Healthcare Providers’ Use of an Antibiotic Time Out for Antibiotic Stewardship in Inpatient Settings

Background:

Appropriate antibiotic use minimizes resistance and toxicity but often involves complex decision-making. Healthcare providers often make reflexive decisions about antibiotic prescribing because of competing cognitive demands. Work in dual process theory by cognitive psychologists demonstrates that decision makers often rely on heuristics or “rules of thumb” in order to minimize effort. We conducted a formative evaluation of a “time out” decision support tool to improve antibiotic decision-making, specifically continuation of vancomycin during a patient’s hospitalization. Taking a “time out” was proposed to increase deliberation and deeper reasoning.

The time out intervention consisted of an electronic dashboard that informed the decision of whether to continue vancomycin, a paper-based clinical summary to prompt the timeout during rounds on the third calendar day of vancomycin, and a templated note that educated users and documented the reasons for continuing vancomycin.

Methods:

Focus groups in a VA medical center were conducted to understand clinical reasoning, workflow processes, and reactions to the intervention. Four internal medicine house staff teams, one ICU team, and a team of three clinical pharmacists were interviewed. ATLAS.ti software was used for qualitative analysis.

Results:

Six themes emerged from the analysis across three categories (Table 1).

Table 1: Themes from qualitative analysis

 

Category	Themes	Description
Reasoning	“It helped me to think”	Increases attention to antibiotic renewal task, display had all information in one place
	Uncertainty reduction	Provides education information; patient’s clinical condition easier to evaluate
Affective	Increased autonomy	Eliminates requirement for approval from ID pharmacist or weekend consults
	Increased responsibility	Concerns about not having sufficient back up
Workflow	Changed role of clinical pharmacist	Fewer interruptions and more time for deeper chart review
	Effort management	Discontinuations viewed as easier than filling out the form; letting the pharmacist decide was less effort

Conclusion:

A “time out” intervention for improving appropriate antibiotic prescribing appears to have multiple impacts on clinical reasoning and decision-making.