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Case Study: Findings from the ASPIRES study in India

Learn through a case study of the ASPIRES study in India.
Case study.
© BSAC and Imperial College London

India is classified as a lower-middle-income country, with a population of approximately 1.3 billion in 2020. There is a high burden of infectious diseases as well as unregulated access to antimicrobials in the community.

Case study context

This section by Dr Vrinda Nampoothiri discusses about the ASPIRES study and the experiences of involving different stakeholders in antimicrobial stewardship (AMS) and Infection Prevention and Control initiatives at Amrita Institute of Medical Sciences, Kochi, Kerala, India. The Infection Prevention and Control (IPC) team there is led by a microbiologist and an infectious diseases physician and consists of infection control nurses and link nurses. The workflow of the IPC team can be seen in the diagram below.

ICU, ward, and lab (via lab culture results) feed into 'daily rounds by ICN for surveillance of HAIs. This plus audits of infection control procedures points to 'providing feedback'. Branching out from providing feedback are 'bedside training and correction', 'monthly unit meeting', 'month and report', and 'quarterly meeting'.

The antimicrobial stewardship (AMS) team at Amrita is led by the medical administrator and includes physicians, intensivists, clinical microbiologists, and clinical pharmacists along with Doctor of Pharmacy (Pharm D) interns in training. The workflow of the AMS team can be seen in the following diagram.

A complex flow diagram exploring the workflow of the AMS team, including the roles of the clinical pharmacist. The full version of this infographic is also available as a PDF, with screen-reader compatibility, in the downloads section.

This infographic is available as a PDF, with screen-reader compatibility, here.

The ASPIRES study

You will have already heard about the ASPIRES study from step 2.11. It is a multi-centre social sciences research project entitled, ‘Antibiotic use across Surgical Pathway: Investigating, Redesigning and Evaluating Systems’. The aim of this project is to address the key drivers of antimicrobial resistance by developing context-relevant preventative measures to reduce the risk of infection and optimise the use of antibiotics, coupled with tailored implementation strategies, along the entire surgical pathway.

At Amrita, this study was conducted in the Gastrointestinal (GI) and Cardiovascular and Thoracic Surgery (CVTS) departments.

A diagram exploring the approach to inquiry for the ASPIRES study. The full version of this infographic is available as a PDF, with screen reader compatibility, in the downloads section.

Click here for a PDF with screen-reader compatibility.

Ethnographic data collection

For this study, the team spent over one hundred hours observing the surgical teams on their ward rounds, ICU rounds, departmental rounds, outpatient clinics, and even in the operating theatre. In addition to that, over fifty face-to-face interviews were conducted with surgeons, surgical residents, nurses, and patients (with/without their carers) admitted to these departments.

Study findings

They identified that the feedback from the IPC and AMS teams to the surgical teams was not optimal. A summary of their findings is shown below.

The first finding was data not consistently shared with and within the team. The second finding was IPC team reports only go to the senior team members, with discussion of this data with junior members not consistent. The third finding was that AMS team feedback is only on a case-to-case basis, even though there is a month end appreciation email sent to head of department in case no instance of inappropriateness was identified in the department that month, this is inconsistent and juniors are again unaware. The final finding was that the role of the IPC and AMS teams is unknown to the surgical team.

ASPIRES intervention development

In order to address this communication gap, the ASPIRES team co-designed an intervention with the surgical, AMS, and IPC teams at the hospital.

This included the development of a shared platform, in which the IPC and AMS teams can present their data to the surgical teams through feedback meetings. In addition to this, the IPC team were trained to conduct a rapid root cause analysis of each surgical site infection (SSI) case that they identified. The findings of such could be provided and discussed in real-time during the feedback meetings with the surgical teams.

Focus-group discussions with the AMS, IPC, and surgical teams towards the end of the project helped to understand their perceptions of the ASPIRES project and its interventions. An example response from a GI surgeon is shown below.

Inside a speech bubble is the following quote: 'So, I think one thing the project definitely did is it kind of created awareness amongst us, surgeons, and our department about the whole idea of infection control, idea of antibiotic stewardship, and we are more aware and we sort of pay more attention towards it now and I think the interventions that you are coming up with probably helped a lot.'

Click ‘next’ to proceed to the next step, where we encourage you to think about applying ethnography to your practice.

© BSAC and Imperial College London
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