Imperial College London

DrRaheelahAhmad

Faculty of MedicineDepartment of Medicine

Non-Clinical Lecturer
 
 
 
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Contact

 

+44 (0)20 3313 3244raheelah.ahmad00

 
 
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Location

 

Hammersmith HospitalHammersmith Campus

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Summary

 

Publications

Publication Type
Year
to

31 results found

Zingg W, Storr J, Park BJ, Ahmad R, Tarrant C, Castro Sanchez E, Tomczyk S, Kilpatrick C, Allegranzi B, Cardo D, Pittet D, the 2017 Geneva IPC-Think Tanket al., 2019, Implementation research for the prevention of antimicrobial resistance and healthcare-associated infections; 2017 Geneva Infection Prevention and Control (IPC)-Think Tank (Part 1), Antimicrobial Resistance and Infection Control, Vol: 8, ISSN: 2047-2994

BackgroundAround 5–15% of all hospital patients worldwide suffer from healthcare-associated infections (HAIs), and years of excessive antimicrobial use in human and animal medicine have created emerging antimicrobial resistance (AMR). A considerable amount of evidence-based measures have been published to address these challenges, but the largest challenge seems to be their implementation.MethodsIn June 2017, a total of 42 experts convened at the Geneva IPC-Think Tank to discuss four domains in implementation science: 1) teaching implementation skills; 2) fostering implementation of IPC and antimicrobial stewardship (AMS) by policy making; 3) national/international actions to foster implementation skills; and 4) translational research bridging social sciences and clinical research in infection prevention and control (IPC) and AMR.ResultsAlthough neglected in the past, implementation skills have become a priority in IPC and AMS. They should now be part of any curriculum in health care, and IPC career paths should be created. Guidelines and policies should be aligned with each other and evidence-based, each document providing a section on implementing elements of IPC and AMS in patient care. International organisations should be advocates for IPC and AMS, framing them as patient safety issues and emphasizing the importance of implementation skills. Healthcare authorities at the national level should adopt a similar approach and provide legal frameworks, guidelines, and resources to allow better implementation of patient safety measures in IPC and AMS. Rather than repeating effectiveness studies in every setting, we should invest in methods to improve the implementation of evidence-based measures in different healthcare contexts. For this, we need to encourage and financially support collaborations between social sciences and clinical IPC research.ConclusionsExperts of the 2017 Geneva Think Tank on IPC and AMS, CDC, and WHO agreed that sustained efforts on implem

Journal article

Zingg W, Park BJ, Storr J, Ahmad R, Tarrant C, Castro Sanchez E, Perencevich E, Widmer A, Krause K-H, Kilpatrick C, Tomczyk S, Allegranzi B, Cardo D, Pittet Det al., 2019, Technology for the prevention of antimicrobial resistance and healthcare-associated infections; 2017 Geneva IPC-Think Tank (Part 2), Antimicrobial Resistance and Infection Control, Pages: 1-5, ISSN: 2047-2994

BackgroundThe high burden of healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) is partially due to excessive antimicrobial use both in human and animal medicine worldwide. How can technology help to overcome challenges in infection prevention and control (IPC) and to prevent HAI and emerging AMR?MethodsIn June 2017, 42 international experts convened in Geneva, Switzerland to discuss four potential domains of technology in IPC and AMR: 1) role and potential contribution of microbiome research; 2) whole genome sequencing; 3) effectiveness and benefit of antimicrobial environmental surfaces; and 4) future research in hand hygiene.ResultsResearch on the microbiome could expand understanding of antimicrobial use and also the role of probiotics or even faecal transplantation for therapeutic purposes. Whole genome sequencing will provide new insights in modes of transmission of infectious diseases. Although it is a powerful tool for public health epidemiology, some challenges with interpretation and costs still need to be addressed. The effectiveness and cost-effectiveness of antimicrobially coated or treated environmental high-touch surfaces requires further research before they can be recommended for routine use. Hand hygiene implementation can be advanced, where technological enhancement of surveillance, technique and compliance are coupled with reminders for healthcare professionals.ConclusionsThe four domains of technological innovation contribute to the prevention of HAI and AMR at different levels. Microbiome research may offer innovative concepts for future prevention, whole genome sequencing could detect new modes of transmission and become an additional tool for effective public health epidemiology, antimicrobial surfaces might help to decrease the environment as source of transmission but continue to raise more questions than answers, and technological innovation may have a role in improving surveillance approaches and supporting best pr

