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Behavioural change interventions in antibiotic stewardship
Esmita Charani
@e_charani
British Society for Antimicrobial ChemotherapyBirmingham
2019
Cultural, social and commercial drivers can confound one-size-fits-allApproach
A need to understand the context
Cannot translate policies from HIC to LMIC
A need for engagement and ownership
Cultural, social and commercial drivers can confound one-size-fits-allApproach
A need to understand the context
Cannot translate policies from HIC to LMIC
A need for engagement and ownership
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EU G20 Forum global challenge of AMR
NHS Sepsis Plan
Infection policy App Launch
Audit and feedback launched in Medicine
Trust wide PPS
Department of Health SSTF guidelines
DH SSTF pop ups added to APP
Treatment of infection pocket guide
Surgical prophylaxis added to APP
O’Neill Report
Chief Medical Officer AMR Report 5 year Strategy
WHO AMR Global Surveillance Report
Electronic Health records (EHR)
Consultant ID Pharmacist
Pharmacist led AMS ward rounds
Integrated academic research in AMR/AMS
Mandatory Clostridium difficile reporting
Care Quality Commission inspections launched
Consultant Microbiologist Surgery
CDC TATFAR Report
ESPAUR
European Union Antibiotic Awareness Day launch
LocalNationalInternational
Sepsis pop ups on EHR
Sepsis big room meetings
NHS CQUINS AMS NHS CQUINS Sepsis
NICE SepsisGuidelines NHS Sepsis Plan
International Surviving Sepsis Guidelines - Update
International Surviving Sepsis Guidelines - Update
International Surviving Sepsis Guidelines – Update
NCEPOD – ‘Just Say Sepsis’
Imperial/UCL Bio Aid Registry
World Sepsis Day Launch NHS tool for measuring impact of Sepsis and AMR
PHE fingertips profile developed
G7 Japan UK Prime Minister announces plans to tackle AMR
National clinical audit Sepsis Sepsis care bundle
AMS – Antimicrobial StewardshipAPP – Smartphone applicationCDC – Centre for Disease Control and Prevention (USA)CQUINS – Commissioning for Quality and Innovation DH SSTF – Department of Health Start Smart Then FocusESPAUR – English Surveillance Programme for Antimicrobial Utilisation and Resistance ReportID – Infectious Diseases NCEPOD – National Confidential Enquiry into Patient Outcome and Death PPS – Point Prevalence SurveyTATFAR – Transatlantic Taskforce on Antimicrobial ResistanceWHO – World Health Organisation
Competing priorities and messages
Measurement is a Social Process
Understand local arrangements
‘Understand local Arrangements’
‘We need to attend to complexity, rather than trying to control for it’.Understanding culture and context matter.
What can the social sciences do for stewardship
Define the problemProvide contextTheory driven systematic approachInvestigate implementation and sustainability of interventionsLearn through evidence synthesis
acquisitiveness,rivalry,vanity, andlove of power
acquisitiveness,rivalry,vanity, andlove of power
0
42
09
2514
7
0%10%20%30%40%50%60%70%80%90%
100%
Goal: How goodby when?
Feedback Action Planning Goal Setting,Feedback &
Action Planning29 RCT 91 ITS
What improves the effectiveness of feedback?
acquisitiveness,rivalry,vanity, andlove of power
acquisitiveness,rivalry,vanity, andlove of power
Ivers N, Jamtvedt G, Flottorp S et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane database of systematic reviews 2012
• Multivariable meta-regression indicated that feedback may be more effective when:
1. The source is a supervisor or colleague2. It is provided more than once
3. It is delivered in both verbal and written formats4. It includes both explicit targets and an action plan
J O’Neill 2014
acquisitiveness,rivalry,vanity, andlove of power
acquisitiveness,rivalry,vanity, andlove of power
We need more evidence from different resource settings
North America43%
Europe39%
South Central America4%
Rest of World14%
5 countries, 24 hospitals, 54 HCWsAMS restricted by professional boundaries
Lack of engagement with wider healthcare workforce
In LMICs lack of heterogeneity in AMS
Surgical specialty most difficult to engage with in AMS
Not enough investment in training nurses and pharmacists
Culture matters
Poor surveillance
Clin Infect Dis. 2011 Oct;53(7):651-62. doi: 10.1093/cid/cir445Clin Infect Dis. 2013 Jul;57(2):188-96. doi: 10.1093/cid/cit212
Cul
ture Explicit
Implicit
Uses in Antibiotic Stewardship Programmes Generating ASP behaviours
Inte
rpre
ting
ASP
beha
viou
r
Cultural artefactse.g. SmartphonesElectronic Medical Records/ Policy
Cultural behaviourMacro/meso level ASPantibiotic decision
making
ActsTeam workInfection diagnosis Antibiotic choices Duration of therapyDecision making
Feelings Identity with team(s)Values Perceived hierarchies
Social environment Meetings, ward-rounds, HandoverTeaching and training, Clinical care, Teams, Clinical specialties, Patient/ carers
Physical environmentMeetings, ward-rounds, HandoverTeaching and training, Clinical careCare setting e.g. hospital, ward, operating theatre
Cultural artefacts Diagnostic tools, Prescribing and decisionMaking toolsPolicy/guidelines
Based on social norm
s Based on value attributed to
social norms
E Charani et al Clin Infect Dis 2018, in press
Surgical teams Are individualistic Make loose and complex decision makingSenior team are often absent from ward, due to operating room and outpatient needs
Medical team Transition lack of ownership between emergency room and inpatient teams, fear of sepsis
Results from a prospective cohort study across acute medical and surgical teams (n=364):
• There is no difference in the spectrum of antibiotics prescribed across
medicine and surgery (p=0.507).
• Surgical patients are significantly more likely to a) receive a greater
number of courses of antibiotics (p=0.001); b) have their initial empirical
therapy escalated (p=0.0037); and c) be on a course not in line with
local policy (p<0.001).
• In surgery, the odds of escalation of therapy significantly increased if the
patient has a positive microbiological culture (OR 3 95% CI 0.154 –
6.576 p=0.013); and if the patient has signs of possible infection on chest
X-ray (OR 3.38 95% CI 09.42 – 12.089 p=0.004).
Charani et al, Under review 2018
Scope for perioperative antimicrobial stewardship
Charani et al. Clin Microbiol Infect. 2017 Oct;23(10):752-760.
Causal diagram mapping the relationship between surgery and infection, and the variables that should be considered as part of antibiotic decision making.
The ASPIRES Study:
Antibiotic use across Surgical Pathways - Investigating,
Redesigning and Evaluating Systems
Developing context-relevant preventative measures to reduce the risk of infection and AMR, and optimise the use of antibiotics, coupled with tailored implementation strategies, along the entire surgical pathway.
Understanding the context
Engaging with local stakeholders
Charani et al 2018
Collaborative AMS Responsibilities- Establish allergy status- Prescribe within guidelines (MP & NMP)- Document indication, dose & duration- Administer therapy timely- Monitor therapy duration- Promote appropriate route of administration- Monitor therapeutic drug levels- Contribute to preparing patient for OPAT- Adhere to infection prevention and control- Review drug susceptibility- Educate and involve patients and citizens- Advocate for AMS programmes & interventions- Promote integration with other programmes (sepsis, hand hygiene, water & sanitation, IPC)
Pharmacy Influence- Comprehensive pharmacy assessment- Awareness of drug-drug, drug-patient interactions, pharmacokinetic/dynamic relationships, co-morbidities- Provision of essential pharmacy care e.g. med reconciliation, medication chart review, estimated discharge date
Nursing Influence- Comprehensive nursing assessment- Provision of essential nursing care e.g. nutrition, fluids, pressure area- Appropriate biological and tissue sampling
Medical Influence- Comprehensive medical assessment- Establish diagnosis, source of infection & necessary source control- Investigations within presenting signs & symptoms
Nurses are biggest workforce in healthcare- Untapped potential Slide courtesy of Dr Enrique Castro-Sanchez
S Afr Med J. 2016 Sep 6;106(10):947-948Lancet Infect Dis 2016; 16: 1017–25
Non-specialist pharmacists co-ordinating prospective audit and feedbackProcess measures introduced following extensive consultations with stakeholdersIncluded behaviour change techniques
INTERDISCIPLINARY AMS MODEL
Is it all about ID teams?
What about where there are no ID teams?
7 core elements and 29 checklist items
Senior hospital management leadership towards AMSAccountability and responsibilities Available expertise on infection management Education and practical training Other actions aiming at responsible antimicrobial useContinuous monitoring and surveillance Reporting and feedback
Daily interdisciplinary Stewardship Committee meeting at AIMS, Kerala coordinated by clinical pharmacists
INTERDISCIPLINARY CULTURE
7 core elements and 29 checklist items
Senior hospital management leadership towards AMSAccountability and responsibilities Available expertise on infection management Education and practical training Other actions aiming at responsible antimicrobial useContinuous monitoring and surveillance Reporting and feedback
Conclusions • Developing effective AMS programmes requires strong
leadership and operational support
• There needs to be an interdisciplinary approach that recognizes the critical role of pharmacists and nurses
• Frugal innovations in choice architecture, surveillance and workforce development can bring about significant improvements in AMS
• Measurement and implementation is a social process that needs to take into account context and complexity • Positive deviance • Champions • Lines of influence
• Culture and context have the power to shape antibiotic prescribing behaviours• We need to develop contextually fit interventions
Haukeland University Hospital, BergenStig Harthug,
Ingrid Smith, Brita Skodvin
All the staff and patients
Imperial College London
Alison Holmes
Azeem Majeed
Raheelah Ahmad
E Castro-Sanchez
Myriam Gharbi
Gabriel Birgand
Luke Moore
Tim Rawson
Nichola Naylor
Bichat Hospital, ParisJean Christophe-Lucet,Xavier LescureAnne Proziello
Amrita Institute of Medical Sciences, IndiaSanjeev Singh, Vrinda Nampoothiri, Surya SurendranPranava V
Imperial NHS Trust Eoghan de BarraKrishna MoorthyMark GilchristUniversity of LeicesterCarolyn Tarrant
Burkina FasoArmel Poda
University of Cape TownMarc MendelsonMark Hampton