Discussion
This in-depth qualitative study explored AMS work processes at two
metropolitan hospitals within a single health district and uncovered
significant differences across sites. Both hospitals conducted the same
AMS tasks, however had different approaches to post-prescription review,
interdepartmental AMS meetings, and tools used to support AMS,
particularly Live AMS. Participants from both hospitals emphasised the
importance of good working relationships between the AMS team and
hospital prescribers, but also identified challenges associated with
providing advice to prescribers. Organisational and cultural differences
were found, with staff at Hospital B reporting they received inadequate
support from hospital executive and senior staff, had increased
prescriber autonomy, and required more resources. Interestingly, no
themes were identified that related to the people element of SEIPS,
which captures a person’s internal characteristics. Instead, results
revealed that AMS work processes were dictated by factors external to
people, including the interactions between people and other elements of
the work system.
The approach taken for post-prescription review was a fundamental
difference between the hospitals and impacted other elements of the AMS
work system. Hospital A focused on all antimicrobials for their
post-prescription reviews, and Hospital B focused predominantly on
restricted antimicrobials. The availability of resources likely
contributed to this difference, with participants at Hospital B
reporting a lack of resources, and a shortage of ward pharmacists which
impacted the AMS pharmacist’s time. Live AMS use may have also
contributed to this difference, with participants at Hospital A observed
using the tool comprehensively for post-prescription review, staff
confirming that Live AMS was a key enabler of post-prescription review.
As the current study did not evaluate patient outcomes, we are unable to
determine the impact of each hospital’s approach to post-prescription
review, however, participants held the view that increased review of
antimicrobials would improve the scope of AMS and consequently patient
outcomes. This is supported by previous research which has shown
clinical pharmacist staffing levels, and inclusion of pharmacists in
medical rounds, are associated with improved patient
mortality.15 Further, participants at Hospital B
identified issues and risks with unrestricted antimicrobials, including
inappropriate continuation of prescriptions, and the need for a clinical
decision support system to support antimicrobial prescribing,
highlighting the value of having oversight of restricted and
unrestricted antimicrobials.
Cultural differences emerged between the two hospitals, particularly
within the AMS teams and their interactions with other departments. The
notion of organisational culture includes the beliefs, values, norms,
and behavioural patterns that define social relationships and are
evident in an organisation’s structures and operational
procedures.16,17 Hospital A’s AMS team felt
well-supported, with involvement from all ID doctors and the AMS
pharmacist working closely with the team. Hospital B participants lacked
senior staff support, governance, and resources needed to enhance
program outcomes. High levels of prescriber autonomy in Hospital B were
also perceived to negatively impact the effectiveness of the AMS team.
This prescribing culture could be attributed to the differences in
interdepartmental meetings, with an increased number of meetings
observed to occur at Hospital A, particularly with surgical specialties.
The focus on surgical specialties is especially important due to their
work processes in the hospital. A London teaching hospital study found
distinct antimicrobial decision-making approaches between medical and
surgical specialties.18 Surgical teams, dealing with
an imbalanced skill mix on the ward and delayed senior input, frequently
deferred de-escalation choices. Limited time and communication
opportunities further hindered multidisciplinary
teamwork.18 Therefore having dedicated time for AMS in
surgical specialties is especially critical.
The interdepartmental AMS meetings were also reported to be a source of
education and helped build rapport between departments. Interestingly,
our results indicated differences in perceptions of interdepartmental
relationships, with the hospital that had increased interdepartmental
AMS meetings reporting they had good relationships with other
departments. This is most likely attributable to the increased in-person
interactions, as described in previous work exploring AMS team
perceptions and activities occurring remotely in the context of COVID-19
restrictions.19 The effectiveness of in-person
collaborative feedback in improving outcomes for AMS programs is well
established in the literature.20-22.
Overall, the Live AMS dashboard was used more at Hospital A than B. Our
results identified various factors which could account for this, such as
advocacy from senior consultants, and the involvement of these
consultants in the development of the system. Further, the lack of
interoperability of the ICU eMM system at Hospital B meant that Live AMS
could not be utilised for this department. Participants at Hospital B
perceived Live AMS to not be useful for their tasks and were less aware
of the features of the system. Interestingly, AMS work appeared to be
completed successfully in the absence of Live AMS, perhaps indicating
that the system was in fact not essential for all tasks. It is well
recognised that AMS programs need to tailor strategies to their
institution23, therefore it follows that the digital
interventions used to facilitate these AMS programs should also be
tailored. A prior understanding of workflows and user needs during
implementation can also determine the expected usefulness and
utilisation of a digital tool.24
Limitations
A strength of this study was its in-depth exploration of the work of AMS
teams. However, the sample size was limited by the size of AMS teams,
and the findings could be influenced by the characteristics and context
specific to each team, potentially limiting the applicability of the
results to other settings. Furthermore, the reliance on observations and
interviews might introduce a degree of subjectivity and potential bias,
which we attempted to overcome by having a second researcher
independently develop the coding framework. As data collection was
conducted during COVID-19 and conducted during a set period, the results
may not capture the full extent of the AMS teams’ work processes over
time (i.e. post-COVID).
Conclusions
In examining the work processes of AMS teams across two similar digital
hospitals we found variations in the way tasks were performed and the
contexts in which work was done. Organisational and cultural factors
impacted the work processes of AMS with endorsement from executives,
allocated resources, senior staff support, and frequent
interdepartmental meetings reported and observed to enable effective AMS
teams. These factors also contributed to improving AMS engagement, and
the relationships between departments, which is vital to successful AMS.
Further, digital system interoperability and the presence of user
champions can promote user acceptance and utilisation of digital tools
that may improve AMS outcomes.