A Qualitative Analysis of Implementation of Antimicrobial Stewardship at 3 Academic Hospitals: Understanding the Key Influences on Success

A qualitative study of the factors impacting implementation of the national action plan to contain antimicrobial resistance (2016-2020) in medical institutions

OBJECTIVE

Antimicrobial resistance (AMR) has emerged as a serious global public health crisis. In response, 2016, 14 ministries in China, under the leadership of the National Health Commission, collaboratively issued the National Action Plan (NAP) to Contain Antibacterial Resistance (2016-2020). The NAP outlines strategies for medical institutions to adopt stewardship and implement AMR control. The purpose of this study was to comprehend stakeholders' perceptions of the NAP and explore the factors that influence its implementation in medical institutions.

METHODS

Semi-structured interviews were conducted with practitioners from medical institution in March and April 2021. Interviews were audio-recorded, transcribed and analyzed using thematic analysis via the framework approach.

RESULTS

Twenty practitioners, representing diverse roles (4 administrators, 7 clinicians, 3 microbiologists, 3 pharmacists, 3 nosocomial infection management personnel) from seven institutions, participated in the study. Substantial efforts have been undertaken to regulate the rational use of antibiotics and enhance the management of hospital infections. Participants demonstrated awareness and concern regarding antimicrobial resistance, with widespread support expressed for the NAP. Among all professions, there were varying opinions on whether they felt restricted in their daily work. The tertiary hospitals have established multidisciplinary cooperation mechanisms. Six main themes were identified as both barriers and facilitators to the implementation of the NAP in the medical institutions: individual factors, leadership, multidisciplinary collaboration, patient factors, training and culture. The capacity for administrative attention is constrained or limited, poor enforcement of guidelines, insufficient specialist staff and the liability pressure on clinicians were perceived barriers. To containing AMR in medical institutions, management of hospital infections, the public's knowledge of antibiotics' usage, routine education and multidisciplinary support would be facilitators.

CONCLUSIONS

Practitioners from medical institutions were highly supportive for the NAP. Consideration of practitioners' perceived barriers and facilitators might enhance implementation of the NAP to contain antimicrobial resistance.

Opioid stewardship program implementation in rural and critical access hospitals in Arizona

OBJECTIVE

The objective of this study is to examine rural hospitals' status in implementing opioid stewardship program (OSP) elements and assess differences in implementation in emergency department (ED) and acute inpatient departments.

DESIGN

Health administrator survey to identify the number and type of OSP elements that each hospital has implemented.

SETTING

Arizona critical access hospitals (CAHs).

PARTICIPANTS

ED and acute inpatient department heads at 17 Arizona CAHs (total of 34 assessments).

MAIN OUTCOME MEASURES

Implementation of 11 OSP elements, by department (ED vs inpatient) and prevention orientation (primary vs tertiary).

RESULTS

The percentage of implemented elements ranged from 35 to 94 percent in EDs and 24 to 88 percent in acute care departments. Reviewing the prescription drug monitoring program database and offering alternatives to opioids were the most frequently implemented. Assessing opioid use disorder (OUD) and prescribing naloxone were among the least. The number of implemented elements tended to be uniform across departments. We found that CAHs implemented, on average, 67 percent of elements that prevent unnecessary opioid use and 54 percent of elements that treat OUD.

CONCLUSIONS

Some OSP elements were in place in nearly every Arizona CAH, while others were present in only a quarter or a third of hospitals. To improve, more attention is needed to define and standardize OSPs. Equal priority should be given to preventing unnecessary opioid initiation and treating opioid misuse or OUD, as well as quality control strategies that provide an opportunity for continuous improvement.

