ePrescribing-Based Antimicrobial Stewardship Practices in an English National Health Service Hospital: Qualitative Interview Study Among Medical Prescribers and Pharmacists (Preprint)

Abstract

BACKGROUND Antimicrobial resistance is a public health emergency. Although behavioural and technological interventions have been developed to reduce unnecessary antimicrobial usage, these often do not integrate effectively with existing workflows, jeopardising their effectiveness. OBJECTIVE We sought to understand existing ePrescribing-based antimicrobial stewardship practices amongst prescribers in the context of use surrounding an electronic prescribing system in an English hospital. METHODS We conducted 18 semi-structured interviews with medical prescribers and pharmacists exploring current prescribing and antimicrobial stewardship practices and investigating potential areas for improvement. Data were thematically analysed using both inductive and deductive methods with the help of NVivo 12. RESULTS Our work showed that the antimicrobial prescribing and review processes involved a complex flow of actions by healthcare practitioners. These were characterised by uncertainty over how to prescribe in individual cases, where medical prescribers often had to face trade-offs between individual patient benefit and more diffuse population health benefits, and a perceived lack of awareness surrounding the rationale for prescribing upon initiation. The relationship between members of clinical teams was characterised by deeply engrained hierarchies that shaped interactions and varied across specialties. For example, more newly qualified doctors were hesitant to change a consultant’s prescribing decision when later reviewing prescriptions. Significant variations between wards and in the relationships and opportunities for collaboration between doctors, pharmacists and microbiologists resulted in differences in antimicrobial stewardship practices. Where different specialities were actively working together, improved coordination and information exchange mitigated the uncertainties experienced by newly qualified doctors thereby improving the reliability of timely antimicrobial prescribing and review. CONCLUSIONS Attention to socio-organisational contexts, existing processes and workflows is crucial when designing and implementing technology-based antimicrobial stewardship interventions. Without such attention, interventions are unlikely to fulfil their goal of improving patient outcomes and combatting antimicrobial resistance. Interventions that help reduce prescriber/reviewer uncertainty and improve multidisciplinary collaboration surrounding initial antimicrobial prescribing and subsequent prescription review are most likely to be effective.