Abstract
In 2021, the World Health Organisation declared antimicrobial resistance (AMR) to be one of the top 10 global public health threats. Antimicrobial stewardship (AMS) can help to optimise antimicrobial use and its implementation improves clinical outcomes, reduces healthcare costs as well as reduces the prevalence of AMR. The research in this thesis explored factors that influence or contribute to the implementation of hospital-based AMS.Three empirical studies using multiple methods were conducted. The first two studies were undertaken to identify factors that influence or contribute to the implementation of AMS in hospitals in the context of AMS locally (England) and globally. The findings from the first two studies informed the development of the questionnaire used in the third study which explored perspectives of hospital-based AMS among healthcare professionals in Thailand.
The first study explored factors that influence the implementation of AMS in acute hospitals across South West England. Semi-structured interviews were conducted with 13 antimicrobial pharmacists, representing 13 acute hospitals across the region. Thematic analysis was used to produce the themes. Several factors were perceived to influence the implementation of AMS, involving at the individual, team, organisation, and national levels. The importance of (i) support from local hospital leadership and (ii) provision of data feedback to demonstrate AMS impact was considered to be essential components to drive immediate and sustainable changes in AMS. This was the first study in reporting the importance of ‘national strategies’ in contributing to AMS implementation.
A case study method which aimed to collect and analyse data from: (i) in-depth interviews with key AMS stakeholders, (ii) documentary analysis, and (iii) routinely collected AMS data, in acute hospitals in South West England, was planned in the next phase. The protocol was finalised; however, it was not able to continue due to the impact of COVID-19 pandemic. A systematic review was undertaken in a substitution.
The second study explored the elements and evaluated the effectiveness of pharmacist-led AMS interventions in improving antimicrobial use in hospital inpatients. Systematic review using narrative synthesis was conducted and included 52 full-text articles. The findings from the review found that most AMS interventions were facilitated by ‘clinical pharmacists’ (n=43 studies) and targeted ‘ward-based physicians’ (n=42 studies). All 52 studies evaluated education-based interventions (often in combination with other interventions) and reported improvements ‘in compliance with target AMS practice’. Pharmacist-led AMS interventions reduced duration of antimicrobial therapy without adversely affecting patient mortality. This review suggests that future hospital-based AMS should consider the involvement of pharmacists in delivering and promoting AMS interventions.
The third study explored and compared perspectives of hospital-based AMS among pharmacists, nurses, and physicians in public hospitals in Thailand. A cross-sectional survey was conducted and the questionnaire was developed using the findings from the interview study and the systematic review. A total of 659 respondents completed the survey, representing one-third (n=236) of public hospitals in Thailand. The survey found that the level of the uptake of AMS strategies varied by hospital size and was limited in small hospitals. Most respondents across the three professionals were supportive of tailoring strategies to reflect local resources, such as ‘the involvement of a trained pharmacist with expertise in antimicrobial utilisation’ and ‘the use of education-based strategies’ in promoting AMS locally. Almost all respondents acknowledged the importance of ‘workforce training’ and the role of ‘local hospital leadership’ in improving multidisciplinary engagement with AMS. The respondents had positive attitudes towards system improvements (e.g., audit and feedback) and the role of national strategies in promoting AMS. This survey suggests that effective strategies are needed to achieve greater engagement of small hospitals with AMS and should be built by reflecting local resources within individual hospitals in Thailand.
The research in this thesis indicates that several factors influence the implementation of hospital-based AMS and involve at the individual, team, organisation, and national levels. Local hospital leadership engagement and monitoring and reporting AMS outcomes are key to ensuring AMS success for the initial and ongoing steps. Tailoring strategies to reflect or fit in with local resources may help to promote AMS implementation in resource-limited settings, such as in Thailand. The inclusion of a trained pharmacist in AMS and the use of education, which include support from local hospital leaders, would be effective and promising strategies in promoting or improving future hospital-based AMS in Thailand.
Date of Award | 22 Feb 2023 |
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Original language | English |
Awarding Institution |
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Supervisor | Jennifer Scott (Supervisor), Paula Smith (Supervisor) & Margaret Watson (Supervisor) |
Keywords
- antimicrobials
- hospital
- Implementation