Adaptation and implementation of the ARK (Antibiotic Review Kit) intervention to safely and substantially reduce antibiotic use in hospitals: a feasibility study

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Summary

Background

Antimicrobial stewardship initiatives in secondary care depend on clinicians undertaking antibiotic prescription reviews but decisions to limit antibiotic treatment at review are complex.

Aim

To assess the feasibility and acceptability of implementing ARK (Antibiotic Review Kit), a behaviour change intervention made up of four components (brief online tool, prescribing decision aid, regular data collection and feedback process, and patient leaflet) to support stopping antibiotic treatment when it is safe to do so among hospitalized patients; before definitive evaluation through a stepped-wedge cluster-randomized controlled trial.

Methods

Acceptability of the different intervention elements was assessed for a period of 12 weeks by uptake of the online tool, adoption of the decision aid into prescribing practice, and rates of decisions to stop antibiotics at review (assessed through repeated point-prevalence surveys). Patient perceptions of the information leaflet were assessed through a brief questionnaire.

Findings

All elements of the intervention were successfully introduced into practice. A total of 132 staff encompassing a broad range of prescribers and non-prescribers completed the online tool (19.4 per 100 acute beds), including 97% (32/33) of the pre-specified essential clinical staff. Among 588 prescription charts evaluated in seven point-prevalence surveys over the 12-week implementation period, 82% overall (76–90% at each survey) used the decision aid. The median antibiotic stop rate post implementation was 36% (range: 29–40% at each survey) compared with 9% pre implementation (P < 0.001).

Conclusion

ARK provides a feasible and acceptable mechanism to support stopping antibiotics safely at post-prescription reviews in an acute hospital setting.

Introduction

Hospital prescribing accounts for a minority of human antibiotic consumption but is where the great majority of broad-spectrum antibiotics are prescribed [1]. Reducing antibiotic overuse in hospitals is challenging because patients who present acutely unwell or who are critically ill require prompt and adequate initial antibiotic therapy [2], [3]. Controlling antibiotic overuse relies on regular review and revision of antibiotic prescribing decisions; in the UK National Health Service (NHS) ‘Start Smart then Focus’ guides that the continued need for antibiotics is assessed at 24–72 h when more diagnostic information is available and treatment response can be assessed [4]. Similarly, recommendations from the US Centers for Disease Control and Prevention (CDC) include antibiotic ‘time-outs’ to prompt reassessment of the continued need for and choice of antibiotic treatment [5].

Wide-ranging educational and practice resources exist to support hospital antibiotic stewardship but significant improvements in hospital antibiotic overprescribing have not been achieved [1], [6], [7]. Knowledge, system, and behavioural factors combine to make it very hard for doctors to take active decisions to stop antibiotics, and less than 10% of antibiotic prescriptions are discontinued at review in the NHS [8], [9]. For these reasons, the Antibiotic Review Kit (ARK) intervention was designed and carefully optimized using an integrated person-based approach to address the barriers to behaviour change [10]. ARK aims to support prescribing and non-prescribing healthcare professionals to apply the ‘review and revise’ approach to antibiotic prescriptions for acute and general medical inpatients, and specifically to stop antibiotic treatment more often when it is safe to do so.

The clinical impact of many research programmes evaluating novel antimicrobial prescribing interventions is hampered by design and reporting limitations [11]. In particular all stages of evaluation should be reported, allowing clinicians to understand how potential barriers and facilitators have been considered. Ahead of the definitive evaluation of ARK in a multi-centre, stepped-wedge, cluster-randomized trial we undertook a single-site feasibility study. Here we report the practicalities of implementing the ARK hospital intervention in a single acute hospital. We investigated the feasibility of adapting the intervention according to local needs while maintaining fidelity to the core elements and acceptability of the intervention to front-line staff.

Section snippets

Ethics

Approvals were obtained from the South Central – Oxford C Research Ethics Committee (17/SC/0034) and Confidentiality Advisory Group (17/CAG/0015). The trial is registered with Current Controlled Trials (ISRCTN:12674243). This study has been reported in line with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)-AMS tool (Supplementary Table S1) [12].

Intervention description

ARK has four components: an online tool; prescribing decision aid (Supplementary Figure S1); data collection and

Core Team and essential clinical staff

At the feasibility site the Core Team included: the Champion (consultant in infectious diseases), the Trust's AMS lead, two acute medicine consultants, two antimicrobial pharmacists, two acute medicine charge nurses and three training-grade doctors. The Core Team received access to the intervention materials in February 2017 to begin planning towards implementation on April 18th, 2017. The team met four times over the 10 weeks to work through the guidance, assign, and deliver key tasks. The

Discussion

This study assessed the feasibility of implementing the novel, multi-faceted ARK intervention which has been developed to address overprescribing of antibiotics to hospitalized patients. The four elements of the intervention were successfully introduced into AMS practice at a medium-sized acute NHS hospital, facing typical pressures of under-staffing and patient burden [14]. The percentage of pre-specified essential staff who completed the online tool greatly exceeded the target level for

Conflict of interest statement

None declared.

Funding sources

This report is independent research funded by the National Institute for Health Research (Programme Grants for Applied Research, Antibiotic Reduction and Conservation in Hospitals (ARK-Hospital), RP-PG-0514-20015). The views expressed in this publication are those of the author(s) and not necessarily those of the National Health Service, the National Institute for Health Research or the Department of Health. A.S.W. is supported by the NIHR Biomedical Research Centre, Oxford. The ARK online tool

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    In this study we report the immediate and sustained effect of the ARK intervention on antibiotic consumption at the hospital level and clinical outcomes at the patient level. Following a feasibility evaluation at Brighton and Sussex University Hospitals NHS Trust, an acute hospital,20 the ARK intervention was evaluated at eligible participating hospitals across all UK nations by use of a stepped-wedge cluster-randomised controlled trial.21 A cluster design was essential to avoid contamination from health-care professionals moving between teams within a hospital.

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    This is challenging in clinical practice. We have reported previously that hospitals which do this well have lower rates of C. difficile infection [34], and interventions to increase stop rates at review are feasible in hospital settings [25]. It is to be expected that at hospitals where antibiotic prescription reviews are done well, fewer antibiotics would be used without compromising patient outcomes.

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Presentations on the ARK intervention have been made at: European Health Psychology Society Conference, Galway, Republic of Ireland, August 21st–25th, 2018 (poster); British Infection Association Spring Scientific Meeting, London, May 17th, 2018 (oral); Federation of Infection Societies Conference, Birmingham, November 30th to December 2nd, 2017 (oral).

These authors contributed equally.

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