# Optimizing antimicrobial stewardship during operational upheaval: lessons in resiliency from the COVID-19 pandemic

## TL;DR

This paper explores how hospitals maintained antimicrobial stewardship during the pandemic and offers strategies for future resilience.

## Contribution

The study introduces systems engineering insights and practical strategies for resilient antimicrobial stewardship during crises.

## Key findings

- Challenges included physician employment models and staff shortages.
- Preexisting strategies like decentralized AMS and strong interprofessional relationships supported resilience.
- Real-time strategies included flexibility and use of automated tools.

## Abstract

The COVID-19 pandemic caused unprecedented operational stress on hospital-based antimicrobial stewardship programs (ASP). We utilized a systems engineering framework to characterize multi-level systems challenges to and strategies for resilient, hospital-based antimicrobial stewardship (AMS) during the COVID-19 pandemic.

Using a national data set, we identified hospitals that had significant COVID-19 burden. We conducted semi-structured interviews with pharmacists, physicians and quality leaders involved in ASPs during the pandemic at those hospitals. Interview guides were developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Transcribed interviews were analyzed using deductive content analysis.

We interviewed 37 participants from 22 different healthcare systems across the country. Challenges to resilient ASP included physician employment model; limited AMS resources; staff shortages due to illness; shift in priorities; increased workload; remote work; and therapeutic momentum. Preexisting strategies to promote resilient AMS included system-wide AMS; decentralized AMS; excellent interprofessional relationships; strong culture of AMS and embracing incremental change. Real-time response strategies included ability to prioritize well; consistency with AMS work; being flexible and adopting change; intensifying infectious disease engagement; dedication to the profession; and reliance on automated tools and technology.

Using a systems engineering informed qualitative approach, participants identified many modifiable challenges to AMS resiliency. Given the unfortunate reality that infectious disease pandemics and periods of operational stress are likely to occur in the future, we recommend that healthcare system leadership utilize the preexisting and real-time response strategies identified in this manuscript as a roadmap to ASP preparedness and a more proactive future response.