How to get senior hospital and clinical engagement

How to get senior hospital and clinical engagement Professor Alison Holmes Professor of Infectious Diseases Director, NIHR Health Protection Research Unit: HCAI and AMR

Engagement through Organisational change Holmes, Dinneen, Public Services Review, 8, 2006 HSJ Feb 2006 Organisational change to drive AS and HCAI reduction Griffiths P, Renz A, Hughes J, Rafferty AM. J Hosp Infect. 2009 Sep;73(1):1-14 http://www.rcpath.org/resources/pdf/ bulletinapril08.pdf E. Lawson, C. Price McKinsey Quarterly 2003: The Psychology of Change Management

Engagement through Organisational change Effective IPC delivery requires expert input operationally and strategically and understanding of interlinking systems and risks in hospital management 2009

Engagement through Organisational change Effective IPC delivery requires expert input operationally and strategically and understanding of interlinking systems and risks in hospital management 2009 2010

Engagement through Organisational change Effective IPC delivery requires expert input operationally and strategically and understanding of interlinking systems and risks in hospital management 2009 2010 2012

UK CMO Report 2013

UK CMO Report 2013

UK CMO Report 2013 Acute trusts and their boards will need to learn a new language and consider how to strengthen infection prevention and control practice using new methods of organisational and behavioural change to reinforce policy implementation.

Some methods to consider: Engage leaders Intelligent design, human factors and decision architecture Better involvement of patients and staff Technology, mhealth and communications

The role of specialty clinical leaders in shaping prescribing practice and behaviour National Clinical leaders Meeting London Nov 24th

Antibiotic prescribing in hospitals 34 % NHS inpatients on antibiotics (47% in independent sector hospitals) Of those on antibiotics 53% for community infection 20% for HAI 13% surgical prophylaxis (30% > one day) English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011

Inappropriate use Unnecessary exposure Various studies on inpatient antibiotic prescriptions identify 30-60% inappropriate Also consider: Rapidity of first dose C. difficile Toxicity and drug interaction IV line usage Cost Davey P, Brown E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2005(4) Willemsen I, Groenhuijzen A, et al Appropriateness of antimicrobial therapy measured by repeated prevalence surveys. Antimicrob Agents Chemo. 2007 Mar;51(3):864-7 Hecker MT. et al. Arch Intern Med 2003;162:972-978. Zarb P, Amadeo B, et al. Identification of targets for quality improvemen in antimicrobial prescribing: the web- based ESAC Point Prevalence Survey 2009. JAC 2011;66:443 9.

Policies and guidelines Guidelines, policy help with decision-making, by providing knowledge and awareness But, they may not shift attitudes or change practice J Carthey et al BMJ 2011; 343 Make optimal antibiotic prescribing default, routine practice Mindlines not guidelines Gabbay, Le May. 2004; BMJ 329

Prescribing context Policies and guidelines not enough Collateral impact not tangible at prescriber/patient level Behaviour and social science underutilised Qualitative evidence highlights the influence of social norms, attitudes, beliefs, important influence of peer leaders Charani E et al CID, October 2011;53(7):651 662

Prescribing is a behaviour Antibiotic prescribing is complex, influenced by many determinants Social sciences and qualitative perspective needed Consider human factors and supporting choice architecture Making some small changes to existing systems to support optimal prescribing choices Principles of optimal prescribing need reinforcing/sharing Unwritten rules of prescribing behaviour need recognising

Unwritten Rules

Unwritten Rules

Unwritten Rules Conclusion To influence the antimicrobial prescribing of individual healthcare professionals, interventions need to address these behaviours and use clinical leadership within existing clinical groups to influence practice

Clinical Leadership Professional organisation involvement or research collaboration enhances success Redefine problem as a social problem that can be solved i.e. involving human action and behaviour, not simple technical fix Social process, sense of community Systems with network and teams and sense of ownership Clinicians behaviours influenced by trusted peers (Dopson et al. 2003). Leaders with authority to breathe legitimacy critical (Hwang and Powell 2005).

Broadening stakeholder involvement Multidisciplinary approach to antibiotic stewardship has largely included: Microbiologists, ID physicians, Pharmacists More recently role of nurses considered, non prescribing knowledge brokers The Chennai declaration 2012: harnessed leadership of multiple medical specialities at start Need to broaden stakeholder involvement: Directly involving clinical specialities and their leaders Engaging local opinion leaders Consider as a key aspect of patient safety and quality clinical care Sharing and promoting the principles of optimal prescribing

Principles of optimal prescribing Start Smart Then Focus Focus = Clinical review and antimicrobial decision making at 48 hrs DoH Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) Antimicrobial Stewardship: START SMART - THEN FOCUS Guidance for antimicrobial stewardship in hospitals (England) 2011. after 24 hrs Cooke FJ, Holmes AH. The missing care bundle: antibiotic prescribing in hospitals. Int J Antimicr Agents. 2007 Pulcini C, Defres S, Aggarwal I, Nathwani D, Davey P. Design of a 'day 3 bundle' to improve the reassessment of inpatient empirical antibiotic prescriptions. JAC. 2008

Impact to be assessed ARHAI Antimicrobial Prescribing Quality Measures November 2014

The critical role of clinical leaders in shaping prescribing practice and behaviour Shared goal of optimising use of antibiotics as intrinsic to quality clinical care, patient safety and public health Ensuring access to effective antimicrobial therapy, minimising negative impact of exposure and sustaining effectiveness

17 th International Congress on Infectious Diseases Hyderabad, March 2-5, 2016 More information at: www.isid.org