development and evaluation of a complex eprescribing-based ... · • people / nudge techniques •...

NIHR Programme Grant for Applied Research

Development and evaluation of a

complex ePrescribing-based

Antimicrobial Stewardship (ePAMS+)

intervention for hospitals.


• 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

Overview


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

The implementation of ePrescribing

systems in English hospitals


Work package 4Integration 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

Work package 3Health 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 2 Assessing impact on prescribing safety

Stepped-wedge design evaluation with 6&12 months follow-up analyses

of prescribing indicators

Work package 1Procurement, implementation, adoption and connectivity

Documentary data, semi-structured interviews, on-site observations, field notes ethnography

Patient and public

involvement

Four Work Packages

NIHR Programme Grant for Applied Researchhttps://www.eprescribingtoolkit.com/

ePrescribing toolkit

https://www.eprescribingtoolkit.com/


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




• 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).

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.


Antimicrobial

Stewardship (ePAMS+) intervention

for hospitalsA 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


New Project Team


• 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”.

Antimicrobial Stewardship (AMS)


Start Smart – Then Focus


AMS in EPMA

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.

Clear ways that EPMA system optimisation may aid Antimicrobial Stewardship in Practice


• 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).

Project Aims


• 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.

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.

Work Packages


• People / Nudge techniques

• Hardware inc reporting

• Software inc decision support

• i.e. AMS facilitated by technology through a suite of interventions

ePAMS+ Complex Intervention


• 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

Pilot and Formal Trial

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.


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

Pilot and Formal Trial


• 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)

User/Practitioner involvement


• 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!

AMS Strategies


Hospitals with eP/EPMA

systems

• Start Smart

• Then Focus

• Surveillance

Technological Strategies


All NHS hospitals in England

• Staff and committees

• Environment

• Opportunities for behaviour change

• Reinforcement

Social Strategies


All NHS hospitals in England

• Mandatory training (all staff)

• Prescriber training and feedback

• Nurse training and feedback

• Patient education

Educational Strategies


Thank you for listening!

Prof Jamie Coleman

[email protected]

mailto:[email protected]


• 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.

• 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.

• ePrescribing toolkit. [Online] https://www.eprescribingtoolkit.com/

• For more information on the NIHR ePAMS+ Programme Grant; [Online]

https://www.ed.ac.uk/usher/eprescribing-antimicrobial/the-programme

References

https://www.eprescribingtoolkit.com/

https://www.ed.ac.uk/usher/eprescribing-antimicrobial/the-programme

development and evaluation of a complex eprescribing-based ... · • people / nudge techniques •...

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