title: Implementation hurdles of an interactive, integrated, point-of-care computerised decision support system for hospital antibiotic prescription.
abstract: Antimicrobial stewardship is used to combat antimicrobial resistance. In Singapore, a tertiary hospital has integrated a computerised decision support system, called Antibiotic Resistance Utilisation and Surveillance-Control (ARUSC), into the electronic inpatient prescribing system. ARUSC is launched either by the physician to seek guidance for an infectious disease condition or via auto-trigger when restricted antibiotics are prescribed. This paper describes the implementation of ARUSC over three phases from 1 May 2011 to 30 April 2013, compared factors between ARUSC launches via auto-trigger and for guidance, examined factors associated with acceptance of ARUSC recommendations, and assessed user acceptability. During the study period, a monthly average of 9072 antibiotic prescriptions was made, of which 2370 (26.1%) involved ARUSC launches. Launches via auto-trigger comprised 48.1% of ARUSC launches. In phase 1, 23% of ARUSC launches were completed. This rose to 38% in phase 2, then 87% in phase 3, as escapes from the ARUSC programme were sequentially disabled. Amongst completed launches for guidance, 89% of ARUSC recommendations were accepted versus 40% amongst completed launches via auto-trigger. Amongst ARUSC launches for guidance, being from a medical department [adjusted odds ratio (aOR)=1.20, 95% confidence interval (CI) 1.04-1.37] and ARUSC launch during on-call (aOR=1.81, 95% CI 1.61-2.05) were independently associated with acceptance of ARUSC recommendations. Junior physicians found ARUSC useful. Senior physicians found ARUSC reliable but admitted to having preferences for antibiotics that may conflict with ARUSC. Hospital-wide implementation of ARUSC encountered hurdles from physicians. With modifications, the completion rate improved.
authors.affiliation: Department of Clinical Epidemiology, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
authors.forename: A L
authors.initials: AL
authors.lastname: Chow
authors.affiliation: Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: A
authors.initials: A
authors.lastname: Ang
authors.affiliation: Department of Clinical Epidemiology, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore.
authors.forename: C Z
authors.initials: CZ
authors.lastname: Chow
authors.affiliation: Department of Pharmacy, Tan Tock Seng Hospital, Singapore.
authors.forename: T M
authors.initials: TM
authors.lastname: Ng
authors.affiliation: Department of Pharmacy, Tan Tock Seng Hospital, Singapore; Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore.
authors.forename: C
authors.initials: C
authors.lastname: Teng
authors.affiliation: Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore.
authors.forename: L M
authors.initials: LM
authors.lastname: Ling
authors.affiliation: Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore.
authors.forename: B S
authors.initials: BS
authors.lastname: Ang
authors.affiliation: Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore. Electronic address: david_lye@ttsh.com.sg.
authors.forename: D C
authors.initials: DC
authors.lastname: Lye
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D020000:Decision Support Systems, Clinical; D003661:Decision Support Techniques; D004363:Drug Utilization / Q000592:standards*; D005260:Female; D006761:Hospitals; D006801:Humans; D008297:Male; D050316:Medical Order Entry Systems; D008875:Middle Aged; D019095:Point-of-Care Systems; D055656:Prescriptions / Q000592:standards*; D012846:Singapore
chemical_list: D000900:Anti-Bacterial Agents
keywords: Antimicrobial stewardship; Computerised decision support system; Electronic medication prescription; Implementation