Barriers to Implementing Registered Nurse-Driven Clinical Decision Support for Antibiotic Stewardship: Retrospective...

Area of Science:

• Health Services Research
• Implementation Science
• Clinical Informatics

Background:

• Up to 50% of antibiotic prescriptions for upper respiratory infections (URIs) are inappropriate.
• Clinical decision support (CDS) systems are underutilized in electronic health records for mitigating unnecessary antibiotic use.

Purpose of the Study:

• To assess barriers to implementing an electronic health record-integrated clinical prediction rule (iCPR) CDS intervention for registered nurses (RNs) delegating care for URI patients.
• To understand implementation challenges in a randomized controlled stepped-wedge trial across multiple health systems.

Main Methods:

• Retrospective case study using quantitative and qualitative data (interviews, surveys, chart reviews).
• Guided by the Consolidated Framework for Implementation Research (CFIR) to characterize barriers.
• Analysis of implementation factors coded as missing, neutral, weak, or strong.

Main Results:

• Barriers were identified across all CFIR domains, with the outer setting (e.g., COVID-19 impact, local conditions) posing the strongest challenges.
• Inner setting barriers included staff changes, RN shortages, competing responsibilities, and varying state policies on RN scope of practice.
• Workflow conflicts, limited resources, optional participation, and lack of incentives also hindered implementation.

Conclusions:

• Significant variability in healthcare system workflows and culture impacted intervention adoption.
• Lessons learned can inform other RN delegation protocol implementations of CDS tools.
• System-wide interventions require consideration of state, health system, practice, and individual-level variability in culture and workflows.