TY  - JOUR
AU  - Stevens, Elizabeth R
AU  - Xu, Lynn
AU  - Kwon, JaeEun
AU  - Tasneem, Sumaiya
AU  - Henning, Natalie
AU  - Feldthouse, Dawn
AU  - Kim, Eun Ji
AU  - Hess, Rachel
AU  - Dauber-Decker, Katherine L
AU  - Smith, Paul D
AU  - Halm, Wendy
AU  - Gautam-Goyal, Pranisha
AU  - Feldstein, David A
AU  - Mann, Devin M
PY  - 2024
DA  - 2024/5/23
TI  - Barriers to Implementing Registered Nurse–Driven Clinical Decision Support for Antibiotic Stewardship: Retrospective Case Study
JO  - JMIR Form Res
SP  - e54996
VL  - 8
KW  - integrated clinical prediction rules
KW  - EHR
KW  - electronic health record
KW  - implementation
KW  - barriers
KW  - acute respiratory infections
KW  - antibiotics
KW  - CDS
KW  - clinical decision support
KW  - decision support
KW  - antibiotic
KW  - prescribe
KW  - prescription
KW  - acute respiratory infection
KW  - barrier
KW  - effectiveness
KW  - registered nurse
KW  - RN
KW  - RN-driven intervention
KW  - personnel availability
KW  - workflow variability
KW  - infrastructure
KW  - infrastructures
KW  - law
KW  - laws
KW  - policy
KW  - policies
KW  - clinical-care setting
KW  - clinical setting
KW  - electronic health records
KW  - RN-driven
KW  - antibiotic stewardship
KW  - retrospective analysis
KW  - Consolidated Framework for Implementation Research
KW  - CFIR
KW  - CDS-based intervention
KW  - urgent care
KW  - New York
KW  - chart review
KW  - interview
KW  - interviews
KW  - staff change
KW  - staff changes
KW  - RN shortage
KW  - RN shortages
KW  - turnover
KW  - health system
KW  - nurse
KW  - nurses
KW  - researcher
KW  - researchers
AB  - 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 
SN  - 2561-326X
UR  - https://formative.jmir.org/2024/1/e54996
UR  - https://doi.org/10.2196/54996
UR  - http://www.ncbi.nlm.nih.gov/pubmed/38781006
DO  - 10.2196/54996
ID  - info:doi/10.2196/54996
ER  -