Barriers and facilitators to implementation of a national antimicrobial stewardship toolkit for inpatient settings
Authors: Nasim M , Hand K , Weston D , Masterton S , Ashiru-Oredope D 
Published: November 2024

Abstract

Introduction
Antimicrobial stewardship (AMS) is vital for combating antimicrobial resistance (AMR). The updated 2023 "Start Smart Then Focus" (SSTF) national antimicrobial stewardship (AMS) toolkit1, designed for inpatient settings, supports optimising prescribing of antimicrobials.

Aim
This project was designed to identify the barriers and facilitators to implementing the national toolkit to improve patient outcomes and reduce AMR.

Method
An online training workshop was conducted for healthcare professionals across England, focusing on the SSTF toolkit. Before the workshop, participants completed a survey that included consent and gathered information on their roles, familiarity with AMS principles, current practices, and perceived barriers and facilitators to AMS implementation. This information in this survey was used to form basis for the workshop and it was helpful in developing content appropriate for the target audience, which will be delivered during the session. The workshop included discussions on knowledge mobilisation, behavioural science using the COM-B model, and SSTF implementation case studies. Participants engaged in breakout sessions to identify implementation challenges at their organisations. Post-workshop surveys collected feedback on learning outcomes. Collaboration with NHS England AMS leads and UKHSA behavioural scientists was integral. The NHS Health Research Authority tool confirmed the project did not require ethical approval as the surveys were service evaluation. Data were analysed using descriptive statistics for quantitative responses and thematic analysis for qualitative feedback, tailoring workshop content to address specific needs.

Results
The workshop attracted 57 out of 71 (80%) registered healthcare professionals, including pharmacists (n=45), doctors(n=3), and nurses(n=4). Post-workshop surveys received a 28%(n=16) response rate. Feedback was positive, with 14 out of 16 (88%) of participants expressing high satisfaction. Highlights included SSTF development, e-prescribing implementation, and sessions on barriers and facilitators.Key barriers identified were lack of time, competing priorities, data complexity, insufficient organisational support, and limited resources3. Facilitators included engaging microbiology consultants and the ePMA team, raising awareness through AMS ward rounds, and embedding the SSTF toolkit into guidelines and education. Participants suggested further support from UKHSA and NHSE, including more teaching sessions, workshops, educational materials, and e-learning resources. Practical tools like posters, lanyard cards, infographics, and virtual sessions were recommended to reinforce implementation. The survey responses were analysed using descriptive statistics for quantitative data, such as satisfaction ratings, and thematic analysis for qualitative feedback. This analysis evaluated the workshop's impact on participants' understanding and readiness to implement the toolkit and provided insights for enhancing future training activities.

Discussion/Conclusion
The workshop identified key facilitators and barriers to SSTF implementation. While the toolkit offers a comprehensive framework for AMS, overcoming barriers requires a multifaceted approach involving education, stakeholder engagement, and continuous support. Clearer role definitions and improved support structures are essential. Limitations include limited participant representation and reliance on self-reported data, which may introduce bias. The study lacks long-term follow-up data to assess sustained impact, and feedback might be influenced by personal experiences or organisational culture, affecting generalisability. Future studies could expand participant diversity, incorporate longitudinal assessments, and explore additional AMS aspects.

References
1. UK Government. Antimicrobial stewardship: start smart - then focus. Antimicrobial stewardship toolkit for inpatient care settings. 2023. Available from: https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus/start-smart-then-focus-antimicrobial-stewardship-toolkit-for-inpatient-care-settings
2. Michie, S., Atkins, L., & West, R. (2014). The behaviour change wheel. A guide to designing interventions. 1st ed. Great Britain: Silverback Publishing, 1003-1010.
3. French, S. D., Green, S. E., O’Connor, D. A., McKenzie, J. E., Francis, J. J., Michie, S., ... & Grimshaw, J. M. (2012). Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implementation Science, 7(1), 1-8.
Please explain what post-workshop surveys were conducted, what data were collected in these and how this data were analysed. resuls
Post-workshop surveys gathered feedback on participant satisfaction with the workshop, the usefulness of specific sessions, their confidence in implementing the SSTF toolkit, remaining barriers, and suggestions for future improvements.
The survey responses were analysed using descriptive statistics for quantitative data, such as satisfaction ratings, and thematic analysis for qualitative feedback. This analysis evaluated the workshop's impact on participants' understanding and readiness to implement the toolkit and provided insights for enhancing future training activities.