Antimicrobial stewardship programs (ASPs) that combine education, clinical guidelines, decision support, restrictions on antimicrobial use, and interventions to change antimicrobial therapy can reduce antibiotic resistance and improve patient outcomes. Reference Davey, Brown and Charani1 Continued development of effective implementation strategies to achieve sustainable improvements in antibiotic prescribing is needed. Reference Rzewuska, Charani and Clarkson2
Concerns about the consequences of inadequately treated infection often prompt initiation of unduly broad-spectrum and unneeded therapy antimicrobial therapy prior to the availability of microbiological or other data to substantiate infection diagnosis. Reference Schweitzer, van Werkhoven and Rodríguez3,Reference Avorn and Solomon4 Antibiotic timeouts, in which a reassessment of the continued need for continuation of initial antibiotic selection are undertaken when more diagnostic information is available, Reference Lee, Frenette, Jayaraman, Green and Pilote5,Reference Graber, Jones and Glassman6 are one CDC-recommended antibiotic stewardship intervention.
We used an antimicrobial Self-Stewardship Time Out Program (SSTOP) to evaluate the implementation of an “antibiotic timeout” intervention at Veterans’ Affairs medical centers. Reference Graber, Jones and Glassman6 Based on dual process theory Reference Jones, Butler and Graber7 , the SSTOP intervention requires providers to undertake a deliberative consideration of specific criteria before continuing therapy. Assisting the increased cognitive effort, SSTOP provides patient-specific decisional support by supplying clinical and microbiological information and links to educational guidelines. We assessed ASP physician and pharmacist experiences related to the SSTOP intervention across implementation sites.
Methods
SSTOP intervention
SSTOP introduced an automated templated note embedded in the electronic health record to prompt providers to review continued use of anti–methicillin-resistant S. aureus (MRSA) therapy (ie, vancomycin) and antipseudomonal β-lactam therapy 3 days after the initiation of antibiotics. SSTOP provided decisional support via an antibiotic dashboard that included a summary report of integrated clinical and laboratory data to assist in determining whether and how to adjust antibiotic therapy after three days of treatment. Facility-level quarterly reports on antibiotic de-escalation rates and usage of targeted antibiotics were provided to ASP physician and pharmacists. Reference Graber, Jones and Goetz8
Setting and participants
The ASP physicians and pharmacists were identified at each site and were invited to participate by e-mail. In-person site visits and individual semistructured interviews with ASP physicians and pharmacists (ie, ASP champions) were conducted at 8 Veterans’ Affairs medical center facilities from January 2019 to January 2021.
The study consent process and procedures were approved by the VA Central Institutional Review Board (CIRB no. 18-03) and by the Research and Development Committee at the Greater Los Angeles VA Health Care System.
Study design
We iteratively designed interview guides for preimplementation interviews (existing stewardship programs) and for postimplementation interviews (implementation process and challenges) (Appendix 1 online). Interviews were conducted via phone or video conference by the qualitative lead (J.B.), then they were audio-recorded and transcribed.
Data analysis
Transcripts were uploaded into MAXQDA, a qualitative data program (VERBI Software, Berlin, Germany). We performed thematic content analysis via consensus-based inductive and deductive coding (Appendix 2 online). Reference Pope9 Our analysis team included experienced qualitative researchers (C.C.G., J.J., and J.B.) with antimicrobial stewardship expertise.
Moreover, 13% of the transcripts were coded via group consensus (by C.C.G., J.J., and J.B.). This process involved all team members who coded transcripts prior to meetings where the final coding consensus was entered into MAXQDA during group discussion. The remaining 87% were coded by paired members of the analysis team (C.C.G. and J.J.). Discrepancies were resolved by the qualitative lead (J.B.) and/or the primary investigator (M.B.G.).
Results
In total, 13 preintervention interviews and 18 postintervention interviews were conducted with 7 ASP physician champions and 8 pharmacist champions. Two sites were unable to launch the note templates due to lack of resources; however, these sites utilized other SSTOP tools and participated in interviews. The SSTOP process and timeline are shown in Figure 1.
Figure 1. SSTOP process and timeline.
Preimplementation responses informed implementation by identifying perceived intervention barriers and facilitators. Pre- and postimplementation barriers and facilitators were similar; thus, we focused on the findings related to the SSTOP note template: feedback, challenges, and opportunities. Five primary themes emerged. Representative quotations are presented in Table 1.
Table 1. Quotations of Key Themes From Semistructured Interviews With Antimicrobial Stewardship Physicians and Pharmacists (ie, ASP Champions)
Note. ASP, Antimicrobial stewardship program; SSTOP, self-stewardship time-out program; ID, infectious disease; MICU, medical intensive care unit; IT, information technology; CAC, clinical applications coordinators.
