Hospital doctors will get a new computer system that nags them to stop prescribing antibiotics when they are no longer needed, as part of a trial across 10 NHS hospitals. This matters because antibiotic prescribing rates in UK hospitals are still rising, despite national guidance telling clinicians to “Start Smart—Then Focus.” The problem is not simple ignorance: doctors face time pressure, lack real-time access to patient information, worry about missing sepsis, and often cannot review a patient’s progress because care is fragmented. The researchers have designed a complex intervention called ePAMS+ that combines electronic prescribing alerts with behavioural and organisational support to help busy clinicians safely reduce inappropriate antibiotic use. If the trial shows ePAMS+ is acceptable, feasible, and cost-effective, the team will incorporate it into the existing national ePrescribing Toolkit for NHS England. That could quietly slow the rise of antimicrobial resistance—a major global threat—without increasing patient deaths, by making it easier for hospital staff to follow best practice in the midst of a hectic shift. The project will also publish at least 10 papers and estimate the cost savings from reduced antibiotic consumption.
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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. Questions What are the main challenges to and facilitators for reducing inappropriate antibiotic use? (WP1) In what ways can ePAMS+ promote antimicrobial stewardship (AMS)? (WP1) How is ePAMS+ best conceptualised/delivered? (WPs1&2) What are suitable secondary outcomes and process measures? (WPs1&2) Is ePAMS+ acceptable/feasible to implement? (WP2) Are our trial procedures acceptable/feasible? (WP2) How much patient-level variability is there in the co-primary outcomes? (WP2) Is ePAMS+ effective in safely reducing inappropriate antibiotic use? (WP3) What are the mechanisms of action/unintended consequences of ePAMS+? (WPs1-3) Is ePAMS+ cost-effective? (WP4) Background/rationale Despite national guidance, antibiotic prescribing rates are still increasing in hospitals. The reasons are multi-factorial, including limited real-time access to information that may influence decisions to initiate antibiotics, concerns about missing potentially serious infection (e.g. sepsis), and lack of continuity of care, which limits the opportunity for an informed review of progress and results in a reluctance to delay initiation of and/or change/discontinue an antibiotic that has already been commenced. These challenges are compounded by the substantial time pressures that clinicians face. The national strategy to address issues surrounding AMS is to encourage clinicians to "Start Smart–Then Focus". Our systematic review and discussions with experts all point to ePrescribing systems–integrated with behavioural and organisational support–having a major role in improving AMS. We have carefully conceptualised a complex ePrescribing-based Antimicrobial Stewardship (ePAMS+) intervention that aligns with national strategy and aims to help busy clinicians overcome a number of the above-described challenges. Research plans We will undertake a mixed-methods programme that comprises four inter-linked Work Packages (WPs): WP1: a) Planning, developing and optimising all elements of ePAMS+; and b) carrying out qualitative feasibility and process studies of ePAMS+ implementation in parallel with WPs2&3. WP2: Agreeing secondary outcome measures through an expert consensus building workshop, developing the methods to collect outcome data and establishing the feasibility of evaluating ePAMS+ through a hybrid cluster-randomised stepped-wedge trial. ePAMS+ and our trial plans will be reviewed in the light of the findings from this feasibility work. WP3: Evaluating the effectiveness of ePAMS+ in achieving our co-primary outcomes of reducing antibiotic consumption without any adverse impact on 30-day mortality through piloting and undertaking a formal evaluation in 10 hospitals. Our secondary outcome measures will include additional important safety and process outcomes based on the consensus building exercise and feasibility work undertaken in WP2. WP4: Estimating the cost-effectiveness of ePAMS+, including cost-minimisation and sensitivity analyses. Outputs/dissemination plans If found to be acceptable, safe and cost-effective, we will incorporate ePAMS+ into our existing national ePrescribing Toolkit to maximise dissemination throughout NHS England. We anticipate publishing at least 10 papers in leading journals. Benefits Reducing the risk of antimicrobial resistance is a major national and global challenge. Our programme of research will make a substantial contribution to this effort through leveraging the increasing technological capability in hospitals to promote AMS in a safe and cost-effective manner.
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