Journal article

Zingg W, Storr J, Park BJ, Jernigan JA, Harbarth S, Grayson ML, Tacconelli E, Allegranzi B, Cardo D, Pittet D, Abbas M, Ahmad R, Ailegranzi B, Andremont A, Bell M, Borg M, Carmeli Y, Castro-Sanchez E, Conly J, Eggimann P, Gastmeier P, Hernandez M, Hetwaldt L, Holmes A, Kilpatrick C, Kolwaite A, Krause K-H, Larson E, Masson-Roy S, Mehtar S, Mendelson M, Lin LM, Moldovan A, Monnet D, Ndoye B, Nthumba P, Ogunsola F, Park B, Perencevich E, Samore M, Seto WH, Srinivasan A, Tarrant C, Tomczyk S, Talaat M, Villegas MV, Voss A, Walsh T, Widmer Aet al., 2019, Broadening the infection prevention and control network globally; 2017 Geneva IPC-think tank (part 3), Antimicrobial Resistance and Infection Control, Vol: 8, Pages: 1-5, ISSN: 2047-2994

BackgroundHealthcare-associated infection (HAI) is a major challenge for patient safety worldwide, and is further complicated by antimicrobial resistance (AMR) due to excessive antimicrobial use in both humans and animals. Existing infection prevention and control (IPC) networks must be strengthened and adapted to better address the global challenges presented by emerging AMR.MethodsIn June 2017, 42 international experts convened in Geneva, Switzerland, to discuss two key areas for strengthening the global IPC network: 1) broadening collaboration in IPC; and 2) how to bring the fields IPC and AMR control together.ResultsThe US Centers for Disease Prevention and Control, the European Centre for Disease Prevention and Control, and the World Health Organization (WHO) convened together with international experts to discuss collaboration and networks, demonstrating the participating organizations’ commitment to close collaboration in IPC. The challenge of emerging AMR can only be addressed by strengthening this collaboration across international organisations and between public health and academia. The WHO SAVE LIVES: Clean Your Hands initiative is an example of a successful collaboration between multiple global stakeholders including academia and international public health organisations; it can be used as a model. IPC-strategies are included within the four pillars to combat AMR: surveillance, IPC, antimicrobial and diagnostic stewardship, research and development. The prevention of transmission of multidrug-resistant microorganisms is a patient safety issue, and must be strengthened in the fight against AMR.ConclusionsThe working group determined that international organisations should take the lead in creating new networks, which will in turn attract academia and other stakeholders to join. At the same time, they should invest in bringing existing IPC and AMR networks under one umbrella. Transmission of multidrug-resistant microorganisms in hospitals and in the

Journal article

Kyratsis Y, Ahmad R, Iwami M, Castro-Sánchez E, Atun R, Holmes AHet al., 2019, A multilevel neo-institutional analysis of infection prevention and control in English hospitals: coerced safety culture change?, Sociol Health Illn

Despite committed policy, regulative and professional efforts on healthcare safety, little is known about how such macro-interventions permeate organisations and shape culture over time. Informed by neo-institutional theory, we examined how inter-organisational influences shaped safety practices and inter-subjective meanings following efforts for coerced culture change. We traced macro-influences from 2000 to 2015 in infection prevention and control (IPC). Safety perceptions and meanings were inductively analysed from 130 in-depth qualitative interviews with senior- and middle-level managers from 30 English hospitals. A total of 869 institutional interventions were identified; 69% had a regulative component. In this context of forced implementation of safety practices, staff experienced inherent tensions concerning the scope of safety, their ability to be open and prioritisation of external mandates over local need. These tensions stemmed from conflicts among three co-existing institutional logics prevalent in the NHS. In response to requests for change, staff flexibly drew from a repertoire of cognitive, material and symbolic resources within and outside their organisations. They crafted 'strategies of action', guided by a situated assessment of first-hand practice experiences complementing collective evaluations of interventions such as 'pragmatic', 'sensible' and also 'legitimate'. Macro-institutional forces exerted influence either directly on individuals or indirectly by enriching the organisational cultural repertoire.

