Think twice: A cognitive perspective of an antibiotic timeout intervention to improve antibiotic use.
To understand clinicians' impressions of and decision-making processes regarding an informatics-supported antibiotic timeout program to re-evaluate the appropriateness of continuing vancomycin and piperacillin/tazobactam.



We implemented a multi-pronged informatics intervention, based on Dual Process Theory, to prompt discontinuation of unwarranted vancomycin and piperacillin/tazobactam on or after day three in a large Veterans Affairs Medical Center. Two workflow changes were introduced to facilitate cognitive deliberation about continuing antibiotics at day three: (1) teams completed an electronic template note, and (2) a paper summary of clinical and antibiotic-related information was provided to clinical teams. Shortly after starting the intervention, six focus groups were conducted with users or potential users. Interviews were recorded and transcribed. Iterative thematic analysis identified recurrent themes from feedback.



Themes that emerged are represented by the following quotations: (1) captures and controls attention ("it reminds us to think about it"), (2) enhances informed and deliberative reasoning ("it makes you think twice"), (3) redirects decision direction ("…because [there was no indication] I just [discontinued] it without even trying"), (4) fosters autonomy and improves team empowerment ("the template… forces the team to really discuss it"), and (5) limits use of emotion-based heuristics ("my clinical concern is high enough I think they need more aggressive therapy…").



Requiring template completion to continue antibiotics nudged clinicians to re-assess the appropriateness of specified antibiotics. Antibiotic timeouts can encourage deliberation on overprescribed antibiotics without substantially curtailing autonomy. An effective nudge should take into account clinician's time, workflow, and thought processes.
VA Salt Lake City Health Care System, George E Whalen VA Medical Center, Salt Lake City, UT, USA; University of Utah, Salt Lake City, UT, USA. Electronic address: makoto.jones@va.gov.
Makoto
M
Jones
VA Salt Lake City Health Care System, George E Whalen VA Medical Center, Salt Lake City, UT, USA; University of Utah, Salt Lake City, UT, USA; IDEAS 2.0 Center, George E. Whalen VA Medical Center, Salt Lake City, UT, USA; Geriatric Research Education and Clinical Center, George E. Whalen VA Medical Center, Salt Lake City, UT, USA.
Jorie
J
Butler
VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
Christopher J
CJ
Graber
VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
Peter
P
Glassman
VA Salt Lake City Health Care System, George E Whalen VA Medical Center, Salt Lake City, UT, USA; Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA.
Matthew H
MH
Samore
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA.
Lori A
LA
Pollack
VA Salt Lake City Health Care System, George E Whalen VA Medical Center, Salt Lake City, UT, USA; University of Utah, Salt Lake City, UT, USA.
Charlene
C
Weir
VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
Matthew Bidwell
MB
Goetz
D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D003071:Cognition; D003657:Decision Making; D006787:Hospitals, Veterans; D006801:Humans; D010818:Practice Patterns, Physicians'
D000900:Anti-Bacterial Agents
Antibiotic discontinuance; Antibiotic stewardship; Dual Process Theory; Physician decision-making