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

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.

Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department

“…In addition, similar to a prior study of hospitalized medical patients with ASB started on antibiotics by any clinician, we found that patients with ASB who were treated with antibiotics had a longer duration of hospitalization [ 2 ]. Because ASB is common, antibiotics are harmful, and diagnosis momentum makes discontinuing antibiotics challenging [ 37 ], stewardship interventions must target both the initial testing by EM clinicians and the continuation of antibiotics by inpatient clinicians.…”

<p>Pediatric Antimicrobial Stewardship Programs: Current Perspectives</p>

“…21,22,25 Implementation, maintenance, and growth of successful ASPs require a willingness to understand and have a flexible mindset about certain cultural norms, including those specific to individual hospitals, medical specialties, and to the hierarchical culture of medicine. 27,28 ASPs must concurrently work to promote behavioral modifications leading to improved antimicrobial utilizationand such efforts often require advocating for cultural change. Staff nurses report that some of the greatest barriers to their involvement in AS stem from unit-specific and hierarchical cultural expectations, including inconsistent nursing inclusion during the rounding process and deference to physicians and pharmacists regarding antibiotic management plans.…”

Examining primary care physician rationale for not following geriatric choosing wisely recommendations

“…Again, clinicians did not seem to recognize the harms associated with overtreatment citing the fact that if the patient was doing fine, they would not make adjustments, specifically because doing this would take time. This compares to literature citing concerns with inefficiency and inertia of previous practice [ 18 , 19 ].…”

“…Several studies have shown that ordering urine testing in asymptomatic women leads to unnecessary antibiotics [ 7 , 16 ] and that PSA screening in asymptomatic older men can lead to negative consequences such as harms from biopsies, surgery or radiation treatment, as well as psychological harm [ 17 ]. There is also literature to support that clinicians want to feel like they have done everything for their patients [ 18 ]. Participating physicians seemed to under-weigh the risks of performing the action when discussing how they approach patient care, though acknowledged these risks when specifically asked general knowledge questions.…”