Background
Methods
Setting
Focus group discussions
Group 1 | One ID physician, two clinical microbiologists |
Group 2 | One cardiologist, one anaesthetist, one endocrinologist |
Group 3 | Four nurse unit managers, two hospital executives, one pharmacist |
Survey
Analysis
Results
Capability
Facilitators
Capability theme | Quotes |
---|---|
Varied antimicrobial knowledge and experience | “[prescribing doctors’] previous experience is very vital… So how often they do use antibiotics. Oncologists have a long history, they’ve got a lot more association with antibiotics than our surgical colleagues, some surgical colleagues still use very old-fashioned approaches to antibiotics and they tend not to keep as up to date as they perhaps should.” (Clinical Microbiologist 1, FG1) “I work in orthopaedics so we have a lot of resistance… even in the last 12 to 24 months we see a lot more coming through… resistance to multiple things and other infections occurring in patients’ wounds.” (NUM 2, FG3) “NUM2: I remember when we first got out first VRE patient on the orthopaedic unit, and it would have been probably 9 or 10 years ago…. [now] it’s kind of like everyone seems to have VRE NUM3: Everyone, I know! … it’s like the boy who cried wolf. It doesn’t shock you anymore.” (FG3) “I know that there are certain antibiotics that I personally shouldn’t prescribe, that are beyond my ability, so I have a low threshold to get an infectious diseases physician involved for anything out of my depth” (Cardiologist, FG2) |
Staff understand the theory of AMS | “My understanding of it is… it’s maybe multidisciplinary involving infectious disease physicians, nurses, and pharmacy sort of taking responsibility for appropriate guidelines and overseeing management of antibiotic use in the hospital. That’s my simple view of it.” (Anaesthetist, FG2) “I’m very much aware of the relevance of the problem currently with resistance and lots of different programs either within hospitals or nationally and even internationally to try and reduce said infections that are resistant to standard therapy. I think it’s something that they, I think that even though there is lots of talk about it, the significance is still underplayed.” (Pharmacist, FG3) |
Staff have limited knowledge of the hospital’s AMS program | “I think it probably, there would be fair to say there’s some confusion over an infectious diseases specialist seeing someone they’ve been referred to versus an infectious disease doctor doing an AMS round? Like looking at it from a stewardship point of view rather than, from a “I’ve been referred to see a complex patient”.” (Pharmacists, FG3) “You know who [the AMS team] are. But I guess like, you don’t know how they got there. If that makes sense. Were they referred? How do they know? I don’t know that. … Like how do they know to come to bed 54 when like, maybe there’s another 6 patients on antibiotics and you kind of think “oh why are they on vancomycin”.” (NUM 2, FG3) “Do we or don’t we? [laughs] I’m not even sure if we have [an AMS program]” (Cardiologist, FG 2) |
Proportion of respondents in 2018 % (n) | Proportion of respondents in 2013 % (n) | p-value | |
---|---|---|---|
Previously involved in care of patient with an antimicrobial resistant infection | 98 (95) | 84 (254) | < 0.0001 |
Have noticed an increased number of cases of antimicrobial resistant infections over the past 10 years | 73 (61) | 70 (174) | 0.56 |
Have heard of AMS | 90 (88) | 41 (121) | < 0.0001 |
The study hospital has an AMS program | 66.7 (66) | N/A | N/A |
Barriers
Motivation
Facilitators
Motivation theme | Quotes |
---|---|
Staff have mixed appreciation for AMS within their own practice | “Well I think there are still a lot of positives. I think it’s a really good program and it’s such an advance on what we had, which was just uncontrolled whatever anyone wanted. So, there’s a lot of positives to it.” (ID physician, FG1) “In the acute casualty area and so on, there may be a role and I don’t know, it depends on the level of training that people come through, ‘cause in our time there was a different training, there were fewer antibiotics, and maybe there is a need for that, but I don’t know.” (Endocrinologist, FG2) |
