academic medical center reported “Attending or Fellow Decision” as the most common barrier to decreasing inappropriate antimicrobial prescriptions. 25 Another study found that “fear of offending senior clinician” is a commonly cited factor in antibiotic decision-making among NPs. 26 …”

“… 29 , 30 It is not surprising that early studies found APPs did not have favorable perceptions of ASP interactions. One early study of NPs at a tertiary care medical center found a majority (66%) reported they were “not familiar” with the center’s ASP and only 17% reported finding ASP interactions “useful” or “very useful.” 27 More recent studies suggest that ASP engagement of APPs is increasing with several more recent studies of APPs finding that the majority of NPs and/or PAs now report ASPs as helpful sources for ID and antimicrobial education were “somewhat useful or useful.” 24 , 25 …”

“…We found that the educational intervention was well-received and improved knowledge acquisition; however, there was no change between pre- and post-intervention prescribing patterns for asymptomatic bacteriuria. 25 Another study on NPs working on cardiothoracic surgery inpatient wards found success in increasing antimicrobial guideline adherence through targeted prescribing feedback coupled with educational outreach; however, the study only involved 11 NPs. 33 …”

“… 34 A reported lack of protected time for education as well as perceptions that continuing education curricula were primarily designed for medical students and physician trainees are both factors that could lead to decreased APP engagement in ASP educational activities. 25 , 35 We had also previously hypothesized that the culture at medical centers could be contributing to a lack of APP engagement, exemplified through the use of terms such as “nonteaching services,” “resident substitutes,” or “midlevels” that remain prevalent in both clinical and research settings and may perpetuate historical biases towards APPs. 5 , 36 – 39 …”