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Background Antimicrobial resistance, the ability of microorganisms to survive antimicrobial drugs, is a public health emergency. Although electronic prescribing (ePrescribing)–based interventions designed to reduce unnecessary antimicrobial usage exist, these often do not integrate effectively with existing workflows. As a result, ePrescribing-based interventions may have limited impact in addressing antimicrobial resistance. Objective We sought to understand the existing ePrescribing-based antimicrobial stewardship (AMS) practices in an English hospital preceding the implementation of functionality designed to improve AMS. Methods We conducted 18 semistructured interviews with medical prescribers and pharmacists with varying levels of seniority exploring current AMS practices and investigating potential areas for improvement. Participants were recruited with the help of local gatekeepers. Topic guides sought to explore both formal and informal practices surrounding AMS, and challenges and opportunities for ePrescribing-based intervention. We coded audio-recorded and transcribed data with the help of the Technology, People, Organizations, and Macroenvironmental factors framework, allowing emerging themes to be added inductively. We used NVivo 12 (QSR International) to facilitate coding. Results Antimicrobial prescribing and review processes were characterized by competing priorities and uncertainty of prescribers and reviewers around prescribing decisions. For example, medical prescribers often had to face trade-offs between individual patient benefit and more diffuse population health benefits, and the rationale for prescribing decisions was not always clear. Prescribing involved a complex set of activities carried out by various health care practitioners who each only had a partial and temporary view of the whole process, and whose relationships were characterized by deeply engrained hierarchies that shaped interactions and varied across specialties. For example, newly qualified doctors and pharmacists were hesitant to change a consultant’s prescribing decision when reviewing prescriptions. Multidisciplinary communication, collaboration, and coordination promoted good AMS practices by reducing uncertainty. Conclusions Design of ePrescribing-based interventions to improve AMS needs to take into account the multitude of actors and organizational complexities involved in the prescribing and review processes. Interventions that help reduce prescriber or reviewer uncertainty and improve multidisciplinary collaboration surrounding initial antimicrobial prescribing and subsequent prescription review are most likely to be effective. Without such attention, interventions are unlikely to fulfill their goal of improving patient outcomes and combatting antimicrobial resistance.
Background Antimicrobial resistance, the ability of microorganisms to survive antimicrobial drugs, is a public health emergency. Although electronic prescribing (ePrescribing)–based interventions designed to reduce unnecessary antimicrobial usage exist, these often do not integrate effectively with existing workflows. As a result, ePrescribing-based interventions may have limited impact in addressing antimicrobial resistance. Objective We sought to understand the existing ePrescribing-based antimicrobial stewardship (AMS) practices in an English hospital preceding the implementation of functionality designed to improve AMS. Methods We conducted 18 semistructured interviews with medical prescribers and pharmacists with varying levels of seniority exploring current AMS practices and investigating potential areas for improvement. Participants were recruited with the help of local gatekeepers. Topic guides sought to explore both formal and informal practices surrounding AMS, and challenges and opportunities for ePrescribing-based intervention. We coded audio-recorded and transcribed data with the help of the Technology, People, Organizations, and Macroenvironmental factors framework, allowing emerging themes to be added inductively. We used NVivo 12 (QSR International) to facilitate coding. Results Antimicrobial prescribing and review processes were characterized by competing priorities and uncertainty of prescribers and reviewers around prescribing decisions. For example, medical prescribers often had to face trade-offs between individual patient benefit and more diffuse population health benefits, and the rationale for prescribing decisions was not always clear. Prescribing involved a complex set of activities carried out by various health care practitioners who each only had a partial and temporary view of the whole process, and whose relationships were characterized by deeply engrained hierarchies that shaped interactions and varied across specialties. For example, newly qualified doctors and pharmacists were hesitant to change a consultant’s prescribing decision when reviewing prescriptions. Multidisciplinary communication, collaboration, and coordination promoted good AMS practices by reducing uncertainty. Conclusions Design of ePrescribing-based interventions to improve AMS needs to take into account the multitude of actors and organizational complexities involved in the prescribing and review processes. Interventions that help reduce prescriber or reviewer uncertainty and improve multidisciplinary collaboration surrounding initial antimicrobial prescribing and subsequent prescription review are most likely to be effective. Without such attention, interventions are unlikely to fulfill their goal of improving patient outcomes and combatting antimicrobial resistance.
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.
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