Lack of staff engagement with the AMS program | “The therapeutic guidelines … a lot of doctors even now, still don’t even know it exists. … they can find it if they can be bothered looking for it. But people are a bit lazy you know, they aren’t going to do it.” (Clinical microbiologist 2, FG1) “I presume there’s an intranet that [the guidelines] might be available on, but I don’t use it” (Anaesthetist, FG2) “Pharmacist: I don’t know whether people have even seen, but the AMS pharmacist and AMS team put together [a document] which recommends the standard prophylactic surgical stuff and that is on the intranet, and it is a guide that is supposed to be what [the hospital] supports as an organisation, but like you said, there’s no accountability to that document NUM2: I’ve never seen it NUM3: It’s definitely stuck up around theatre, but so is a lot of stuff.” (FG3) |
Staff want to receive more feedback and monitoring data | “I think there is an unaddressed issue that there’s no monitoring of the ID physicians’ management. So, they’re not actually answerable to each other. … So that’s regarded as success, is referral to an ID physician, and occasionally we’ve had cases where we’ve not agreed with what they’ve done and they’re also not subject to their own internal peer review. And I think that if we had that it would hugely strengthen the whole program” (Clinical microbiologist 1, FG1) “I’d like to be pulled up if I’m doing the wrong thing, but again no one’s ever done that to me.” (Cardiologist, FG2) “We all question as clinicians, oh that’s not right, but the patient still gets it. Cos there’s no … system or processes to say well actually no, that’s inappropriate. Like there’s no sort of big brother” (Executive 1, FG3) “And like you said the standard [antimicrobials] isn’t tracked so you can’t, aside from doing an actual audit, you can’t track the baseline stuff. It’s only the overuse of say Tazocin that we can see because we dispense it. Then we can track it and then the AMS pharmacist can go and say no.” (Pharmacist, FG3) “I think the general antibiotic dispensing is something that needs to be looked at. ‘Cause it’s only sort of the drugs that are like prescribed from dispensing are the ones they look at, whereas it’s the everyday, every joint, that are prescribed.” (NUM 2, FG3) |
Cost is a driving force of AMS and antimicrobial prescribing | “The other thing that is a factor, from a business model more than anything else, the drugs that are in that category start to become more expensive, so as a private organisation we absolutely care because the fund may or may not pay for it. And they also obviously result in people being in hospital for longer, so not only is the pharmacy cost increased but the actual physical cost of that patient becomes an issue for a department, separate to the whole resistance issue.” (Pharmacist, FG2) “with our patient when she was on the really expensive drugs, there was a lot of debate going on about it and who would pay, there was a lot of cross-questioning done to the infectious diseases doctor and the surgeon. That’s the only time I’ve really seen them question big time, like the medical director was involved, like one patient, ‘cause of the cost.” (NUM2, FG 3) “I think we’re slowly making headway but we’ve still got a way to go. But [improvements to AMS are] all expensive.” (Clinical microbiologist 1, FG1) “we’ve got health funds who are saying, if there’s a hospital acquired infection or a complication we’re not going to pay, because you should have done something about it.” (Executive 1, FG3) |
Barriers
Proportion of respondents in 2018 % (n) | Proportion of respondents in 2013 % (n) | p-value | |
---|---|---|---|
Antimicrobial resistance is a serious problem at the study hospital | 40 (39) | 45 (149) | 0.47 |
Antimicrobial resistance affects patients under my care | 44 (41) | 36 (119) | 0.25 |
There is antimicrobial prescribing across the study hospital that does not comply with current national antimicrobial guidelines | 34 (32) | 31 (101) | 0.47 |
Improving antimicrobial prescribing at the study hospital will help decrease antimicrobial resistance at the hospital | 62 (58) | 58 (192) | 0.45 |
Opportunity
Facilitators
Opportunity theme | Quotes |
---|---|
Everyone is responsible for appropriate prescribing and decision making | “I think all of the medical professionals involved in the patient’s care should be responsible [for appropriate antimicrobial prescribing]. … Everybody. The pharmacist, the surgeons, the ID physicians, the general physicians, the microbiologists, the whole lot and the hospital executive are responsible as well. … Everybody looking after patients need to know when to use antibiotics and which ones to use, for how long, and doses, everybody needs to know that.” (CM 1, FG 1) “And because I don’t admit patients myself, so although I’m responsible for in part of their care … I’m not the decision maker on which antibiotic and unfortunately I sometimes have to give what I don’t necessarily think what is necessary or correct.” (Anaesthetist, FG 2) |
