AMS: Antimicrobial stewardship, eMM: electronic medication management; ICU: Intensive care unit; ID: Infectious diseases

Live AMS

Observations revealed that Live AMS was used for more tasks, and more comprehensively, when reviewing medication orders at Hospital A compared to Hospital B (Table 2). Hospital A used Live AMS to guide review of patients during meetings, but it was not used in interdepartmental AMS meetings at Hospital B. The AMS pharmacist at Hospital B extracted antimicrobials from Live AMS but used a macro on Microsoft Excel to filter the list to the antimicrobials they review daily. Furthermore, due to lack of interoperability between the ICU eMM and Live AMS at Hospital B, the AMS pharmacist had to extract antimicrobials from the ICU patients separately to conduct a review.
Typically all antimicrobial agents were reviewed at Hospital A, while AMS staff at Hospital B predominantly reviewed restricted antimicrobials due to time constraints. In interviews, participants at Hospital A identified Live AMS as a key facilitator to reviewing all antimicrobials. “Live AMS allows for that paradigm shift from a program that focuses on restricted antimicrobials, to focusing on all antimicrobials” (A2) . Further, participants found Live AMS invaluable for reviewing patients, and reported Live AMS supported AMS meetings, reviewing patients’ antimicrobial history, and made the review process easy and efficient. ”Having the ability to use that tool to drive the review, like a real-time review of patients on antibiotics. I have no idea how I would have done it if we didn’t have the Live AMS tool”. (A8) Several participants at Hospital A also believed Live AMS positively impacted patient safety. “It definitely has an impact on safety in that I can immediately identify, particularly on this front interface, check doses quickly and efficiently” (A7).
AMS teams from both hospitals perceived Live AMS was easy and intuitive to use. “It’s actually quite intuitive” (A7) and Whoever has put live AMS together, they’ve made most of the basic functions reasonably straightforward to understand and use.” (B3). However, at Hospital B, many participants did not see a need for Live AMS. For example, a consultant said, in relation to reviewing antimicrobials, ”so much of the work that we do is either we get the automated reports in the morning, or alternatively, we’re working closely with the pharmacist who has already done some of the work filtering” (B1). Some participants were also not aware of the features of Live AMS, and one participant was unaware the tool existed.
Interviews uncovered different levels of involvement by the AMS teams of each hospital in the development of Live AMS. Hospital A’s consultants were largely engaged in creating the tool, while the current AMS team at Hospital B had not participated in its development. Interview participants explained that the individuals who had been engaged in Live AMS development were no longer working at Hospital B. Observations also found that senior consultants at Hospital A , but not Hospital B, championed use of the tool, recommended it to other clinicians in meetings and on the phone.

Electronic medication management (eMM)

Participants described benefits and disadvantages of eMM with respect to antimicrobial prescribing and AMS. Perceived benefits were that eMM saved time, reduced errors, enabled working remotely, improved legibility, and avoided loss of information. Participants also reported improved access and transparency of antimicrobial prescribing information which facilitated review and auditing. “eMeds [eMM] has been great because it allows us visibility of prescribing, obviously, in real time, without the need to hunt down medication charts on the ward or physically be on the ward. It gives us great quality information about dosing, duration, etc. so it’s been really, really useful for antimicrobial stewardship” (B2).
A perceived disadvantage of eMM at both hospitals was that it was difficult to make system changes. Several unintended consequences were also described. For example, order sentences could promote inappropriate prescribing as it was easier for prescribers to pick a pre-written order from the list than refer to guidelines. “People generally choose just the first order sentence rather than try and figure out what dose” (A6). Participants at Hospital B also reported a negative outcome of eMM was that antimicrobial prescriptions could be left ongoing inappropriately “The one thing that I always think is that it’s easier to leave something going” (B5).
Several participants at Hospital B reported a lack of antimicrobial decision support tools available for prescribers and viewed that as a need “We don’t have an antimicrobial prescribing decision support system within eMeds [eMM]. So it’s not linked very well to our restrictions, or our formulary for antimicrobials, which is challenging for both the prescribers and for the AMS service to establish whether antimicrobials are appropriate or not.” (B2)

Communication, AMS phone and AMS pager

At both hospitals, challenges with contacting doctors to communicate pertinent results or seek clarification were observed (Table 2). It would sometimes take numerous phone calls, going through switchboards, to reach a doctor.
Hospital A was observed to use a dedicated AMS phone. During observations it was noted that when a doctor called the AMS team to ask for approval to use an antimicrobial, the AMS team member would take that opportunity to ask about other patients in that doctors’ care. In interviews, participants described the AMS phone as an advice line, an educational tool, and that it supported relationships with other departments. “We have an antibiotic phone for advice, which I think is a great tool, if not for us, for other people. It maintains relationships… I don’t personally like tools where people put online requests for certain antibiotics, yes or no, because they’ve already predetermined which antibiotic they want. And often, it’s impersonal and doesn’t allow you to educate.” (A3)
Prescribers at Hospital B would contact the AMS pager for approval, and the advanced trainee’s phone for advice (Table 2). “And then we also carry an antimicrobial stewardship pager…where we just get calls from people that don’t particularly want advice, they know what they want to prescribe, but they need approval for it anyway.” (B5)

Interdepartmental AMS meetings