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.