Culture and team dynamics in the implementation of antibiotic stewardship programmes

Abstract

Background: Antibiotic prescribing in secondary care remains suboptimal. Across the world, healthcare organisations are at different stages of implementing diverse and multiple interventions to optimise antibiotic prescribing. Antibiotic stewardship is the collective term to describe these efforts. The aim of antibiotic stewardship programmes (ASP) is to optimise antibiotic prescribing behaviours. Aims: In this thesis, three studies investigated ‘how’ and ‘why’ culture and team dynamics influences antibiotic decision making, and ‘what’ the effect is in terms of patient level outcomes. The specific research questions were: 1) How are ASP developed and implemented in different healthcare settings in different countries? 2) How do culture and team dynamics influence antibiotic prescribing decision making for individual patients in the ward setting?; 3) What if any, are the differences in antibiotic prescribing practises in acute medical and surgical specialties? Study Design: Mixed methods design through three separate but connected studies at the macro and meso level: 1) A qualitative study, including face-to-face interviews and observations, conducted across four countries (Norway, England, France, and India) investigating the implementation of ASP in different health care settings; 2) An ethnographic study (including face-to-face interviews, non-participant observations, and documentary analysis) of antibiotic decision-making across acute surgical and acute medical teams in one teaching hospital in London; 3) A prospective cohort study investigating the antibiotic decision-making outcomes across the surgical and medical teams from 2. Results: Resources remain a limiting factor in the implementation of ASP across the world. Cultural boundaries in healthcare still limit the involvement of allied healthcare professionals in ASP, despite examples of success in the use of pharmacists (England, India) in mobilising hospital wide ASP. With a dedicated leadership, local champions, and interdisciplinary collaboration social norms can be changed in the most hierarchical and rigid contexts to deliver sustainable ASP. A cross cutting finding of this study was the specialty level cultures and norms that determine and predict antibiotic decision making and adherence to ASP in surgery. Across all the countries, it was recognised that the surgical specialty is difficult to engage with ASP. At the meso level, there is variation in the observed norms, values and behaviours in antibiotic decision making in medicine and surgery. Lack of ownership and senior surgeon input into antibiotic prescribing in surgery leads to suboptimal care. Across both specialties antibiotics are prescribed in 20% of patients in the absence of signs of infection. Surgical patients are exposed to the same spectrum of antibiotics as medical patients. However, surgical patients are significantly more likely to a) receive a significantly higher number of courses of antibiotics (p=0.001); b) have their initial empirical therapy escalated (p=0.0037); and c) receive a course not in line with local policy (p<0.001). Conclusion: This thesis provides new insights into the macro and meso level influence of culture on ASP in different healthcare settings, from the perspective of the people tasked with implementing ASP. National and local policies and targets need to recognise the local stakeholders in ASP. There needs to be a complete and transparent, shared understanding of the principles of good antibiotic prescribing across the entire work force in acute care. ASP champions and leadership can be used to overcome hierarchical and rigid national and organisational cultures. There is variation in the social norms and antibiotic prescribing behaviours between medicine and surgery. ASP needs to target surgical specialties. The ownership of the antibiotic prescriptions in the surgical pathway needs to be clarified. ASP interventions in surgery should focus on patients in hospitals for greater than 48 hours when they are likely to have their antibiotic therapy escalated.