Journal article

Ahmad R, Zhu J, Lebcir MR, Atun Ret al., How the health-seeking behaviour of pregnant women affects neonatal outcomes: findings of System Dynamics modelling in Pakistan, BMJ Global Health, ISSN: 2059-7908

Background: Limited studies have explored how health-seeking behaviour during pregnancy through to delivery affect neonatal outcomes. We modelled health-seeking behaviour across urban and rural settings in Pakistan, where poor neonatal outcomes persist with wide disparities. Methods and Findings: A System Dynamics model was developed and parameterised. Following validation tests, the model was used to determine neonatal mortality for pregnant women considering their decisions to access, refuse, and switch antenatal care services in four provider sectors: public, private, traditional, and charitable. Four health-seeking scenarios were tested across different pregnancy trimesters. Health-seeking behaviour in different sub-groups by geographic locations, and social network effect was modelled. The largest reduction in neonatal mortality was achieved with antenatal care provided by skilled providers in public, private or charitable sectors, combined with the use of institutional delivery. Women’s social networks had strong influences on if, when and where to seek care. Interventions by Lady Health Workers had a minimal impact on health-seeking behaviour and neonatal outcomes after Trimester 1. Optimal benefits were achieved for urban women when antenatal care was accessed within Trimester 2, but for rural women within Trimester 1. Antenatal care access delayed to Trimester 3 had no protective impact on neonatal mortality. Conclusions: System Dynamics modelling enables capturing complexity of health-seeking behaviours and impact on outcomes, informing: intervention design, implementation of targeted policies, and uptake of services specific to urban/rural settings considering structural enablers/barriers to access, cultural contexts, and strong social network influences.

Journal article

McLeod M, Ahmad R, Shebl NA, Micallef C, Sim F, Holmes Aet al., 2019, A whole-health-economy approach to antimicrobial stewardship: Analysis of current models and future direction., PLoS Med, Vol: 16, Pages: e1002774-e1002774

In a Policy Forum, Alison Holmes and colleagues discuss coordinated approaches to antimicrobial stewardship.

Journal article

Rawson TM, Ahmad R, Toumazou C, Georgiou P, Holmes Aet al., 2019, Artificial intelligence can improve decision-making in infection management, Nature Human Behaviour, ISSN: 2397-3374

Antibiotic resistance is an emerging global danger. Reaching responsible prescribing decisions requires the integration of broad and complex information. Artificial intelligence tools could support decision-making at multiple levels, but building them needs a transparent co-development approach to ensure their adoption upon implementation.

Journal article

Charani E, Smith I, Skodvin B, Perozziello A, Lucet JC, Lescure FX, Brigand G, Poda A, Ahmad R, Singh S, Holmes AHet al., 2019, Investigating the cultural and contextual determinants of antimicrobial stewardship programmes across low-, middle- and high-income countries – a qualitative study, PLoS ONE, Vol: 14, ISSN: 1932-6203

BackgroundMost of the evidence on antimicrobial stewardship programmes (ASP) to help sustain the effectiveness of antimicrobials is generated in high income countries. We report a study investigating implementation of ASP in secondary care across low-, middle- and high-income countries. The objective of this study was to map the key contextual, including cultural, drivers of the development and implementation of ASP across different resource settings.Materials and methodsHealthcare professionals responsible for implementing ASP in hospitals in England, France, Norway, India, and Burkina Faso were invited to participate in face-to face interviews. Field notes from observations, documentary evidence, and interview transcripts were analysed using grounded theory approach. The key emerging categories were analysed iteratively using constant comparison, initial coding, going back the field for further data collection, and focused coding. Theoretical sampling was applied until the categories were saturated. Cross-validation and triangulation of the findings were achieved through the multiple data sources.Results54 participants from 24 hospitals (England 9 participants/4 hospitals; Norway 13 participants/4 hospitals; France 9 participants/7 hospitals; India 13 participants/ 7 hospitals; Burkina Faso 8 participants/2 hospitals) were interviewed. Across Norway, France and England there was consistency in ASP structures. In India and Burkina Faso there were country level heterogeneity in ASP. State support for ASP was perceived as essential in countries where it is lacking (India, Burkina Faso), and where it was present, it was perceived as a barrier (England, France). Professional boundaries are one of the key cultural determinants dictating involvement in initiatives with doctors recognised as leaders in ASP. Nurse and pharmacist involvement was limited to England. The surgical specialty was identified as most difficult to engage with in each country. Despite challenges, on

Journal article

Charani E, Ahmad R, Rawson T, Castro-Sanchez E, Tarrant C, Holmes Aet al., 2018, The differences in antibiotic decision-making between acute surgical and acute medical teams: An ethnographic study of culture and team dynamics, Clinical Infectious Diseases, ISSN: 1058-4838

