Qualitative assessment of antibiotic stewardship teams' efforts to perform prospective audit-and-feedback at hospital discharge.

Objective: How antibiotic stewardship programs can effectively reduce antibiotic overuse at hospital discharge is unclear. In this study, we assessed barriers and facilitators to performing prospective audit-and-feedback at this transition of care. Design: A qualitative study using semi-structured interviews. Setting: Ten acute-care hospitals participating in a stepped-wedge cluster-randomized trial, including three Veteran's Health Administration hospitals, two academic medical centers and five community hospitals. Participants: Fourteen antimicrobial stewards in participating hospitals across the United States. Methods or Interventions: A semi-structured interview guide was created applying the RE-AIM framework to focus on perceptions of implementing the intervention. All interviews were audio recorded, transcribed, and coded in a three-person team. Using thematic analysis, codes were developed and collapsed into themes. Results: Half of the intervention sites struggled to identify patients at discharge, limiting the stewardship teams' ability to conduct prospective audit-and-feedback at discharge. In contrast, strong provider-stewardship relationships and existing hospital initiatives, such as handshake stewardship and discharge planning meetings, facilitated implementation. Stewardship teams at four sites also reported not needing to guide antibiotic use for patients with Infectious Disease (ID) consults, as they agreed with the documented recommendations from the ID specialists. Conclusions: Our findings underscore the importance of accounting for the hospital and organizational context when implementing discharge-focused audit-and-feedback interventions, paying particular attention to existing policies, procedures, and the dynamics between antibiotic stewardship teams and front-line prescribers.