Exploring Influences on the Implementation of Interventions To Improve Antibiotic Review in Scottish Acute Care Hospitals
Authors:   , Matuluko Ayodeji Benedicta 
Published: September 2024

Background: Antimicrobial resistance (AMR) is worsened by inappropriate antibiotic prescribing and use and is a threat to global health security. Antimicrobial stewardship (AMS) encompasses programmes, strategies and processes to optimise the prescription and use of antibiotics. Existing international evidence evaluating AMS interventions has confirmed their effectiveness in hospital settings, with gaps identified in the design of AMS interventions and the study of their implementation in complex healthcare settings. In Scottish acute care hospitals, prevalence data indicates that intravenous (IV) antibiotic use has driven increased overall rates of antibiotic consumption. In keeping with international strategies to strengthen AMS, national targets to reduce overall IV antibiotic use led to the creation of the Hospital Antibiotic Review Programme (HARP) by the Scottish Antimicrobial Prescribing Group (SAPG), to improve the review of antibiotics in the Scottish acute care hospital context. Educational materials, training and a quality improvement (QI) toolkit make up the HARP programme. To build on an existing research collaboration between Glasgow Caledonian University and SAPG, this funded PhD project was conceived as a collaborative evaluation of the implementation and effectiveness of HARP, which was a priority action area for SAPG. Literature review: The PhD project was preceded by an extensive review of the current evidence for the effectiveness of AMS interventions in the acute care setting. Firstly, a scoping review of 189 studies confirmed the effectiveness of AMS interventions, with gaps remaining in the theoretical underpinning of interventions. Furthermore, a systematic review of 14 studies found that interventions specifically designed to improve the review of antibiotics in acute care hospitals, as an element of AMS, were effective; however, there is limited application of theory in the design and evaluation of these interventions. Aim: The PhD thesis aimed to apply theoretical approaches from implementation science, and evidence, to inform, design and evaluate the implementation of HARP. A secondary aim, driven by enforced changes in healthcare delivery during the coronavirus disease (COVID-19) pandemic, sought to explore the impact of the pandemic on AMS in Scottish acute care hospitals. Methods: The research aims and objectives were answered in four stages. (1) Stage one involved a theoretically informed document analysis of the proposed SAPG HARP using the Theoretical Domains Framework (TDF), the Behaviour Change Wheel (BCW) and Normalisation Process Theory (NPT) to identify potential theoretical gaps in the intervention, to inform implementation. (2) Stage two was a qualitative study to evaluate the pilot implementation of HARP in two National Health Service (NHS) Scotland Boards in early 2019. Two pilot implementers were invited to one-on-one semi-structured interviews to elucidate their perspectives on the delivery of HARP educational materials. Thematic analysis of the data, followed by content analysis and mapping to the TDF domains and NPT constructs allowed theoretical interpretation of barriers and enablers at this pilot stage. (3) Stage three was the evaluation of the implementation of HARP in one case site following its formal launch in March 2020. Four staff in one NHS Scotland Board, different from the pilot implementation sites, were invited to one-on-one semi-structured interviews to explore HARP implementation in their Board. Similar to stage two, thematic analysis of the data was followed by content analysis and then mapping to the TDF domains and NPT constructs for the theoretical interpretation of barriers and enablers to HARP implementation in one case site. (4) Stage four was a qualitative thematic analysis study that explored the broader impact of the COVID-19 pandemic on AMS, across acute care hospitals in Scotland. Thirteen participants from seven NHS Scotland Boards participated in one-on-one semi-structured interviews. Findings: Stage one resulted in the identification of theory-based gaps in the content of HARP and in the implementation plan, with respect to how sufficiently they addressed existing barriers and enablers to AMS, based on previous theoretical analyses. Stage one culminated in the provision of recommendations to SAPG to enable refinement of HARP. National implementation of HARP was subsequently stalled due to the COVID-19 pandemic. Stage two and three findings revealed barriers and enablers to the implementation of HARP. The resultant themes from stage two included issues relating to variable staff engagement with HARP, a need to adapt the HARP programme to site needs, the complexity of choosing clinical areas to implement HARP and the importance of acknowledging the role of nurses in the review of antibiotics. Stage three findings identified issues similar to stage one and two. Final interpretation at Stage three, using NPT, suggested that barriers to implementation of HARP related to limited coherence of the principles of IV review of antibiotics, and problems with cognitive participation of HARP due to competing priorities and limited engagement of senior clinicians. Collective action and reflexive monitoring, while limited during the early stage of HARP implementation, were impeded when AMS teams were not clear on their HARP related roles and when there was limited engagement with antibiotic prescribing indicators. Stage four findings provided further depth of understanding of the challenges of HARP implementation by identifying how the pandemic impacted on the AMS workload and workforce, with increased recognition of AMS teams being a positive outcome of the pandemic. Conclusions: This PhD project is the first to provide an in-depth theory-informed evaluation of HARP implementation, as well as qualitative insights into the impact of the COVID-19 pandemic on the delivery of AMS across Scottish acute care hospitals. Of particular significance, therefore, the PhD thesis addresses the challenges in the design of robust, theory-informed interventions and real-world implementation of healthcare interventions during a period of pandemic crisis. Further work to adapt education on the principles of review to specific healthcare professional groups and clinical specialties, and engaging key stakeholders in implementation, may lead to better embedding of HARP and strengthen efforts towards reducing wider antimicrobial consumption and AMR rates in Scotland.