BackgroundCultural and social determinants influence antibiotic decision-making in hospitals. We investigated and compared cultural determinants of antibiotic decision-making in acute medical and surgical specialties.MethodsAn ethnographic observational study of antibiotic decision-making in acute medical and surgical teams at a London teaching hospital was conducted (August 2015–May 2017). Data collection included 500 hours of direct observations, and face-to-face interviews with 23 key informants. A grounded theory approach, aided by Nvivo 11 software, analyzed the emerging themes. An iterative and recursive process of analysis ensured saturation of the themes. The multiple modes of enquiry enabled cross-validation and triangulation of the findings.ResultsIn medicine, accepted norms of the decision-making process are characterized as collectivist (input from pharmacists, infectious disease, and medical microbiology teams), rationalized, and policy-informed, with emphasis on de-escalation of therapy. The gaps in antibiotic decision-making in acute medicine occur chiefly in the transition between the emergency department and inpatient teams, where ownership of the antibiotic prescription is lost. In surgery, team priorities are split between 3 settings: operating room, outpatient clinic, and ward. Senior surgeons are often absent from the ward, leaving junior staff to make complex medical decisions. This results in defensive antibiotic decision-making, leading to prolonged and inappropriate antibiotic use.ConclusionsIn medicine, the legacy of infection diagnosis made in the emergency department determines antibiotic decision-making. In surgery, antibiotic decision-making is perceived as a nonsurgical intervention that can be delegated to junior staff or other specialties. Different, bespoke approaches to optimize antibiotic prescribing are therefore needed to address these specific challenges.

Journal article

Mizuno S, Iwami M, Kunisawa S, Naylor N, Yamashita K, Kyratsis Y, Meads G, Otter J, Holmes A, Ahmad Ret al., 2018, Comparison of national strategies to reduce methicillin-resistant Staphylococcus aureus (MRSA) infections in Japan and England, Journal of Hospital Infection, Vol: 100, Pages: 280-298, ISSN: 0195-6701

BackgroundNational responses to healthcare-associated infections vary between high-income countries but when analysed for contextual comparability, interventions can be assessed for transferability.AimTo identify learning from country-level approaches to addressing meticillin-resistant Staphylococcus aureus (MRSA) in Japan and England.MethodsA longitudinal analysis (2000-17), comparing epidemiological trends and policy interventions. Data from 441 textual sources concerning infection prevention and control (IPC), surveillance, and antimicrobial stewardship interventions were systematically coded for: type - mandatory requirements, recommendations, or national campaigns; method - restrictive, persuasive, structural in nature; level of implementation - macro (national), meso (organisational), micro (individual) levels. Healthcare organisational structures and role of media were also assessed.FindingsIn England significant reduction has been achieved in number of reported MRSA bloodstream infections. In Japan, in spite of reductions, MRSA remains a predominant infection. Both countries face new threats in the emergence of drug-resistant Escherichia coli. England has focused on national mandatory and structural interventions, supported by a combination of outcomes-based incentives and punitive mechanisms, and multidisciplinary IPC hospital teams. Japan has focused on (non-mandatory) recommendations and primarily persuasive interventions, supported by process-based incentives, with voluntary surveillance. Areas for development in Japan include resourcing of dedicated data management support and implementation of national campaigns for healthcare professionals and the public.ConclusionPolicy interventions need to be relevant to local epidemiological trends, while acceptable within health system cultures and public expectations. Cross-national learning can help inform the right mix of interventions to create sustainable and resilient systems for future infection and econom

Journal article

Alividza V, Mariano V, Ahmad R, Charani E, Rawson T, Holmes A, Castro Sanchez EMet al., 2018, Investigating the impact of poverty on colonization and infection with drug-resistant organisms in humans: a systematic review, Infectious Diseases of Poverty, Vol: 7, ISSN: 2049-9957

