JMIR Publications

ABSTRACT

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 (EHR) but their use by providers has been limited.

Objective:

We adapted a CDS-based intervention for registered nurses (RN), consisting of triage to identify lower-acuity URI patients 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 four academic health systems in New York, Wisconsin, and Utah.

Methods:

We used the Consolidated Framework for Implementation Research (CFIR) to characterize the initial barriers. Clinical workflows and triage-template utilization in the first year of implementation were collected via chart review as well as study staff and site personnel interviews.

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 RN scope-of-practice varied by state and institutional application of those laws, with some allowing more RN clinical autonomy. 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:

Even in a relatively straightforward clinical workflow, workflow differences appreciably impacted intervention adoption. 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. Clinical Trial: Clinical Trials Registration: https://clinicaltrials.gov/ct2/show/, (NCT02465931).