Perspectives on Antibiotic Stewardship Programs among Health Care Providers at Two University Hospitals in Egypt

The perspectives of healthcare professionals on antibiotic stewardship programs (ASPs) should be explored. Any antibiotic stewardship strategy must be individualized based on patient needs, prescription habits, and local resources. The current study aimed to explore the perspectives of healthcare providers on antibiotics stewardship and their awareness of these perspectives. Furthermore, potential barriers to the application of ASPs should be identified and addressed. This exploratory cross-sectional study utilized a qualitative method to evaluate critical care physicians, pediatricians, and clinical pharmacists (n = 43). The mean age of the physicians was 32 ± 1.5 years. Among them, approximately two-thirds (66%) were women. A thematic content analysis was performed to examine the responses of the participants and to prioritize the recommendations for and barriers to the implementation of ASPs from the perspective of healthcare providers. According to the interviewees, the primary obstacles include lack of time in implementation and monitoring and lack of awareness of the need for ASPs. All respondents recommended the implementation of supervised and continuous trainings. In conclusion, the abovementioned barriers must be adequately addressed to facilitate the implementation of ASPs.

Pharmacists' Perspectives of Their Roles in Antimicrobial Stewardship: A Qualitative Study among Hospital Pharmacists in Malaysia

Antimicrobial resistance has negatively impacted patient outcomes and increased healthcare costs. Antimicrobial stewardship (AMS) includes all activities and policies to promote the judicious use of antimicrobials. Pharmacists are key players in AMS models worldwide. However, there is a research gap in the role of pharmacists as antimicrobial stewards in Malaysia. This study aimed to explore hospital pharmacists' perspectives on their roles in, and barriers and facilitators to the implementation of AMS strategies. Individual, semi-structured interviews were conducted with 16 hospital pharmacists involved in AMS activities from 13 public hospitals in Kuala Lumpur and Selangor. Audio-taped interviews were transcribed verbatim and imported into NVivo software version 10.0 (QSR). A thematic analysis method was used to identify themes from the qualitative data until theme saturation was reached. Respondents perceived pharmacists as having important roles in the implementation of AMS strategies, in view of the multiple tasks they were entrusted with. They described their functions as antimicrobial advisors, antimicrobial guardians and liaison personnel. The lack of resources in terms of training, manpower and facilities, as well as attitudinal challenges, were some barriers identified by the respondents. Administrative support, commitment and perseverance were found to be facilitators to the role of pharmacists in AMS. In conclusion, pharmacists in public hospitals play important roles in AMS teams. This study has provided insights into the support that AMS pharmacists in public hospitals require to overcome the barriers they face and to enhance their roles in the implementation of AMS strategies.

A Retrospective, Longitudinal External Study of the robustness and reproducibility of National Antibacterial Prescribing Survey Data

BACKGROUND

Point prevalence surveys are used internationally to audit antibacterial use as well as the impact of interventions on improving prescribing and resistance rates. The annual National Antibacterial Prescribing Survey provides data on the appropriateness of antibacterial agent prescribing in Australian hospitals. Assessing the survey's robustness and result reproducibility is essential to its role in improving antibacterial prescribing practice.

AIM

To evaluate the reproducibility of internal assessments of antibacterial agent prescribing of both guideline compliance and appropriateness from a Western Australian hospital.

METHOD

Census data of 1051 prescriptions from 2013 to 2017 surveys were independently assessed for compliance based on Australian Therapeutic Guidelines - Antibiotics, and appropriateness, based on agent selection, therapy duration and microbiological test results. Concordance of these findings with internal hospital assessments was analysed.

RESULTS

This external study did not reproduce internal hospital audit results for compliance with guideline parameters. Non-compliant prescribing rate was significantly (p < 0.001) higher externally at 50.7% (533/1051) than internal assessment at 34.9% (367/1051). External analysis also found a significantly smaller proportion of prescriptions to be appropriate (551/1051, 52.4%) compared to internal analysis (745/1051, 70.9%) p < 0.001. Cohen's Kappa analysis found a moderate agreement for compliance (0.49) and appropriateness (0.50) between the external and internal evaluations.

CONCLUSION

The lack of adequate reproducibility of compliance and appropriateness assessments may limit the generalisability of the audit's results. Validating point prevalence surveys that assess antibacterial agent prescribing can increase confidence and improve reproducibility of their findings; as they provide important data for antimicrobial stewardship programs.