Specialist staff supporting AMS are valued by clinicians | “Executive 2: we have an antimicrobial stewardship pharmacist… He works closely with the infectious diseases doctors and he tracks and monitors that and reports in a sort of governance way every month … Pharmacist: … the AMS pharmacist does a brilliant job and does have a huge role in intervening, monitoring, and then obviously reporting back” (FG 3) “We’re blessed with very good ID physician cover here, so that no matter what happens you usually get someone involved if you need to for specialist areas.” (Endocrinologist, FG 2) “Nursing staff are really valuable … they’re our allies… they’re a very vital key in that chain because they’re the ones who are on the wards… all the nursing staff see all the patients, so they can highlight something that’s going on.” (CM1, FG1) “Within our departments [nursing staff are] probably the best person on the ward that knows everything that’s going on. So, we can contribute.” (NUM2, FG 3) |
Clinicians value their autonomy | “No idea what the [hospital] guidelines are. But I’m not changing mine [prescribing practices]. I’m like that surgeon of yours. I haven’t had an infection in 19 years, mine are working.” (Cardiologist, FG 2) “I guess because we’re used to seeing it and the certain people who have a certain preference or a certain way of doing things, whether or not it matches guidelines or not, we sometimes forget to question it.” (Pharmacist, FG 3) “one of the surgeons has his own variation on [the surgical prophylaxis guidelines]. And I’m not the decision-maker for which antibiotic. So, if he wants that, as long as the patient’s not allergic to it or there is no other contraindication, so, a joint replacements, I know cephazolin is the drug we should be using but he adds ceftriaxone” (Anaesthetist, FG 2) “NUM3: A lot of [the doctors], they don’t read [the guidelines]. Even if they do, like we said, they’ve just got their practice. Because it is a culture, no one’s forcing them to do anything. They don’t actually have any rules NUM2: Yeah, they can do what they want. Basically.” (FG3) “Pharmacist: if the prescriber says that “well I’ve done that for 5 years and I’ve never had an infection so why wouldn’t I?” … It’s hard to argue that resistance thing ‘cause they know for them their patients have had a good outcome NUM 2: And it could be related to the antibiotic or it could just be related to their practice Pharmacist: Yeah, the antibiotic might not be necessary.” (FG3) |
Leadership is needed for AMS success | “You feel like it needs to come from you know, the medical director … we can question as much as we like but I don’t think … it will particularly change their practice.” (NUM 3, FG 3) “If the ICU consultant can’t event ask the surgeon a question, how can the nurses ask them a question?” (NUM 4, FG 3) “It’s kind of like, who governs the prescribing doctors here? … is it the exec or is like the medical director? And if you raise it what kind of response are you going to get? … but there’s not that much governance in the private sector, in my experience. I worked in the public system a really long time ago, but here they can just do what they want.” (NUM 2, FG 3) “I think that’s where sometimes when we talk about being a private organisation, that has lots of visiting doctors… you can’t give them rules but you can give them guides. Where sort of the passive audit approach is potentially helpful to say well, this is the guide and this is what you’re doing – can we talk about it? And that’s about as far as our senior people can actually… question those prescribers that you can’t question… They’re never going to change unless it happens from above, there’s no point the nurses calling or myself calling for that.” (Pharmacist, FG 3) “[The AMS program] has the support of the hospital and the executive because without that it would never be successful, and I think it is very successful here” (Clinical Microbiologist 1, FG 1) |
Barriers
Proportion of respondents in 2018 % (n) | Proportion of respondents in 2013 % (n) | p-value | |
---|---|---|---|
I would be willing to participate in any initiatives involving antimicrobial use at the study hospital | 68 (63) | 50 (167) | 0.003 |
The current antimicrobial prescribing policy at the study hospital should continue | 49 (45) | N/A | N/A |
The current antimicrobial prescribing restrictions and approval processes in place at the study hospital should continue | 50 (46) | N/A | N/A |
The AMS team at the study hospital should continue | 61 (63) | N/A | N/A |