NIHR Programme Grant for Applied Research
Development and evaluation of a
complex ePrescribing-based
Antimicrobial Stewardship (ePAMS+)
intervention for hospitals.
NIHR Programme Grant for Applied Research
• 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
NIHR Programme Grant for Applied Research
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
NIHR Programme Grant for Applied Research
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
NIHR Programme Grant for Applied Research
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
The implementation of ePrescribing
systems in English hospitals
NIHR Programme Grant for Applied Research
• 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
NIHR Programme Grant for Applied Research
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.
The implementation of ePrescribing
systems in English hospitals
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 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
NIHR Programme Grant for Applied Research
New Project Team
NIHR Programme Grant for Applied Research
• 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)
NIHR Programme Grant for Applied Research
Start Smart – Then Focus
NIHR Programme Grant for Applied Research
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
NIHR Programme Grant for Applied Research
• 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
NIHR Programme Grant for Applied Research
• 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
NIHR Programme Grant for Applied Research
• 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
NIHR Programme Grant for Applied Research
• People / Nudge techniques
• Hardware inc reporting
• Software inc decision support
• i.e. AMS facilitated by technology through a suite of interventions
ePAMS+ Complex Intervention
NIHR Programme Grant for Applied Research
• 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.
NIHR Programme Grant for Applied Research
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
NIHR Programme Grant for Applied Research
• 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
NIHR Programme Grant for Applied Research
• 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
NIHR Programme Grant for Applied Research
Hospitals with eP/EPMA
systems
• Start Smart
• Then Focus
• Surveillance
Technological Strategies
NIHR Programme Grant for Applied Research
All NHS hospitals in England
• Staff and committees
• Environment
• Opportunities for behaviour change
• Reinforcement
Social Strategies
NIHR Programme Grant for Applied Research
All NHS hospitals in England
• Mandatory training (all staff)
• Prescriber training and feedback
• Nurse training and feedback
• Patient education
Educational Strategies
NIHR Programme Grant for Applied Research
Thank you for listening!
Prof Jamie Coleman
NIHR Programme Grant for Applied Research
• 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
Top Related