Theme 1: SSTOP intervention was perceived as valuable and straightforward
Feedback from ASP champions indicates ways in which prescribers were critical of aspects of the note template, but they liked the note template process overall and deemed it to be straightforward. ASP champions perceived that many providers valued the note template, indicating it was helpful in both thinking about antibiotics prior to initiation and for identification of appropriate antibiotics.
The data feedback reports developed and distributed by the SSTOP team allowed sites to see the intervention in action. Comparative rankings motivated sites to view their reports and to compare their antimicrobial use. Several sites indicated their intent to continue using the SSTOP templates after study completion.
Theme 2. Strong existing stewardship and local culture facilitated SSTOP implementation
Facilitators of successful implementation included pre-existing strong stewardship support, participation of local champions (eg, infectious disease fellow), and implementation setting (eg, medicine service). Implementing the templates first in a setting led by a group of clinicians with low resistance helped ensure the success of the template.
Theme 3. Implementation barriers included staff turnover (eg, rotating residents), service level support (ie, surgery service), insufficient information technology (IT) support, and the need to remind providers to use the template
Many facilities involved in the SSTOP intervention were academic/teaching institutions, thus as each new set of residents rotated through their facility extra time/effort was required to ensure everyone was educated on the SSTOP templates and protocols. Installing the SSTOP templates required access and support of clinical applications coordinators (CACs) at each site. Some sites lacked steady access to this resource and therefore experienced challenges and delays in SSTOP implementation. The primary perceived barrier to SSTOP template utilization was lack or loss of a local champion to ensure that the template was completed.
Theme 4. Recommendations largely centered on enhancing note template usability and SSTOP feedback reports (eg, inclusion of patient/provider-level data)
Sites offered suggestions to improve note template usability, such as having an open text field embedded within the note and including provider-level antimicrobial use in feedback reports.
Theme 5. COVID-19 affected clinical practice and SSTOP implementation
All sites reported that high volumes of COVID-19 cases were a significant challenge. Specific pandemic-related barriers included reduction of stewardship activities such as regular MRSA screening practices, weekly stewardship rounds, and stewardship committee planning. Other barriers included changes in workflow due to staff working from home and staff being pulled into multiple directions (eg, writing COVID-19 policies), which complicated the implementation of SSTOP.
Discussion
We identified facilitators of and barriers to SSTOP implementation and related antibiotic stewardship activity as well as the impact of COVID-19 on these activities. Reference Jones, Butler and Graber7 The SSTOP note templates were considered generally valuable and straightforward (theme 1). Dual process theory is a meta-theory explaining one’s motivation, attention, and decision making. We used it to design the SSTOP tools to direct clinicians toward system 2 thinking, that is, rule-based, deliberative cognitive processing. Concurrently, we facilitated the development of more stewardship-friendly automatic system 1 thinking by supporting patterns of thought and behavior that will make appropriate stewardship more intuitive. Reference Jones, Butler and Graber7 As in our prior work, clinicians using SSTOP templates explicitly reported their cognition guided by templates. Reference Jones, Butler and Graber7
Implementation was facilitated by local champions and a strong culture of stewardship (theme 2). Conversely, barriers to implementation included the complex mission of facilities with roles in education and training and IT support issues such as coordination with CACs (theme 3). Many of these barriers may be difficult to overcome; however, themes 2 and 3 reflect the importance of a stewardship culture and social and tangible support for attending physicians and residents to participate in that culture. The importance of culture is further supported by theme 4, tailoring to the site-specific context.
Clinicians noted the motivating factor of comparison to other facilities, which may point to the important process of social comparison in this context that could be studied further and used to strengthen stewardship interventions. Reference Meeker, Linder and Fox10 Clinicians indicated the template facilitated earlier involvement with ID specialists, a potential enhancement to collaboration that may strengthen clinician–ASP relations.
The impact of the emergence of COVID-19 (theme 5) was far-reaching due to temporary cessations of stewardship activities, briefly, at-home work schedules, and demands for ID specialists to help develop COVID-19 policies and provide patient care.
This study had one limitation. We focused on ASP physician and pharmacist experiences in this study. Thus, the experiences of prescribing clinicians were not captured.
Our findings support the value of the SSTOP “time out” intervention as an effective antibiotic stewardship strategy, and we identified potential barriers to implementation. Plans for continued utilization of the note templates after the project concluded suggests that SSTOP may serve to achieve sustainable promotion of antibiotic use improvements.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2022.266
Acknowledgments
The views presented in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans’ Affairs or the US government.
Financial support
Financial support for this work was supported by the Quality Enhancement Research Initiative (QUERI award no. QUE 15-269).
Conflicts of interest
All authors report no conflicts of interest relevant to this article.
