AMS: Antimicrobial stewardship, ID: Infectious diseases
Junior AMS team members at both hospitals reported feeling well supported by the ID/microbiology consultants on the AMS team but there were differences in the composition of AMS teams with respect to consultant numbers (Table 4). “Most other hospitals it’s just one or two clinicians that are given that AMS portfolio to provide oversight. But here, we’ve got six [infectious diseases] consultants and they are all involved in AMS equivocally … Very important because it says a lot about, and it actually shows the united front to the rest of the hospital” (A8). At Hospital B not all ID consultants were involved in AMS. “Senior clinicians, both within and outside of infectious diseases, don’t see the value of AMS in the same way that the AMS clinicians do.” (B1).
Participants from both hospitals highlighted the importance of relationships between the AMS team and prescribers in enabling a successful AMS program. Perceptions of interdepartmental relationships varied between the hospitals (Table 4). At Hospital A, most participants reported having positive relationships with other departments including senior staff. “We’ve got good relationships with our departments , so being able to sit down and talk to teams regularly every week, so those surgical meetings that we do. So with those meetings that we have, it’s an opportunity to talk to people and I think at [Hospital A] there’s not many doors we can’t open and not many people we can’t talk to (A1)”. In contrast, some participants from Hospital B reported a general lack of support from senior staff in other departments. “I think the problem is that we could do a lot better if we had more engagement from senior clinicians and more resources to support that (B1). A key barrier to successful AMS activities at Hospital B reportedly stemmed from high levels of prescriber autonomy. “I think [Hospital B], in particular, by virtue of its highly sub specialised service delivery, is a place where there is exceptionally high prescriber autonomy, compared to other settings that I’ve worked (B2) and “I think they’re used to operating with a level of autonomy that they see can be compromised by an AMS program” (B1) .
Participants from both hospitals described challenges associated with prescribers not taking the advice of the AMS team and several participants reported this was particularly the case if AMS recommendations came from an advanced trainee or pharmacist, not an ID/microbiology consultant. For example, a consultant said“I guess the conflict that comes up sometimes might be an issue. So… usually when I ring someone, they listen to me. But sometimes the pharmacist comes to me saying that so and so’s not accepted this advice or so and so was being rude to me or something like that.” (A1)As indicated in Table 4 participants explained that it was challenging to provide advice to junior doctors, as they are often not the decision makers, and competing views between the senior doctors and AMS team placed junior doctors in a difficult position. “They’re [junior doctors] not making the decision. And at the end of the day, they want to please their team. So if I don’t give them what the team wants then they can feel really conflicted.” (B4)
Staff perceptions of the level of executive support being provided at an organisational level varied between the hospitals (Table 4). A participant from Hospital A said “You need support from the executives to be able to have influence, and to sponsor you or whatever you are implementing here in the AMS space. Like we have very good relations with the DMS, even with the surgeons” (A8).
In contrast, at Hospital B, the AMS team explained that there was an historical lack of executive support, and the result was a lack of governance and resources. “There needs to be more resource allocation for a site like [Hospital B]” (B1) and “I think there’s been some organisational dispute about where AMS sits as a programme in the hospital. So there has been some previous belief that AMS sits as an activity of infectious diseases and microbiology, rather than a hospital wide patient safety quality programme, which is how I view it. And that has led to the siloing of the activity as something that is only about infectious diseases and infectious diseases physicians.” (B2)
Both hospitals had an AMS policy in place (Table 4), however some participants at Hospital B perceived that their policy was not well enforced and promoted. Further, participants at Hospital B described a general lack of knowledge of AMS in the organisation, which contributed to poor AMS. “There’s no way of enforcing the policy about restrictions, so because the JMOs [junior medical officers] don’t know what’s restricted, they will prescribe anyway.” (B2)
At both hospitals, participants reported that the rotational nature of employment made the delivery of successful AMS programs difficult as prescribing habits vary between sites and individuals, and continuous education was required. “You can’t just be like, ‘Oh we’re done, AMS is done’ you have to constantly try an educate, and your staff are constantly turning around, coming from other hospitals … it is an ongoing challenge the fact that medicine is so migratory.” (A4).
At Hospital B some participants said a key barrier to successful AMS was the shortage of ward pharmacists, as pharmacists were seen as essential for identifying antimicrobial issues on the wards. Observations found this also impacted the AMS pharmacist, who was seen to support other pharmacy activities unrelated to AMS. “I think probably pharmacy is the biggest difference. I’d say this hospital seems to have less pharmacists on the wards… and pharmacists are usually key to identifying patients who have been on antibiotics for a long time, especially the ones that slipped through the cracks that are on green [unrestricted] antimicrobials” (B5)

Environment

The key theme identified relating to environment was the location of the AMS pharmacist. Through observations at Hospital A, the AMS pharmacist office was found to be co-located with ID/microbiology doctors, while at Hospital B the AMS pharmacist was located in the pharmacy department separate to the AMS doctors. Co-location of the pharmacist and doctors in the AMS team at Hospital A was observed to result in more frequent ad hoc discussions about AMS compared to Hospital B.