%0 Journal Article
%@ 2561-326X
%I JMIR Publications
%V 8
%N 
%P e54996
%T Barriers to Implementing Registered Nurse–Driven Clinical Decision Support for Antibiotic Stewardship: Retrospective Case Study
%A Stevens,Elizabeth R
%A Xu,Lynn
%A Kwon,JaeEun
%A Tasneem,Sumaiya
%A Henning,Natalie
%A Feldthouse,Dawn
%A Kim,Eun Ji
%A Hess,Rachel
%A Dauber-Decker,Katherine L
%A Smith,Paul D
%A Halm,Wendy
%A Gautam-Goyal,Pranisha
%A Feldstein,David A
%A Mann,Devin M
%+ Department of Population Health, New York University Grossman School of Medicine, 180 Madison Ave, Room 17-13, New York, NY, 10016, United States, 1 6465012558, elizabeth.stevens@nyulangone.org
%K integrated clinical prediction rules
%K EHR
%K electronic health record
%K implementation
%K barriers
%K acute respiratory infections
%K antibiotics
%K CDS
%K clinical decision support
%K decision support
%K antibiotic
%K prescribe
%K prescription
%K acute respiratory infection
%K barrier
%K effectiveness
%K registered nurse
%K RN
%K RN-driven intervention
%K personnel availability
%K workflow variability
%K infrastructure
%K infrastructures
%K law
%K laws
%K policy
%K policies
%K clinical-care setting
%K clinical setting
%K electronic health records
%K RN-driven
%K antibiotic stewardship
%K retrospective analysis
%K Consolidated Framework for Implementation Research
%K CFIR
%K CDS-based intervention
%K urgent care
%K New York
%K chart review
%K interview
%K interviews
%K staff change
%K staff changes
%K RN shortage
%K RN shortages
%K turnover
%K health system
%K nurse
%K nurses
%K researcher
%K researchers
%D 2024
%7 23.5.2024
%9 Original Paper
%J JMIR Form Res
%G English
%X Background: Up to 50% of antibiotic prescriptions for upper respiratory infections (URIs) are inappropriate. Clinical decision support (CDS) systems to mitigate unnecessary antibiotic prescriptions have been implemented into electronic health records, but their use by providers has been limited. Objective: As a delegation protocol, we adapted a validated electronic health record–integrated clinical prediction rule (iCPR) CDS-based intervention for registered nurses (RNs), consisting of triage to identify patients with low-acuity URI followed by CDS-guided RN visits. It was implemented in February 2022 as a randomized controlled stepped-wedge trial in 43 primary and urgent care practices within 4 academic health systems in New York, Wisconsin, and Utah. While issues were pragmatically addressed as they arose, a systematic assessment of the barriers to implementation is needed to better understand and address these barriers. Methods: We performed a retrospective case study, collecting quantitative and qualitative data regarding clinical workflows and triage-template use from expert interviews, study surveys, routine check-ins with practice personnel, and chart reviews over the first year of implementation of the iCPR intervention. Guided by the updated CFIR (Consolidated Framework for Implementation Research), we characterized the initial barriers to implementing a URI iCPR intervention for RNs in ambulatory care. CFIR constructs were coded as missing, neutral, weak, or strong implementation factors. Results: Barriers were identified within all implementation domains. The strongest barriers were found in the outer setting, with those factors trickling down to impact the inner setting. Local conditions driven by COVID-19 served as one of the strongest barriers, impacting attitudes among practice staff and ultimately contributing to a work infrastructure characterized by staff changes, RN shortages and turnover, and competing responsibilities. Policies and laws regarding scope of practice of RNs varied by state and institutional application of those laws, with some allowing more clinical autonomy for RNs. This necessitated different study procedures at each study site to meet practice requirements, increasing innovation complexity. Similarly, institutional policies led to varying levels of compatibility with existing triage, rooming, and documentation workflows. These workflow conflicts were compounded by limited available resources, as well as an implementation climate of optional participation, few participation incentives, and thus low relative priority compared to other clinical duties. Conclusions: Both between and within health care systems, significant variability existed in workflows for patient intake and triage. Even in a relatively straightforward clinical workflow, workflow and cultural differences appreciably impacted intervention adoption. Takeaways from this study can be applied to other RN delegation protocol implementations of new and innovative CDS tools within existing workflows to support integration and improve uptake. When implementing a system-wide clinical care intervention, considerations must be made for variability in culture and workflows at the state, health system, practice, and individual levels. Trial Registration: ClinicalTrials.gov NCT04255303; https://clinicaltrials.gov/ct2/show/NCT04255303 
%M 38781006
%R 10.2196/54996
%U https://formative.jmir.org/2024/1/e54996
%U https://doi.org/10.2196/54996
%U http://www.ncbi.nlm.nih.gov/pubmed/38781006