Clinicians' experience of providing care: a rapid review

BACKGROUND

Health care services internationally are refocussing care delivery towards patient centred, integrated care that utilises effective, efficient and innovative models of care to optimise patient outcomes and system sustainability. Whilst significant efforts have been made to examine and enhance patient experience, to date little has progressed in relation to provider experience. This review aims to explore this knowledge gap by capturing evidence of clinician experience, and how this experience is defined and measured in the context of health system change and innovation.

METHODS

A rapid review of published and grey literature review was conducted utilising a rapid evidence assessment methodology. Seventy-nine studies retrieved from the literature were included in the review. Fourteen articles were identified from the grey literature search and one article obtained via hand searching. In total, 94 articles were included in the review. This study was commissioned by and co-designed with the New South Wales, Ministry of Health.

RESULTS

Clinician experience of delivering health care is inconsistently defined in the literature, with identified articles lacking clarity regarding distinctions between experience, engagement and work-related outcomes such as job satisfaction. Clinician experience was commonly explored using qualitative research that focused on experiences of discrete health care activities or events in which a change was occurring. Such research enabled exploration of complex experiences. In these contexts, clinician experience was captured in terms of self-reported information that clinicians provided about the health care activity or event, their perceptions of its value, the lived impacts they experienced, and the specific behaviours they displayed in relation to the activity or event. Moreover, clinician's experience has been identified to have a paucity of measurement tools.

CONCLUSION

Literature to date has not examined clinician experience in a holistic sense. In order to achieve the goals identified in relation to value-based care, further work is needed to conceptualise clinician experience and understand the nature of measurement tools required to assess this. In health system application, a broader 'clinician pulse' style assessment may be valuable to understand the experience of clinical work on a continuum rather than in the context of episodes of change/care.

Perspectives of Physician and Pharmacist Stewards on Successful Antibiotic Stewardship Program Implementation: A Qualitative Study

Background

Antibiotic stewardship programs (ASPs) are required at every hospital regardless of size. We conducted a qualitative study across different hospital settings to examine perspectives of physician and pharmacist stewards about the dynamics within their team and contextual factors that facilitate the success of their programs.

Methods

Semistructured interviews were conducted in March-November 2018 with 46 ASP stewards, 30 pharmacists, and 16 physicians, from 39 hospitals within 2 large hospital systems.

Results

We identified 5 major themes: antibiotic stewards were enthusiastic about their role, committed to the goals of stewardship for their patients and as a public-health imperative, and energized by successful interventions; responsibilities of pharmacist and physician stewards are markedly different, and pharmacy stewards performed the majority of the day-to-day stewardship work; collaborative teamwork is important to improving care, the pharmacists and physicians supported each other, and pharmacists believed that having a strong physician leader was essential; provider engagement strategies are a critical component of stewardship, and recommendations must be communicated in a collegial manner that did not judge the provider competence, preferably through face-to-face interactions; and hospital leadership support for ASP goals and for protected time for ASP activities is critical for success.

Conclusions

The physician-pharmacist team is essential for ASPs; most have pharmacists leading and performing day-to-day activities with physician support. Collaborative, persuasive approaches for ASP interventions were the norm. Stewards were careful not to criticize or judge inappropriate antibiotic prescribing. Further research should examine whether this persuasive approach undercuts provider appreciation of stewardship as a public health mandate.

Finding "What's Wrong With Us": Antibiotic Prescribing Practice Among Physicians in the United States

Antibiotic stewardship-or the responsible use of antibiotics-has been touted as a solution to the problem of antibiotic resistance. Antibiotic stewardship in medical institutions attempts to change the antibiotic prescribing "behaviors" and "habits" of physicians. Interventions abound targeting "problem prescribers," or those physicians whose practice is out of line with physician peers. Thus, the locus of decision-making in antibiotic prescribing is thought to be the found with the individual physician. Based on 18 months of participant observation and in-depth interviewing of antibiotic-prescribing physicians at two medical institutions in the United States, this paper will question notions of antibiotic stewardship that center on individual "behaviors" and "habits." Many physicians have taken to heart a reductionist approach in studies of antibiotic prescribing, including several physicians I encountered during research who enthusiastically located the benefit of my research in the ability to identify "what's wrong with us." In this paper, I use two representative ethnographic case studies to argue that antibiotic stewardship interventions aimed at identifying and correcting "bad" physician practice limit the possibilities of understanding the social dynamics of the institution. Through an analysis of everyday encounters in the hospital setting, I show how decision-making in antibiotic prescribing can more productively be located between and among institutions, physicians, patient charts, and other hospital-based staff members (e.g., pharmacists, nurses). By demonstrating that antibiotic prescribing is a collective practice occurring through engagement with social and material surroundings, I argue that we can better account for the weighted ways in which social action and relations unfold over time.

