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