Development and evaluation of a complex ePrescribing-based Antimicrobial Stewardship (ePAMS+) intervention for hospitals. NIHR Programme Grant for Applied Research
Overview • Previous NIHR grant Research into implementation and effectiveness of EPMA • Antimicrobial Stewardship • Current NIHR grant (Feb 2019 – Feb 2024) • Design of ePAMS+ and trial • EPMA community involvement • Next Steps NIHR Programme Grant for Applied Research
The implementation of ePrescribing systems in English hospitals Original aims to: • Describe the procurement, implementation, adoption and maintenance of the basic and more advanced hospital EPMA systems • Estimate their effectiveness and cost-effectiveness • Develop best practice recommendations for procurement and a toolkit for their successful integration into NHS hospitals NIHR Programme Grant for Applied Research
Four Work Packages Work package 1 Procurement, implementation, adoption and connectivity Documentary data, semi-structured interviews, on-site observations, field notes ethnography Work package 2 Assessing impact on prescribing safety Stepped-wedge design evaluation with 6&12 months follow-up analyses of prescribing indicators Patient and public Work package 3 involvement Health economics and a value of investment analysis Estimation of costs (including opportunity costs) of computer systems of different types; framework for cost categories Work package 4 Integration across WPs to develop recommendations and a toolkit for the NHS Interlink the qualitative and quantitative components; develop a detailed typology of existing systems and their capabilities NIHR Programme Grant for Applied Research
ePrescribing toolkit https://www.eprescribingtoolkit.com/ NIHR Programme Grant for Applied Research
The implementation of ePrescribing systems in English hospitals Data Collection • Three NHS hospital Trusts • Inpatient prescription orders audited pre- and post-implementation of eP for: – 78 prescribing indicators – Documentation (i.e. legality, legibility, multiple charts) • A minimum of 4000 orders at each site and at each stage • Two different systems implemented NIHR Programme Grant for Applied Research
The implementation of ePrescribing systems in English hospitals • CDS implementation varied across the sites. • Passive CDS was used infrequently. • Sites 2 and 3 used interruptive CDS almost exclusively. • Indicators with interruptive CDS saw significant reductions in error rate after CPOE implementation at: – Site 1 (2.9% vs. 0.3%, p<0.001); – Site 2 (5.5% vs. 3.0%, p=0.002); and – Near-significant reduction at Site 3 (7.8% vs. 5.7%, p=0.056). NIHR Programme Grant for Applied Research
The implementation of ePrescribing systems in English hospitals Conclusions • The implementation of CPOE with CDS was associated with a significant reduction in the rate of high-risk errors amendable to CDS. • The level of alerting implemented across the hospitals was significantly different, and not comparable between the sites with the same system. • The presence of interruptive CDS had the biggest impact on the rate of error. Pontefract SK, Hodson J, Slee A, Shah S, Girling AJ, Williams R, Sheikh A, Coleman JJ. Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre-post study. BMJ Qual Saf. 2018 Sep 1;27(9):725-36. NIHR Programme Grant for Applied Research
Antimicrobial Stewardship (ePAMS+) intervention for hospitals A follow up NIHR Programme Grant for Applied research building on the success of the previous grant and exploring more specific implementation of sociotechnical intervention to improve antimicrobial use NIHR Programme Grant for Applied Research
New Project Team NIHR Programme Grant for Applied Research
Antimicrobial Stewardship (AMS) • In the European Union (EU), antimicrobial resistant infections are responsible for ≥ 25,000 deaths annually. • Resistant infections predicted to cause up to 10 million deaths globally by 2050. • Antibiotic prescribing rates are still increasing in hospitals. • Imperative to stem inappropriate use of antimicrobials across a range of industries – including in healthcare. • National strategy for AMS in hospitals is to encourage clinicians to “Start Smart – Then Focus ”. NIHR Programme Grant for Applied Research
