Facilitators | Barriers | |
Capability
(eg, knowledge, skills, habits) |
Awareness of stewardship
Prescribers, nurses and pharmacists generally acknowledge that antimicrobial prescribing practices can be improved and expressed a willingness to change.35 89 When prescribers are aware of policies and initiatives that advance stewardship, they are amenable to change.95 |
Uncertainty in diagnosis
At the time of empiric prescribing, prescribers do not always have a conclusive diagnosis. For the sake of documentation, prescribers may provide ambiguous justification: ‘as per consultant’, ‘infection’, ‘sorry’.86 |
Opportunity
(eg, environmental context and resources, social influences) |
Reminders/prompts
Reminders can be manual or electronic actions that act as prompts for prescribers to document indications. Pharmacists and physicians both felt that an indication prompt was considered a high priority software feature.54 Other reminders can include electronic alerts or stickers that signal prescribers to complete documentation, especially in time pressure environments.35 Electronic health systems or apps Electronic health systems such as CPOE can improve documentation by reducing time as well as having drop-down options available. In one study having access to an AMS mobile application improved prescribers' awareness of stewardship as well as documentation of indication and duration in drug charts.95 Prescribers have also suggested the addition of an indication list on CPOE or a free text space can aid in documentation.25 |
Time consuming
A proportion of prescribers believe that the additional time it takes to document indications, takes away from other important tasks.24 35 ‘Providing an indication with the antibiotic order required an extra 1–10 or 11–20 s’ 25 Logistics of implementing required indications Incorporating indication documentation into the CPOE or pharmacy systems can be a barrier to implementation. The indication would have to be added as part of a free text space, or a drop down menu. Prescribers believe it can be a challenge, since ambiguous or complicated conditions will not fit into an option that is available in the menu. Depending on the system design obtaining meaningful reasons for use can be a challenge.24 61 |
Motivation
(eg, professional role, beliefs about capabilities, beliefs about consequences) |
Improved communication
Having an indication documented on the order or chart improves staff communication and provides clarity. Staff indicated that documentation on the ward helped in communicating the antimicrobial plan on discharge from the ICU (Chaves N, 2014). It also reduced the need for pharmacists to unnecessarily contact prescribers.118 Reduced errors Documentation of the indication provides a second check for pharmacists. It can be used to assess appropriateness of drug selection, dose and duplicate therapy. Pharmacists mentioned that documenting the indication can be beneficial by increasing medication safety especially when deviating from standard dosages118 or identifying drug-indication mismatches.54 |
Alert fatigue
Prescribers can become desensitised to frequent alarms or alerts, leading to unresponsiveness or missed notifications. Mandatory fields in CPOE can be bypassed by prescribers writing letters or characters. Without appropriate use of the mandatory checkpoints, it acts as a nuisance, with no additional benefit to prescribing.24 54 Competing priorities Some prescribers felt that indication documentation was not a high priority and did not believe the data was being monitored or used.24 |
COM, Capability, Opportunity, Motivation; CPOE, computerised provider order entry.