ePrescribing-Based Antimicrobial Stewardship Practices in an English National Health Service Hospital: Qualitative Interview Study Among Medical Prescribers and Pharmacists.

BACKGROUND Antimicrobial resistance, the ability of microorganisms to survive antimicrobial drugs, is a public health emergency. Although electronic prescribing (ePrescribing) based interventions designed to reduce unnecessary antimicrobial usage exist, these often do not integrate effectively with existing workflows. As a result, ePrescribing-based interventions may have limited impact on addressing antimicrobial resistance. OBJECTIVE We sought to understand existing ePrescribing-based antimicrobial stewardship practices in an English hospital preceding the implementation of functionality designed to improve antimicrobial stewardship. METHODS We conducted 18 semi-structured interviews with medical prescribers and pharmacists with varying levels of seniority exploring current antimicrobial stewardship practices and investigating potential areas for improvement. Participants were recruited with the help of local gatekeepers. Topic guides sought to explore both formal and informal practices surrounding antimicrobial stewardship, and challenges and opportunities for ePrescribing-based intervention. We coded audio-recorded and transcribed data with the help of the People, Organizations and Macro-environmental factors (TPOM) framework, allowing emerging themes to be added inductively. We used NVivo 12 to facilitate coding. RESULTS Antimicrobial prescribing and review processes were characterised by competing priorities and uncertainty of prescribers and reviewers around prescribing decisions. For example, medical prescribers often had to face trade-offs between individual patient benefit and more diffuse population health benefits, and the rationale for prescribing decisions was not always clear. Prescribing involved a complex set of activities carried out by various healthcare practitioners who each only had a partial and temporary view of the whole process, and whose relationships were characterised by deeply engrained hierarchies that shaped interactions and varied across specialties. For example, newly qualified doctors and pharmacists were hesitant to change a consultant’s prescribing decision when reviewing prescriptions. Multidisciplinary communication, collaboration and coordination promoted good AMS practices by reducing uncertainty. CONCLUSIONS Design of ePrescribing-based interventions to improve antimicrobial stewardship needs to take into account the multitude of actors and organisational complexities involved in the prescribing and review processes. Interventions that help reduce prescriber/reviewer uncertainty and improve multidisciplinary collaboration surrounding initial antimicrobial prescribing and subsequent prescription review are most likely to be effective. Without such attention, interventions are unlikely to fulfil their goal of improving patient outcomes and combatting antimicrobial resistance.