Developing and implementing complex digitalization initiatives in healthcare: a qualitative study of a complex hospital-based electronic prescribing-based intervention to support antimicrobial stewardship (ePAMS+) (Preprint)

Abstract

Antimicrobial resistance (AMR) represents a growing concern for public health. Complex interventions incorporating educational, behavioral, and technological components offer the potential to improve antimicrobial stewardship (AMS). However, there are currently limited insights into how such interventions can be delivered in real world settings.

We here sought to explore the feasibility of implementing and evaluating a complex intervention designed to improve AMS in hospitals, identifying the challenges associated with development and implementation.

We conducted a qualitative evaluation embedded within a feasibility trial of a complex AMS intervention with educational, behavioral, and technological components using in-depth interviews and observations in five wards of an English hospital. Two and seven weeks after intervention initiation, we interviewed a wide range of managers and users of the intervention including senior and junior prescribers, and non-prescribing nurses, pharmacists, microbiologists, and implementation staff two and seven weeks after go-live. Topics discussed included perceived impacts of different elements of the intervention, and facilitators and barriers to effective use. Interviews were supplemented by observations of ward rounds to gain insights into AMS practices. Data were audio-recorded, transcribed, and inductively and deductively analyzed thematically using NVivo12 software.

We conducted 25 interviews and two observation sessions. We found that, in exploring how effects were produced, tracing the adoption and impact of the various components of this complex intervention was difficult as it had been introduced into a setting subject to intense (COVID-19) pressures alongside other changes in technology and practice. These competing pressures in the hospital environment particularly affected behavioral/educational components (e.g. training, awareness building activities) which were often delivered ad-hoc. We found that the participatory intervention design had addressed typical use cases but had not catered for edge cases that only became visible when the intervention was delivered in real-world settings. This included for example variations in prescribing workflows across different specialties and conditions. As the feasibility trial intervention was implemented alongside existing prescribing pathways, use was not compulsory, and users were able to work around it. Organisation-wide implementation will address this issue making ePAMS+ the only way to prescribe antimicrobials.

Effective design of complex interventions to support AMS can support acceptance and use. However, not all requirements and potential barriers to use can be fully anticipated or tested in advance of full implementation in real-world settings.