Nearly 50% of antibiotic use is unnecessary or inappropriate (Lee, 2014). Unnecessary use of antibiotics can lead to undesirable consequences such as Clostridium difficile infection (CDI) and antimicrobial resistance (AMR). Optimising antibiotic management, commonly referred to as antimicrobial stewardship (Allerberger, 2009), is one of the strategies adopted to reduce unnecessary and inappropriate use (Aryee, 2003). The Scottish Antimicrobial Prescribing Group (SAPG) developed four indicators which they expect healthcare staff to comply with. These measures include antibiotic choice compliant with guidelines, an indication for antibiotics documented, a duration or a review date documented and the patients receive all the doses. This study uses a systems approach to identify the barriers and facilitators to safe and effective use of antimicrobials using a definition of safe and effective use as whether staff are compliant with the SAPG indicators.
Human factors is the study of systems of which people are at the centre. The Systems Engineering Initiative for Patient Safety (SEIPS) framework is a human factors framework (Holden et al, 2013) which illustrates all relevant components in a sociotechnical work system and how they interact to determine processes and shape outcomes. This framework has been used in previous healthcare research to analyse medication errors (Frith et al, 2013) and identify barriers and facilitators to infection control measures (Yanke et al, 2015). The SEIPS model was used in the design of the methods, data analysis and results to identify the systems barriers and facilitators to safe and effective management of antimicrobials in continuing care wards.
The research questions included;
1. What are the challenges and facilitators to management of antimicrobials as identified by subject matter experts?
2. How do different groups of health professionals experience antimicrobial management and coping strategies?
3. What are the main challenges that occur in the study wards?
A multi-method approach was used consisting of a focus group, a point prevalence survey, semi-structured interviews and an instant reporting system. The focus group included members of a national group who focus on antimicrobials, the Association of Scottish Antimicrobial Pharmacists (ASAP) group. The other methods were carried out in two wards within Ninewells Hospital, a medical ward and a surgical ward.
The focus group with ASAP was carried out over 30 minutes to identify the systems barriers and facilitators to antimicrobial management as perceived by subject matter experts (SME). Participant information forms were emailed to all members prior to the focus group to allow time for members to decide whether to participate. Another copy of the participant information form and consent forms were given out at the beginning of the focus group. The focus group was audio-recorded and transcribed verbatim by the researcher.
A point prevalence survey (PPS) was carried out over four points in time in each of the two study wards using a data collection form developed by the researcher. Data were collected on all patients who were prescribed antibiotics at the time of data collection. These data were used to identify compliance with the four SAPG indicators.
Semi-structured interviews were carried out with staff of different roles and levels within the study ward to identify barriers and facilitators as described by staff working in the system. Staff were recruited by email or on the ward by the researcher. All staff were given a participant information form and signed a consent form. All interviews were audio-recorded and transcribed verbatim by the researcher.
An instant reporting system was implemented in the two study wards. Boxes including project information and the researcher’s email address were put on both wards with instant reporting forms developed by the researcher.
The data were analysed using the programme NVivo (version 11 for Windows). Transcripts for the focus group and interviews were uploaded to the programme. Deductive thematic analysis was used to identify relevant elements of the SEIPS model work system. Inductive thematic analysis was used to identify any additional themes not included in the deductive analysis.
Ethical approval was given by the University of Dundee Research Ethics Committee (UREC).
Two main processes were identified in the focus group; collecting national indicator data and compliance with the indicators themselves. Barriers to collecting data included; motivation, design of the data collection app, not checking whether choice is compliant with guidelines, the frequency of staff changeover, training and the time it takes to complete the task. Facilitators to collecting the data included nursing staff permanently on the ward collecting the data, training and organisational culture when a consultant is driving the audit. Many barriers were identified to compliance with the indicators including competing priorities on the ward, knowledge, decision making, patient characteristics, commitment, available space on prescribing tools to document required information, organisational culture, workload and not reviewing at appropriate times. Facilitators to compliance with the indicators include knowledge, motivation, having a ward champion, an antibiotic section on the kardex, organisational culture, feedback, incentive systems, training and weekly meeting to discuss performance.
Non-compliance with the indicators was identified on both study wards. Indication was documented more reliably than the duration or review date. The medical ward had 100% compliance with documenting indication in three of the four weeks. Compliance with documenting a duration or review data varied from 11-100%. The surgical ward had 100% compliance with documenting indication in two of the four weeks. Compliance with documenting a duration or review date varied from 17-50%. Both wards had a small number of missed doses. A reason for all missed doses was recorded by the nursing staff.
Participants identified different configurations of the antimicrobial management work system. Participants on the medical ward identified elements in relation to the persons, tools and technology, organisation, internal environment, tasks and external environment components. Participants on the surgical ward identified elements in relation to the persons, tools and technology, organisation, internal environment and task components but not the external environment component. Many barriers were identified including the consultants’ priorities and perception of importance of management on the surgical ward and the confidence of the foundation year (FY) doctors on the medical ward. Facilitators included the pharmacists on the surgical ward and the consultants on the medical ward.
There were only two challenges reported in the instant reporting system. Both were reported in the medical ward and both identified a lack of patient samples being sent to identify causative organisms when patients are in the admitting wards prior to the patients receiving antibiotics.
All components of the SEIPS model work system were included as involved in antimicrobial management. Using the SEIPS model allowed the researcher to identify the elements involved under each component and therefore assist with the design of multi-level interventions.
The barriers and facilitators identified during the focus group were in line with what was found in the interviews on the study ward. The difference is that when barriers or facilitators are discussed, many aspects could be described as both depending on context. For example, the pharmacist on the surgical ward was viewed as a facilitator, however, as they were the person to review antibiotics, when they were not on the ward other staff do not think to review them themselves. The pharmacist is therefore also a barrier in this respect. Additionally, organizational culture was a facilitator on the medical ward, as the consultants perceived management as important, but as a barrier on the surgical ward. By interviewing the subject matter experts (SME) during the focus group a wider view of the system across different areas could be identified but by interviewing the staff on the wards which elements acted as barriers or facilitators to that specific system could be determined.
There is currently little literature on barriers and facilitators to antimicrobial management despite appropriate management being one of the strategies to reduce the rate of antimicrobial resistance (AMR). This study adds to current knowledge by adding to what is known about barriers and facilitators and by highlighting that these will differ depending on the area in which people work. This study compared one medical and one surgical ward, however, differences may also exist between medical wards and between surgical wards.
There were many limitations to this study. A limitation included gaps in the data as the participants did not include consultants from the surgical ward despite being described by the participants as having an important role in management on the ward. Another limitation included the small number of instant reports and data on only three of four indicators presented in the PPS.
Neither study ward was compliant with all four indicators developed by SAPG. As this was used as the definition of safe and effective management within this study both wards had aspects that could be improved upon to improve the safety and effectiveness of antimicrobial management.
The antimicrobial management system is complex and includes multiple barriers and facilitators within the work system. These barriers and facilitators differed between both wards with some common themes. Role model behaviour, knowledge, priorities, teamwork, difficulty of tasks, time, ease of use of tools, access to online materials, usability of guidelines and availability of support were all identified as influencing antimicrobial management. It was also identified that whether these themes acted as barriers or facilitators depended on the clinical area. As there are multiple barriers and facilitators in each area it is important that interventions to improve antimicrobial management are multifaceted and specific to the area.
Further work should identify what is meant by “antimicrobial management”, what is the most important aspects of appropriate management and whether this should be tailored to the differences in systems across different areas.
|Date of Award||2017|
|Supervisor||Peter Davey (Supervisor) & Evie Fioratou (Supervisor)|