Antimicrobial Stewardship in Veterinary Medicine

While antimicrobial resistance is already a public health crisis in human medicine, therapeutic failure in veterinary medicine due to antimicrobial resistance remains relatively uncommon. However, there are many pathways by which antimicrobial resistance determinants can travel between animals and humans: by close contact, through the food chain, or indirectly via the environment. Antimicrobial stewardship describes measures that can help mitigate the public health crisis and preserve the effectiveness of available antimicrobial agents. Antimicrobial stewardship programs have been principally developed, implemented, and studied in human hospitals but are beginning to be adapted for other applications in human medicine. Key learning from the experiences of antimicrobial stewardship programs in human medicine are summarized in this article-guiding the development of a stewardship framework suitable for adaptation and use in both companion animal and livestock practice. The antimicrobial stewardship program for veterinary use integrates infection prevention and control together with approaches emphasizing avoidance of antimicrobial agents. The 5R framework of continuous improvement that is described recognizes the importance of executive support; highly motivated organizations and teams (responsibility); the need to review the starting position, set objectives, and determine means of measuring progress and success; and a critical focus on reducing, replacing, and refining the use of antimicrobial agents. Significant issues that are currently the focus of intensive research include improved detection and diagnosis of infections, refined dosing regimens that are simultaneously effective while not selecting resistance, searches for alternatives to antimicrobial agents, and development of improved vaccines to enhance immunity and reduce disease.

Impact of Empowering Leadership on Antimicrobial Stewardship: A Single Center Study in a Neonatal and Pediatric Intensive Care Unit and a Literature Review

Background: Antimicrobial stewardship (AMS) is an important strategy of quality improvement for every hospital. Leadership is an important factor for implementation of quality improvement and AMS programs. Recent publications show successful AMS programs in children's hospitals, but successful implementation is often difficult to achieve and literature of AMS in neonatal and pediatric intensive care units (NICU/PICU) is scarce. Lack of resources and prescriber opposition are reported barriers. A leadership style focusing on empowering frontline staff to take responsibility is one approach to implement changes in health care institutions. Aim: Literature review regarding empowering leadership and AMS in health care and assessment of the impact of such a leadership style on AMS in a NICU/PICU over 3 years. Methods: Assessment of the impact of a leadership change September 1, 2015 from control-driven to an empowering leadership style on antibiotic use and hospital acquired infections. Prospective analysis and annual comparison of antibiotic use, rate of suspected and confirmed ventilator-associated pneumonia (VAP) and central-line associated blood stream infection (CLABSI) including antibiotic use overall, antibiotic therapy for culture-negative and culture-proven infections including correct initial choice and streamlining of antibiotics in the NICU/PICU of the Children's Hospital of Lucerne between January 1, 2015 and December 31, 2017. Results: Five articles were included in the literature review. All five studies concluded that an empowering leadership style may lead to a higher engagement of physicians. Three out of five studies reported improved AMS as reduced rate in hospital-acquired infections and improved prevention of MRSA infections. From 2015 to 2017, antibiotic days overall and antibiotic days for culture-negative situations (suspected infections and prophylaxis) per 1000 patient days declined significantly from 474.1 to 403.9 and from 418.2 to 309.4 days, respectively. Similar, the use of meropenem and vancomycin declined significantly. Over the 3 years, suspected and proven VAP- and CLABSI-episodes decreased with no confirmed episodes in 2017. Conclusion: An empowering leadership style which focuses on enabling frontline physicians to take direct responsibilities for their patients may be a successful strategy of antimicrobial stewardship allowing to overcome reported barriers of AMS implementation.