BackgroundPoverty increases the risk of contracting infectious diseases and therefore exposure to antibiotics. Yet there is lacking evidence on the relationship between income and non-income dimensions of poverty and antimicrobial resistance. Investigating such relationship would strengthen antimicrobial stewardship interventions.MethodsA systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Ovid, MEDLINE, EMBASE, Scopus, CINAHL, PsychINFO, EBSCO, HMIC, and Web of Science databases were searched in October 2016. Prospective and retrospective studies reporting on income or non-income dimensions of poverty and their influence on colonisation or infection with antimicrobial-resistant organisms were retrieved. Study quality was assessed with the Integrated quality criteria for review of multiple study designs (ICROMS) tool.ResultsNineteen articles were reviewed. Crowding and homelessness were associated with antimicrobial resistance in community and hospital patients. In high-income countries, low income was associated with Streptococcus pneumoniae and Acinetobacter baumannii resistance and a seven-fold higher infection rate. In low-income countries the findings on this relation were contradictory. Lack of education was linked to resistant S. pneumoniae and Escherichia coli. Two papers explored the relation between water and sanitation and antimicrobial resistance in low-income settings.ConclusionsDespite methodological limitations, the results suggest that addressing social determinants of poverty worldwide remains a crucial yet neglected step towards preventing antimicrobial resistance.

Journal article

Castro Sanchez EM, Iwami M, Ahmad R, Atun R, Holmes Aet al., 2018, Articulating citizen participation in national antimicrobial resistance plans: a comparison of European countries, European Journal of Public Health, ISSN: 1101-1262

BackgroundNational action plans determine country responses to anti-microbial resistance (AMR). These plans include interventions aimed at citizens. As the language used in documents could persuade certain behaviours, we sought to assess the positioning and implied responsibilities of citizens in current European AMR plans. This understanding could lead to improved policies and interventions.MethodsReview and comparison of national action plans for AMR (NAP-AMR) obtained from the European Centre for Disease Prevention and Control (plans from 28 European Union and four European Economic Area/European Free Trade Association countries), supplemented by European experts (June–September 2016). To capture geographical diversity, 11 countries were purposively sampled for content and discourse analyses using frameworks of lay participation in healthcare organization, delivery and decision-making.ResultsCountries were at different stages of NAP-AMR development (60% completed, 25% in-process, 9% no plan). The volume allocated to citizen roles in the plans ranged from 0.3 to 18%. The term ‘citizen’ was used by three countries, trailing behind ‘patients’ and ‘public’ (9/11), ‘general population’ (6/11) and ‘consumers’ (6/11). Increased citizen awareness about AMR was pursued by ∼2/3 plans. Supporting interventions included awareness campaigns (11/11), training/education (7/11) or materials during clinical encounters (4/11). Prevention of infection transmission or self-care behaviours were much less emphasized. Personal/individual and social/collective role perspectives seemed more frequently stimulated in Nordic countries.ConclusionCitizen roles in AMR plans are not fully articulated. Documents could employ direct language to emphasise social or collective responsibilities in optimal antibiotic use.

Journal article

Rawson T, Moore L, Castro Sanchez E, Charani E, Hernandez Perez B, Alividza V, Husson F, Toumazou C, Ahmad R, Georgiou P, Holmes Aet al., 2018, Development of a patient-centred intervention to improve knowledge and understanding of antibiotic therapy in secondary care, Antimicrobial Resistance and Infection Control, Vol: 7, ISSN: 2047-2994

Introduction: We developed a personalised antimicrobial information module co-designed with patients. This study aimed to evaluate the potential impact of this patient-centred intervention on short-term knowledge and understanding of antimicrobial therapy in secondary care. Methods:Thirty previous patients who had received antibiotics in hospital within 12 months were recruited to co-design an intervention to promote patient engagement with infection management. Two workshops, containing five focus-groups were held. These were audio-recorded. Data were analysed using a thematic framework developed deductively based on previous work. Line-by-line coding was performed with new themes added to the framework by two researchers. This was used to inform the development of a patient information module, embedded within an electronic decision support tool (CDSS). The intervention was piloted over a four-week period at Imperial College Healthcare NHS Trust on 30 in-patients. Pre- and post-intervention questionnaires were developed and implemented to assess short term changes in patient knowledge and understanding and provide feedback on the intervention. Data were analysed using SPSS and NVIVO software. Results: Within the workshops, there was consistency in identified themes. The participants agreed upon and co-designed a personalised PDF document that could be integrated into an electronic CDSS to be used by healthcare professionals at the point-of-care. Their aim for the tool was to provide individualised practical information, signpost to reputable information sources, and enhance communication between patients and healthcare professionals.Eighteen out of thirty in-patients consented to participant in the pilot evaluation with 15/18(83%) completing the study. Median (range) age was 66(22-85) years. The majority were male (10/15;66%). Pre-intervention, patients reported desiring further information regarding their infections and antibiotic therapy, including side effects

