Improving antibiotic use in hospitals: development of a digital antibiotic review tracking toolkit (DARTT) using the behaviour change wheel

Figures & data

Figure 1. The Behaviour Change Wheel, highlighting the COM-B model, intervention functions and policy categories (Michie et al., 2014), licensed under the Creative Commons Attribution License 2.0.

Figure 2. The BCW intervention design process.

Box 1. Focus groups sample characteristics.

Characteristic	Total number of participants (n = 17)
Healthcare professionals (HCPs)	14
Health service users	3
Gender
Male	7
Female	10
Age range
21–30	1
31–40	7
41–50	3
51–60	4
>60	2
Ethnicity
White British	14
Mixed (white Asian)	1
White (other)	2
Current clinical position (HCPs only n = 14)
Consultant physician	2
Microbiology consultant	2
Clinical pharmacist	2
Advanced nurse practitioner	3
Nurse (i.e. infection surveillance, clinical research manager)	5
Years of clinical experience
5–10	3
11–20	4
21–30	4
>30	3

Table 1. Specifying the target behaviour (Step 3).

Steps involved in specifying the target behaviour	Details
Target behaviour	Active ‘antibiotic time-out’—to have a structured discussion after newly ordered antibiotics have been administered to a patient for a period of 2–3 days to determine whether the patient is clinically responding; whether microbiologic data support the continued use of the ordered antimicrobial(s) or de-escalation to a narrower-spectrum agent; and whether the dose, route and duration of therapy are appropriate.
Who needs to perform the behaviour?	HCPs involved in prescribing or administration of antibiotics to inpatients, irrespective of grade and experience.
What do they need to do differently to achieve the desired behaviour?	Carry out a timely and comprehensive antibiotic reassessment and modify therapy based on the clinical status and culture results.
When do they need to do it?	At 48–72 hours after initiation of antibiotics.
Where do they need to do it?	In acute hospitals (including acute and general medical settings).
How Often do they need to do it?	Daily after the initial reassessment.
With Whom do they need to do it?	A multi-disciplinary person-centred approach in consultation with patients and/or guardians.

Table 2. Behavioural analysis of determinants influencing active ‘antibiotic time-out’ within the context of hospital prescribing (Step 4).

COM-B	TDF	What needs to change for the target behaviour to occur?
Capability—physical	Physical skills	Acquire competence in changing and discontinuing antibiotics; Improved communication skills; Ability to engage patients in shared decision-making.
Capability—Psychological	Knowledge	Increase prescriber knowledge of how to initiate and perform antibiotic time-out; Increase knowledge of current guidelines and the threat posed by AMR when deciding to continue a broad-spectrum antibiotic; Increase patient and family’s knowledge of the AMR and the risks of antibiotics.
	Memory, attention and decision processes	Increase awareness of the importance of person-centred prescribing.
	Behavioural regulation	Ability to weigh up information from guidelines, patient’s pre-existing conditions and testing to inform prescribing decisions; Reduce cognitive overload on prescribers.
Opportunity—physical	Environmental context and resources	Increase use of resources to effectively document and communicate prescribing decisions; Increase transparency of prescribing; Provide easy access to antimicrobial guidelines. Reduce time pressures/streamline clinical workflow; Improve collaboration of care decisions; Consistent provision of professional development and training opportunities around antibiotic time-out for all clinical staff; Use of triggers to review antibiotics; Facilitate discussions with patients and families about antibiotics. Provision of resources and tools to support patient and family member involvement in antibiotic decisions. Increase access to rapid diagnostic tests—outwith the scope of the intervention.
Opportunity—social	Social influences	Increase social support from peers and other specialties in initiating active reassessment of antibiotics; Normalise questions around antibiotics.
Motivation—reflective	Beliefs about capabilities	Empower prescribers to make autonomous decisions during antibiotic time-out; Increase confidence in initiating antibiotic time-out and changing or stopping therapy. Increase confidence to challenge decisions of senior colleagues; Empower patients and families to ask questions about antibiotics.
	Beliefs about consequences	Reduce invisibility of consequences of poor practice.
	Social/professional role and identity	Understand personal and professional responsibilities of the role; Reduce responsibility avoidance; Harness leadership to show that most people perform the desired behaviour.
	Goals	Employ strategies to initiate a formal antibiotic time-out.
Motivation—automatic	Reinforcement	Monitor prescribing decisions and provide feedback on performance.
	Emotion	Reduce fear of de-escalating/stopping antibiotics.

Box 2. Interviewee characteristics.

Characteristic	Total number of participants (n = 18)
Healthcare professionals	15
Health service users	3
Gender
Male	9
Female	9
Age range
21–30	3
31–40	4
41–50	5
51–60	5
>60	1
Ethnicity
White British	17
Black African	1
Current clinical position (HCPs only n = 15)
Consultant physician	2
Microbiology consultant	2
Infectious diseases consultant	1
Medical trainees (FY1/FY2/Registrar)	3
Clinical pharmacist	3
Advanced nurse practitioner	3
Nurse (infection surveillance)	1
Years of clinical experience
<5	3
5–10	2
21–30	8
>30	2

Michie, S., Atkins, L., & West, R. (2014). The behaviour change wheel: A guide to designing interventions. Silverback Publishing.

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Data availability statement

The data supporting the findings of this study are available from the corresponding author [GW] on request.