Table 1.

Aspects of Ambulatory Antimicrobial Stewardship Interventions as Applied to Components of the Ambulatory Work System, SEIPS 2.0¹³^*

Tools / Technology Components	Person(s) Components	Organizational Components	Task Components	Physical Environment Components	External Environment Components
• EHR-based CDSS^{20,38,41 to 42,50,54,67,70,72}	• Commitment to use and agreement with CDSS²⁰	• CDSS alters practice workflow²⁰	• Improves efficiency²⁰	• Computer location^20,33	• External clinician guidelines^{20,26,30,37,39–41,54–55,65–67,76}
• Hyperlink to patient education^20,54,66	• Technically savvy staff²⁰	• Role of person initiating task is different in different clinics (ie, triage nurse, medical assistant, and clinician)^20,69	• Ordering an antibiotic in EHR²¹	• Brochures and posters in exam rooms and waiting rooms^{24,31,38,43,46,59–60,66}	• New guidelines written⁵⁷
• Hyperlink to and accessibility of guidelines^39,40,54,66	• Comfort with prior ARI templates²⁰	• Computerized patient flow manager designed by clinics³³	• Protocols support decision making⁷³		• Regional clinician newsletter^61,72
• EHR-based audit and feedback²⁰	• Providers signed letter/poster soliciting support^{27,31,56,58,59}	• Patients see physicians with different practices^66,72,73	• Amoxicillin as placebo if physician did not think they need antibiotics⁷⁶		• Insurance policies regarding cost-sharing^25,66
• EHR-based antibiotic prescribing agreement⁴⁹	• Prescribing feedback^{22,23,37,3–41,44,46,51,54,57,60,62–63,67}	• Previsit triage and education by nurses may prevent visits⁷²	• Limited time during patient visits, antibiotics to save time^66,72,73,77		• Meetings with community leaders³⁸
• Template for ARI clinic visits⁴¹	• Intensive intervention for highest prescribers⁵⁸	• Large health systems enable system-level alerts⁶⁶	• Competing demands⁷²		• Mass media campaign^{38,56,61,72,74}
• EHR-based accountable justifications and suggested alternatives (pop-up of alternatives and educational material)^21,44	• Clinician instruction on evidence-based medicine^30,72	• Need for hospital lab^35,69	• Restricted susceptibility testing⁷⁰		• Education at pharmacies, health fairs, child care centers, and offices^38,47,48,75
• Limited printing capabilities²⁰	• Clinician instruction on problem solving and communication^{30,49,52,53,59}	• Peer comparison^{21,23,44,46,51,60,62–63}	• Diagnostic uncertainty^72,76		• CDC campaigns for judicious antibiotic use^43,54
• Tool adaptability^20,62,77	• Older prescribers: prescriptions influenced by habit⁷⁰	• Other clinicians see accountable justification^21,44	• Checklist completed by clinician and patient⁶²		• Disclosed prescribing status monthly to patients, health authorities, and health workers⁴⁵
• Network issues²⁰	• Newer prescribers: nervous about making mistakes⁷³	• Group follow-up meetings with individual feedback^24,52–54	• Communicating with patients^59,64,65,77		• Health ministry-required tasks⁷⁰
• Mailed intervention^{22,38,43,47,48,55,58 to 60,75}	• Depend on patient to decide to take antibiotics³⁶	• On-site group educational time^{24,38–41,43,59,66,67}	• Setting expectations^36,64,66		• Performance-based incentives^66,70,72
• Printed patient education^{23.36,41–43,47,59–60,65,70,71,73,75}	• Engaged patients: focus groups with elderly volunteers⁶⁰	• Academic detailing^{47,75,52–54,58,67}	• Educating patients^{59,64,66,70,73}		• Patient can get antibiotics elsewhere^66,68
• Letters/posters/videos about avoiding inappropriate antibiotic prescribing with clinician photos or signatures^{27,31,56,58,59}	• Patient/family pressure and expectations^62,64,72,74	• Large training sessions^55,59	• Use physical exam to communicate^64,77		• Other countries or healthcare settings thought to be responsible for resistance⁶⁸
• Refrigerator magnets^38,59,60	• Patient physical traits^{20,64,65,67,70,77}	• Local clinicians led initiative at local hospital medical staff meetings³⁸	• Flexible interventions increase feasibility⁶⁷		• Willing to postpone treatment if told others would do the same⁷¹
• Flip chart or reference card for ARI self-management^38,60	• Patient symptoms^{20,62,64,65,73}	• Clinicians compensated for each visit³⁸	• Interventions should engage GPs⁶⁷		• Social capital⁷¹
• Stickers, lapel pins, and otoscope insufflators^47,75	• Patient background and knowledge⁷⁴	• Practice-specific antibiotic prescribing rates^{39,40,43,49,59,70}	• CRP testing has associated tasks (eg, quality assurance)⁶⁹		• Loss of income from POC testing and reimbursement⁶⁹
• All received printed versions of poster and electronic version of guideline⁴⁶	• Avoiding confrontation⁶⁴	• Clinic champions^41–43			• Legal protections⁷³
• Discussion guide at well-child visits^20,47,75	• Negotiating with patients⁶⁴	• Kick-off dinners^47,75			• School or day care requires antibiotics⁷⁴
• Prescription pads for treatment of viral infections^47,58,71,75	• Hedging⁶⁴	• Peer review of colleague transcripts with simulated patients^52,53			• Adaptability of intervention to regional culture⁷⁷
• Delayed prescription: prescribe antibiotics to take only if symptoms worsen^36,71	• Patient reward for copays and taking off work⁶⁶	• Clinics set goals⁵⁹
• Website for feedback required physicians to log in with individual access code³⁷	• Most PCPs did not see antibiotic resistance as a problem in their practice⁶⁸	• Clinic pride⁶⁴
• Dashboard⁵¹	• Worried about patient illness from not prescribing antibiotics^67,70	• Relationships with patients^64,71
• Want local resistance data⁶⁸		• GPs assume practice already follows guidelines⁶⁷
• Limit antibiotic availability in outpatient settings⁷⁰		• Antibiotic resistance seen as issue for secondary care rather than primary care⁶⁸
• CRP POC testing^{24,35,52,53,62,65,69,77}		• No accountability for prescribing⁷²
• Procalcitonin testing²⁶		• Peer support helpful with demanding patients⁷³
• POC streptococcal testing⁶⁵		• Fewer visits, decreased income⁷⁷
• Multiplex PCR for respiratory viruses³²		• Dermatologic consultation²⁷ • Institutional guidelines²⁹ • Prior approval of ID physician⁷⁰

SEIPS, Systems Engineering In Patient Safety; PCP, primary care provider; CDSS, clinical decision support system; POC, point of care; ARI, acute respiratory infection; EHR, electronic health record; CDC, Centers for Disease Control and Prevention; GP, general practitioner; CRP, C-reactive protein; ID, infectious diseases; PCR, polymerase chain reaction.
↵* Studies described include rigorously designed quantitative and qualitative studies describing antibiotic stewardship interventions and the context around antibiotic prescribing decisions, included through November 7, 2016.