Skip to main content Accessibility help
×
Home

Threatened efficiency not autonomy: Prescriber perceptions of an established pediatric antimicrobial stewardship program

  • Julia E. Szymczak (a1) (a2), Eimear Kitt (a3), Molly Hayes (a4), Kathleen Chiotos (a3) (a5), Susan E. Coffin (a3) (a5) (a6), Emily R. Schriver (a4), Ashley M. Patton (a4), Talene A. Metjian (a4) and Jeffrey S. Gerber (a1) (a3) (a5)...

Abstract

Background:

Implementing antimicrobial stewardship programs (ASPs) can be challenging due to prescriber resistance. Although barriers to implementing new ASPs have been identified, little is known about how prescribers perceive established programs. This information is critical to promoting the sustainability of ASPs.

Objective:

To identify how prescribers perceive an established pediatric inpatient ASP that primarily utilizes prior authorization.

Methods:

We conducted a cross-sectional survey administered from February through June 2017 in a large children’s hospital. The survey contained closed- and open-ended questions. Descriptive statistics and thematic content analysis approaches were used to analyze responses.

Results:

Of 394 prescribers invited, 160 (41%) responded. Prescribers had an overall favorable impression of the ASP, believing that it improves the quality of care (92.4% agree) and takes their judgment seriously (73.8%). The most common criticism of the ASP was that it threatened efficiency (26.0% agreed). In addition, 68.7% of respondents reported occasionally engaging in workarounds. Analysis of 133 free-text responses revealed that prescribers perceived that interacting with the ASP involved too many phone calls, caused communication breakdowns with the dispensing pharmacy, and led to gaps between approval and dispensing of antibiotics. Reasons given for workarounds included not wanting to change therapy that appears to be working, consultant disagreement with ASP recommendations, and the desire to do everything possible for patients.

Conclusions:

Prescribers had a generally favorable opinion of an established ASP but found aspects to be inefficient. They reported engaging in workarounds occasionally for social and emotional reasons. Established ASPs should elicit feedback from frontline prescribers to optimize program impact.

Copyright

Corresponding author

Author for correspondence: Julia E. Szymczak, Email: jszymcza@pennmedicine.upenn.edu

