Design, Measurement, and Evaluation of an Education Strategy in the Hospital Setting to Combat Antimicrobial Resistance: Theoretical Considerations and a Practical Example
Celine Pulcini (Informatics Section, Division of Community Health Sciences, Dundee, Scotland) Sally Crofts (Department of Anaesthesia and Intensive Care, Ninewells Hospital, Dundee, Scotland) Diane Campbell (Department of Anaesthesia and Intensive Care, Ninewells Hospital, Dundee, Scotland) Peter Davey (Informatics Section, Division of Community Health Sciences, Dundee, Scotland)
Abstract
Antimicrobial resistance has become a major source of concern worldwide. The failure to implement basic infection control measures and the excessive use of antibacterials are the main causes of this problem. Both can be improved by restrictive or education strategies. Bacterial resistance is multifactorial, and so a multifaceted intervention is more likely to be effective. This article focuses on the design, measurement, and evaluation of an education strategy among healthcare professionals in the hospital setting, aiming at controlling hospital-acquired infection and antimicrobial resistance. An intervention conducted in our hospital, designed to decrease the ventilator-acquired pneumonia rate in the intensive care unit, is used as a practical example. Behavioral theories and continuous quality improvement techniques provide a framework for the design of educational interventions. Institutional support is essential, as is the multidisciplinary involvement of leaders and early adopters. Improvement interventions aim to change the daily practice of professionals, and it is critical to recognize that measures to evaluate improvement are fundamentally different from measures for research or accountability. In particular, improvement studies aim at understanding a specific process, on an individual medical site, and results are fed back almost in real time to the appropriate team. Such studies require use of few measures that must be easy to collect continuously or at regular close intervals, using small sample sizes, to ensure sustainability. Many small tests of change may be required before implementation with one clinical team; the spread to other clinical teams usually requires starting the entire process again. In our practical example, the Plan, Do, Study, Act cycle appeared to be a very useful tool, and it can be applied in any clinical setting to bring about large changes in practice in a short period of time. Improvement studies can be achieved by clinical teams without additional resources. Evaluation of the impact of changes in process on clinical or microbiological outcomes will require more sophisticated data collection or analysis, and may require additional resources for research. Nonetheless, the flexibility and simplicity of this approach makes the changes more likely to be accepted by clinical teams and to become embedded into their daily practice.
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