Table 3. Organizational features.

Elements of the organization that impact beta-lactam TDM implementation include attributes of the setting itself and decisions made about the workflow.

Factors	Representative quotes	Strategies
Setting Human capital Physical and information infrastructure Governance and leadership	“The people who are institutionalizing it are behind desks…They’re not thinking about the 90 other things that we have to complete at the same time. They’re not thinking about how I might be giving this medication, and the patient’s jerking, coming off sedation, trying to pull out the tube, and family members crying in the room.” (ID 20, Bedside nurse (critical care); Center 1-NI) “Right now, you’re dealin’ with a very burnt-out healthcare profession. We have nurses leaving the bedside in droves…We have a lot of fresh, fresh faces…That’s another barrier. Lack of experience.” [ID 28, Bedside nurse (critical care); Center 1-NI] “The one thing that comes across as a big-picture principle is communication. The crux of the matter is, if the individual organizations and specialties could actually talk to each other…in forums such as journal club, a conference, or in-house grand rounds.” [ID 18, Physician, attending (critical care); Center 3-FI] “I think having the lab availability more often, having that is a huge difference to actually making it be something meaningful that your team understands.” [ID 1, Pharmacist (critical care); Center 2-PI] “Well, we were working with the stewardship team, which includes physician and pharmacists, and we’re in discussions with them about how we would roll this out, and who would have access to it initially, and then how that would be broadened. Then a policy had to be written and approved within the Department of Pharmacy in the hospital, and then that had to be approved by the Pharmacy and Therapeutics Committee at the hospital. All of the in-house regulatory steps were put in place, and the approvals were acquired.”[ID 29, Laboratory personnel; Center 2-PI]	Develop and deliver a multifaceted education and training program for diverse stakeholders Secure access to rapid turnaround validated assays Provide access to online evidence-based resources about beta-lactam TDM Integrate beta-lactam TDM operational processes into the electronic health record Create policies, protocols, and practice guidelines with input from the multidisciplinary team Engage relevant leadership and administrative oversight groups for endorsement and resources.
Workflow Patient selection Therapeutic target Process mapping (timing of laboratory draws, roles and responsibilities, real-time feedback, and scenario-based strategies)	“…Meningitis, ventriculitis, intra-abdominal infections, patients post-trauma or post-burns…likely augmented renal clearance, especially in young patients. We would do TDM-guided therapy, and we have seen quite significant changes in dosing based on TDM in these patient groups” [ID 18, Physician, attending (critical care); Center 3-FI] “I think you need to have a really good understanding of what you’re gonna do with that result. You need to understand how the antibiotic works. What is the PK/PD of the antibiotic? What does that result mean? Are you looking at a trough? Are you looking at the area under the curve? Obviously, with beta-lactams, you’re looking for the time above MIC, but if you don’t have an understanding of what that means and how it relates to an MIC, or even what an MIC is, which a lot of people don’t really know ‘cause it is quite specialized, then it’s not very useful…I think it does require a fair amount of training and really good pharmacy support to really understand all aspects “ [ID 23, Physician, trainee (infectious diseases); Center 3-FI] “..one other thing is it would be nice to know the trends of what I’m doing. That’s something I’ve talked with our team about. I like to know how often am I decreasing the dose? How often am I increasing the dose? Even though I know this is an individualized regimen, and oftentimes the response I get is, “Get more levels. Then you’ll know.” [ID 1, Pharmacist (critical care), Center 2-PI] “I think it really depends on the differences between your peak and your trough. If you’re seeing something like accumulation by having a little variation between that peak and trough, that gets me a little bit more concerned about do I need to hold the dose? I’ve been in that situation before. Do I need to de-accumulate the drug first before I would administer more drug?” [ID 1, Pharmacist (critical care), Center 2-PI]	Create standard selection criteria for use of beta-lactam TDM Develop a local consensus on PK/PD targets for beta-lactam TDM and disseminate the choice and justification to end users. Utilize clinical decision support to communicate the timing of blood samples for PK analysis Integrate checklists, calculators, and standard documentation schema in the EHR Engage diverse clinicians in regular multidisciplinary patient care rounds Provide systematic and regular feedback to clinicians on beta-lactam TDM performance metrics Debrief with care team members on difficult clinical scenarios