An in-depth exploration of antimicrobial stewardship: The interplay between people and systems

Abstract

Background: Antimicrobial stewardship (AMS) programs use a suite of coordinated strategies, including digital interventions, to optimise antimicrobial use in hospitals. The aim of this thesis was to understand and identify ways to improve AMS processes in digital hospitals.

Methods: Two systematic reviews were conducted (1) to synthesise the evidence on the effectiveness of digital interventions to improve AMS in hospitals, and (2) to identify factors influencing acceptance and use of digital interventions for AMS. Observations and interviews were conducted with AMS teams in two metropolitan hospitals and two regional hospitals in Australia. Content analysis was conducted to understand the AMS work processes and drivers of effective AMS.

Results: Digital interventions for AMS generally led to decreased use of antimicrobials and increased appropriateness of prescribing, but this impact varied between interventions, and evaluation of sociotechnical outcomes was limited. Digital interventions were more likely to be accepted and utilised if end-users perceived them as useful, better than pre-existing ways of working, improved job performance, and were compatible with workflow. Active promotion of the system, peer influence, and education were strategies that promoted use. Organisational culture was found to be critical to AMS program success, including a cohesive AMS team, executive support, resource allocation, and positive interdepartmental relationships. Rapport was improved through in-person interactions. Technology, executive support, and high prescriber autonomy were found to negatively impact relationships. People and relationships, especially infectious diseases consultants, appeared to be more critical for successful AMS in regional contexts.

Conclusion: This thesis comprehensively examined AMS processes in digital hospitals, highlighting the importance of understanding user perceptions, work processes, and organisational contexts in optimising AMS programs.