References

Hide All
1.Gerber, JS, Newland, JG, Coffin, SE, et al. Variability in antibiotic use at children’s hospitals. Pediatrics 2010;126:10671073.
2.Levy, ER, Swami, S, Dubois, SG, Wendt, R, Banerjee, R. Rates and appropriateness of antimicrobial prescribing at an academic children’s hospital, 2007–2010. Infect Control Hosp Epidemiol 2012;33:346353.
3.Newland, JG, Gerber, JS, Weissman, SJ, et al. Prevalence and characteristics of antimicrobial stewardship programs at freestanding children’s hospitals in the United States. Infect Control Hosp Epidemiol 2014;35:265271.
4.McPherson, C, Lee, BR, Terrill, C, et al. Characteristics of pediatric antimicrobial stewardship programs: current status of the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) collaborative. Antibiotics (Basel) 2018;7(1). pii: e4.
5.Pakyz, AL, Moczygemba, LR, VanderWielen, LM, Edmond, MB, Stevens, MP, Kuzel, AJ. Facilitators and barriers to implementing antimicrobial stewardship strategies: results from a qualitative study. Am J Infect Control 2014;42(10 Suppl):S257S263.
6.Kapadia, SN, Abramson, EL, Carter, EJ, et al. the expanding role of antimicrobial stewardship programs in hospitals in the United States: lessons learned from a multisite qualitative study. Joint Comm J Qual Patient Safety 2018;44:6874.
7.Katz, MJ, Gurses, AP, Tamma, PD, Cosgrove, SE, Miller, MA, Jump RLP. Implementing antimicrobial stewardship in long-term care settings: an integrative review using a human factors approach. Clin Infect Dis 2017;65:19431951.
8.James, R, Luu, S, Avent, M, Marshall, C, Thursky, K, Buising, K. A mixed methods study of the barriers and enablers in implementing antimicrobial stewardship programmes in Australian regional and rural hospitals. J Antimicrob Chemother 2015;70:26652670.
9.Perozziello, A, Routelous, C, Charani, E, et al. Experiences and perspectives of implementing antimicrobial stewardship in five French hospitals: a qualitative study. Int J Antimicrob Agent 2018;51:829835.
10.Cantey, JB, Vora, N, Sunkara, M. Prevalence, characteristics, and perception of nursery antibiotic stewardship coverage in the United States. J Pediatr Infect Dis Soc 2017;6(3):e30e35.
11.Broom, J, Broom, A, Plage, S, Adams, K, Post, JJ. Barriers to uptake of antimicrobial advice in a UK hospital: a qualitative study. J Hosp Infect 2016;93:418422.
12.Broom, J, Broom, A, Kirby, E, Gibson, AF, Post, JJ. How do hospital respiratory clinicians perceive antimicrobial stewardship (AMS)? A qualitative study highlighting barriers to AMS in respiratory medicine. J Hosp Infect 2017;96:316322.
13.Jeffs, L, Thampi, N, Maione, M, Steinberg, M, Morris, AM, Bell, CM. A qualitative analysis of implementation of antimicrobial stewardship at 3 academic hospitals: understanding the key influences on success. Can J Hosp Pharm 2015;68:395400.
14.Metjian, TA, Prasad, PA, Kogon, A, Coffin, SE, Zaoutis, TE. Evaluation of an antimicrobial stewardship program at a pediatric teaching hospital. Pediatr Infect Dis J 2008;27:106111.
15.Harris, PA, Taylor, R, Thielke, R, Payne, J, Gonzalez, N, Conde, JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377381.
16.Seemungal, IA, Bruno, CJ. Attitudes of housestaff toward a prior-authorization-based antibiotic stewardship program. Infect Control Hosp Epidemiol 2012;33:429431.
17.Bannan, A, Buono, E, McLaws, ML, Gottlieb, T. A survey of medical staff attitudes to an antibiotic approval and stewardship programme. Intern Med J 2009;39:662668.
18.Stach, LM, Hedican, EB, Herigon, JC, Jackson, MA, Newland, JG. Clinicians’ attitudes towards an antimicrobial stewardship program at a children’s hospital. J Pediatr Infect Dis Soc 2012;1:190197.
19.Steinberg, M, Dresser, LD, Daneman, N, et al. A national survey of critical care physicians’ knowledge, attitudes, and perceptions of antimicrobial stewardship programs. J Intensive Care Med 2014;31:6165.
20.StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP.
21.NVivo qualitative data analysis software. QSR International Pty Ltd. Version 12, 2016.
22.Salsgiver, E, Bernstein, D, Simon, MS, et al. Knowledge, attitudes, and practices regarding antimicrobial use and stewardship among prescribers at acute-care hospitals. Infect Control Hosp Epidemiol 2018;39:316322.
23.Flannery, DD, Swami, S, Chan, S, Eppes, S. Prescriber perceptions of a pediatric antimicrobial stewardship program. Clin Pediatr (Phila) 2014;53:747750.
24.Venugopalan, V, Trustman, N, Manning, N, Hashem, N, Berkowitz, L, Hidayat, L. Administration of a survey to evaluate the attitudes of house staff physicians towards antimicrobial resistance and the antimicrobial stewardship programme at a community teaching hospital. J Glob Antimicrob Resist 2016;4:2127.
25.Szymczak, JE, Newland, JG. The social determinants of antibiotic prescribing. In: Barlam, TF, Neuhauser, MM, Tamma, PD, Trivedi, KK, eds. Practical Implementation of an Antibiotic Stewardship Program. Cambridge, UK: Cambridge University Press; 2018. Pp. 4562.
26.Sikkens, JJ, van Agtmael, MA, Peters, EJG, et al. Behavioral approach to appropriate antimicrobial prescribing in hospitals: the Dutch Unique Method for Antimicrobial Stewardship (DUMAS) participatory intervention study. JAMA Intern Med 2017;177:11301138.
27.LaRosa, LA, Fishman, NO, Lautenbach, E, Koppel, RJ, Morales, KH, Linkin, DR. Evaluation of antimicrobial therapy orders circumventing an antimicrobial stewardship program: investigating the strategy of “stealth dosing.” Infect Control Hosp Epidemiol 2007;28:551556.
28.Calfee, DP, Brooks, J, Zirk, NM, Giannetta, ET, Scheld, WM, Farr, BM. A pseudo-outbreak of nosocomial infections associated with the introduction of an antibiotic management programme. J Hosp Infect 2003;55:2632.
29.Seemungal, IA, Bruno, CJ. Attitudes of housestaff toward a prior-authorization-based antibiotic stewardship program. Infect Control Hosp Epidemiol 2012;33:429431.
30.Cosgrove, SE, Seo, SK, Bolon, MK, et al. Evaluation of postprescription review and feedback as a method of promoting rational antimicrobial use: a multicenter intervention. Infect Control Hosp Epidemiol 2012;33:374380.
31.Dixon-Woods, M, Suokas, A, Pitchforth, E, Tarrant, C. An ethnographic study of classifying and accounting for risk at the sharp end of medical wards. Soc Sci Med 2009;69:362369.
32.Broom, A, Gibson, AF, Broom, J, Kirby, E, Yarwood, T, Post, JJ. Optimizing antibiotic usage in hospitals: a qualitative study of the perspectives of hospital managers. J Hosp Infect 2016;94:230235.
33.Szymczak, JE. Infections and interaction rituals in the organisation: clinician accounts of speaking up or remaining silent in the face of threats to patient safety. Sociol Health Illn 2016;38:325339.
34.Kronman, MP, Banerjee, R, Duchon, J, et al. Expanding existing antimicrobial stewardship programs in pediatrics: what comes next. J Pediatr Infect Dis Soc 2018;7:241248.
35.Livorsi, DJ, Heintz, B, Jacob, JT, Krein, SL, Morgan, DJ, Perencevich, EN. Audit and feedback processes among antimicrobial stewardship programs: a survey of the Society for Healthcare Epidemiology of America research network. Infect Control Hosp Epidemiol 2016;37:704706.
36.Lennox, L, Maher, L, Reed, J. Navigating the sustainability landscape: a systematic review of sustainability approaches in healthcare. Implement Sci 2018;13:27.
Type Description Title
PDF
Supplementary materials

Szymczak et al. supplementary material
Szymczak et al. supplementary material 1

 PDF (130 KB)
130 KB

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed