Behavioural change interventions in antibiotic stewardship

Esmita Charani

e.charani@imperial.ac.uk

@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

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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

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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