Start Smart – Then Focus NIHR Programme Grant for Applied Research
AMS in EPMA Clear ways that EPMA system optimisation may aid Antimicrobial Stewardship in Practice King A, Cresswell KM, Coleman JJ, Pontefract SK, Slee A, Williams R, Sheikh A. Investigating the ways in which health information technology can promote antimicrobial stewardship: a conceptual overview. Journal of the Royal Society of Medicine. 2017 Aug;110(8):320-9. NIHR Programme Grant for Applied Research
Project Aims • To develop and evaluate a multifaceted intervention (ePAMS+) that incorporates technical, behavioural and organisational components to safely reduce inappropriate antibiotic use in adult medical in-patients. • A mixed-methods programme that comprises four inter- linked Work Packages (WPs). NIHR Programme Grant for Applied Research
Work Packages • WP1: Plan, develop and optimise all elements of ePAMS+ and conduct feasibility and process studies of ePAMS+ implementation. • WP2: Agree secondary outcome measures and methods to collect outcome data and establish the feasibility of evaluating ePAMS+ through a hybrid cluster randomised stepped-wedge trial. NIHR Programme Grant for Applied Research
Work Packages • WP3: Evaluate the effectiveness of ePAMS+ in achieving our co-primary outcomes: – Reducing antibiotic consumption without any adverse impact on 30-day mortality • WP4: Estimating the cost-effectiveness of ePAMS+, including cost-minimisation and sensitivity analyses. NIHR Programme Grant for Applied Research
ePAMS+ Complex Intervention • People / Nudge techniques • Hardware inc reporting • Software inc decision support • i.e. AMS facilitated by technology through a suite of interventions NIHR Programme Grant for Applied Research
Pilot and Formal Trial • Sites: 10 hospitals with established use of integrated ePrescribing systems (Cerner Millennium) • Population: Adult (≥16 years) medical in-patients except haematology-oncology patients • Design: Stepped wedge design Figure 2. WP3 hybrid cluster-randomised stepped-wedge trial design. Each row represents one study site. Shaded areas indicate study periods in which the ePAMS+ intervention will be implemented. NIHR Programme Grant for Applied Research
Pilot and Formal Trial Outcomes • The co-primary outcomes are – average total antibiotic consumption as measured by DDD per 1000 admissions; – 30-day mortality post admission. • The ePAMS+ intervention will be considered successful only if it significantly reduces antibiotic prescribing while demonstrating non- inferiority with regard to 30-day mortality NIHR Programme Grant for Applied Research
User/Practitioner involvement • Iterative qualitative research with intended users – junior and senior doctors from a range of wards and specialties, nurses, pharmacists, IT staff, managers, vendor representatives – Focus groups / Interviews • Lay-led , health service users’ focus groups (PPI applicants) – patients ’ and carers’ views on how ePrescribing can support antimicrobial stewardship • Roundtable and online discussion fora (as research goes on) NIHR Programme Grant for Applied Research
AMS Strategies • Assessment of AMS strategies adopted in NHS Hospitals in England • Questionnaire study [online] • Aim: To identify the technological, social and educational strategies adopted in the hospital to support antimicrobial stewardship. • Important that we establish baseline AMS strategies to inform ePAMS+ design (headroom) and monitor changes over time Coming to your inbox soon! NIHR Programme Grant for Applied Research
Technological Strategies Hospitals with eP/EPMA systems • Start Smart • Then Focus • Surveillance NIHR Programme Grant for Applied Research
Social Strategies All NHS hospitals in England • Staff and committees • Environment • Opportunities for behaviour change • Reinforcement NIHR Programme Grant for Applied Research
Educational Strategies All NHS hospitals in England • Mandatory training (all staff) • Prescriber training and feedback • Nurse training and feedback • Patient education NIHR Programme Grant for Applied Research
Thank you for listening! Prof Jamie Coleman j.j.coleman@bham.ac.uk NIHR Programme Grant for Applied Research
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