Antimicrobial stewardship programs are being introduced in hospitals internationally amidst the problem of escalating antimicrobial resistance. But sustained behavioral change in the area of antibiotic prescribing has been difficult to achieve.
While we have an understanding of doctors’ roles in antibiotic optimization within hospital contexts , the role of hospital management in successes or failures of antimicrobial stewardship programs (and optimization of antibiotics more broadly) has not been explored. Our new study published in the Journal of Hospital Infection examines this very question – the role of the manager as an enabler, or indeed a barrier, to antibiotic optimization.
Researchers in the study performed semistructured interviews with 23 hospital managers at three hospitals in two different states in Australia to specifically examine their opinions on antibiotic resistance, antibiotic governance, and their roles as senior management. The results illustrate how hospital managers prioritize financial pressures and immediate clinical demands over longer-term issues such as antibiotic prescribing and resistance. Here is an example of those pressures, described by one manager:
“I think the problem is [antimicrobial stewardship] in a competitive market. Are the waiting lists more newsworthy than antibiotic prescribing? Absolutely. You get more adverse events happening because of the waiting lists. … So, of course it’s not going to be the [antibiotic] prescribing that comes up to the top of that.” –Departmental Director
The study results also showed how managers find it challenging to comprehend, or act on the basis of, antibiotic-prescribing audits and had little faith in the value of data on antibiotic use and appropriateness. Other clinical areas with more clearly defined targets (and consequences for failing to meet targets) were prioritized over antibiotic prescribing in medical management decision making. Managers also found it difficult to influence the behavior of doctors and thought that it was a clinical responsibility to improve practice. In the words of one:
“I am a believer in delegated accountability and people on the shop floor knowing what they’re doing and being held accountable for it.” – Divisional Director
Managers perceived that there was limited accountability among doctors for antibiotic use and limited education and feedback to doctors:
“Those figures [on suboptimal prescribing] you give me, I haven’t heard them before. So, that in itself is a problem, and I would suggest you’d probably find a large number of medical staff haven’t been exposed to that.”
– Divisional Director
This study was performed in three hospitals with active antimicrobial stewardship programs. In Australia, as is becoming the pattern in countries within the Organisation for Economic Co-operation and Development (OECD), there is a legislative requirement for hospitals to have an effective antimicrobial stewardship program. And yet, meaningful sustained change in antibiotic prescribing is elusive, as evidenced by national antibiotic-prescribing data . The study results raise the important question of who is perceived as responsible for antibiotic-prescribing improvement and the actual and potential role of hospital managers in enacting change. It seems likely that both “top-down” influence (by managers and executive) and “bottom-up” influence (clinician-driven processes) will be required for effective and sustained practice change.
It is also clear from the results of this study that hospital managers do not perceive clear or immediate consequences for failing to improve antibiotic prescribing, and the perceived “distant” threat of antimicrobial resistance is not prioritized among other competing pressures. In addition, the widespread nature of antibiotic use makes it difficult to audit and even more difficult to communicate the extent of the problem.
These data would suggest that to move forward we need to look at an incentive structure for antibiotic-prescribing improvements or consequences in the short term for failing to optimize antibiotic use, and clearly defined goals for antibiotic optimization in hospitals.
Jennifer Broom, MBChB, PhD, is an infectious diseases physician at the Sunshine Coast Hospital and Health Service and an associate professor of medicine at the University of Queensland, Brisbane, Australia. Alex Broom, PhD, is professor of sociology in the School of Social Sciences at the University of New South Wales, Sydney.
