Human Factors Engineering Improves Effectiveness of Ambulatory Antibiotic Stewardship


Ambulatory antibiotic stewardship interventions are more effective when focused on tools, technology, the person, organization, tasks, and environment components.

Sara C. Keller, MD

Findings from a study published in the Journal of the American Board of Family Medicine reports that a human factors engineering approach, which addresses the strengths and limitations of interactive systems involving people and technology in the workplace, may improve ambulatory antibiotic stewardship (AS) interventions by examining the “role of the clinic's processes or physical layout or external pressures' role in antibiotic prescribing.”

“Human factors engineering approaches have only recently been used in ambulatory clinics to describe defects in testing, apply new electronic health record (EHR) technologies, and improve clinic workflows,” leading researcher Sara C. Keller, MD, of the John Hopkins University School of Medicine, told Contagion®. “Our review is the first to incorporate a human factors engineering approach to understanding ambulatory AS.”

Study investigators performed a systematic review of controlled interventions and qualitative studies of ambulatory AS for acute respiratory infections. A total of 42 quantitative studies and 17 qualitative studies were included in the analysis. Each study examined whether and how investigators integrated principles of a human factors engineering model (ie, the Systems Engineering Initiative for Patient Safety 2.0 model) in ambulatory AS.

According to the investigators, the model used in these analyses “describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes.” A total of 5 components comprise the work system: 1) tools and technology, 2) organization, 3) person, 4) tasks, and 5) environment and external environment.

In the review of the included studies, researchers found that a focus on tools and technology, such as clinical decision support as well as point-of-care testing, assisted in improving the effectiveness of the interventions. Interventions which focused on the person (eg, clinician education), as well as the organization (eg, audit and feedback and academic detailing), also had high effectiveness. Additionally, effective interventions also focused on tasks, such as delayed antibiotic prescribing, the environment (eg, commitment posters), and the external environment such as media campaigns.

The tools and technologies’ component is described as objects people use to work, and AS interventions using these objects often include clinical decision support systems (CDSS), EHRs, educational tools (eg, newsletters, booklets, and videotapes), AS messaging tools (eg, magnets and lapel pins), and point-of-care (POC) testing. In the review, investigators identified CDSS tools and EHR-based interventions as highly effective. Conversely, interventions using tools for patient and family education as well as multifaceted educational tools were not consistently effective.

Patient and family factors, such as comorbidities, symptoms, education, and antibiotic knowledge, often influenced the decision to prescribe antibiotics. Clinician training on communication and problem-solving strategies also influenced AS interventions. In 1 randomized-controlled trial included in the systematic review, a decrease in antibiotic prescriptions was observed among physicians who attended a seminar on problem-solving strategies.

In some studies, researchers found that clinician education, as well as audit and feedback interventions, may hold success in AS interventions, particularly for decreasing antibiotic prescribing. These findings are not consistent across healthcare systems, however. Clinicians’ physical environment did not show substantial changes in antibiotic prescriptions. An example of a physical environment component included posters which encouraged avoiding antibiotics for chest colds. Despite the lack of benefit of these posters, a study did show a decrease in unnecessary antibiotic prescribing following signed commitments that were visible in the environment.

A limitation of the study includes its non-randomized design as well as a lack of a comparator group. Additionally, the findings from the study may not generalize to AS interventions for conditions other than acute respiratory infections.

“Evidence-based AS interventions impact different portions of the ambulatory work system, and using a human factors engineering approach may facilitate the intervention’s success,” according to Dr. Keller. “Future work in ambulatory AS should address the entire work system in which the intervention is implemented.”

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