Journal article

Birgand G, Castro-Sánchez E, Hansen S, Gastmeier P, Lucet J-C, Ferlie E, Holmes A, Ahmad Ret al., 2018, Comparison of governance approaches for the control of antimicrobial resistance: Analysis of three European countries, Antimicrobial Resistance and Infection Control, Vol: 7, ISSN: 2047-2994

Policy makers and governments are calling for coordination to address the crisis emerging from the ineffectiveness of current antibiotics and stagnated pipe-line of new ones - antimicrobial resistance (AMR). Wider contextual drivers and mechanisms are contributing to shifts in governance strategies in health care, but are national health system approaches aligned with strategies required to tackle antimicrobial resistance? This article provides an analysis of governance approaches within healthcare systems including: priority setting, performance monitoring and accountability for AMR prevention in three European countries: England, France and Germany. Advantages and unresolved issues from these different experiences are reported, concluding that mechanisms are needed to support partnerships between healthcare professionals and patients with democratized decision-making and accountability via collaboration. But along with this multi-stakeholder approach to governance, a balance between regulation and persuasion is needed.

Journal article

Rawson T, Castro Sanchez E, Charani E, Husson F, Moore L, Holmes A, Ahmad Ret al., 2017, Involving citizens in priority setting for public health research: implementation in infection research, Health Expectations, Vol: 21, Pages: 222-229, ISSN: 1369-7625

BackgroundPublic sources fund the majority of UK infection research, but citizens currently have no formal role in resource allocation. To explore the feasibility and willingness of citizens to engage in strategic decision making, we developed and tested a practical tool to capture public priorities for research.MethodA scenario including six infection themes for funding was developed to assess citizen priorities for research funding. This was tested over two days at a university public festival. Votes were cast anonymously along with rationale for selection. The scenario was then implemented during a three-hour focus group exploring views on engagement in strategic decisions and in-depth evaluation of the tool.Results188/491(38%) prioritized funding research into drug-resistant infections followed by emerging infections(18%). Results were similar between both days. Focus groups contained a total of 20 citizens with an equal gender split, range of ethnicities and ages ranging from 18 to >70 years. The tool was perceived as clear with participants able to make informed comparisons. Rationale for funding choices provided by voters and focus group participants are grouped into three major themes: (i) Information processing; (ii) Knowledge of the problem; (iii) Responsibility; and a unique theme within the focus groups (iv) The potential role of citizens in decision making. Divergent perceptions of relevance and confidence of “non-experts” as decision makers were expressed.ConclusionVoting scenarios can be used to collect, en-masse, citizens' choices and rationale for research priorities. Ensuring adequate levels of citizen information and confidence is important to allow deployment in other formats.

Journal article

Naylor NR, Zhu N, Hulscher M, Holmes A, Ahmad R, Robotham JVet al., 2017, Is antimicrobial stewardship cost-effective? A narrative review of the evidence, Clinical Microbiology and Infection, Vol: 23, Pages: 806-811, ISSN: 1198-743X

AIMS: This narrative review aimed to collate recent evidence on the cost-effectiveness and cost-benefit of antimicrobial stewardship (AMS) programmes, to address the question 'is AMS cost-effective?', while providing resources and guidance for future research in this area. SOURCES: PubMed was searched for studies assessing the cost-effectiveness, cost-utility or cost-benefit of AMS interventions in humans, published from January 2000 to March 2017, with no setting inclusion/exclusion criteria specified. Reference lists of retrieved reviews were searched for additional articles. CONTENT: Recent evidence on the cost-effectiveness and cost-benefit of AMS is described, studies suggest persuasive and structural AMS interventions may provide health economic benefits to the hospital setting. However, overall, cost-effectiveness evidence for AMS is severely limited, especially for the community setting. Recommendations for future research in this area are therefore provided, including discussion of appropriate health economic methodological choice. IMPLICATIONS: Health systems have a finite and decreasing resource, decision makers currently do not have necessary evidence to assess whether AMS programmes provide sufficient benefits. Although the evidence-base of the cost-effectiveness of AMS is increasing, it remains inadequate for investment decision-making. Robust health economics research needs to be completed to enhance the generalizability and usability of cost-effectiveness results.

Journal article

Charani E, Ahmad R, Tarrant C, Birgand G, Leather A, Mendelson M, Moonesinghe SR, Sevdalis N, Singh S, Holmes Aet al., 2017, Opportunities for system level improvement in antibiotic use across the surgical pathway, International Journal of Infectious Diseases, Vol: 60, Pages: 29-34, ISSN: 1201-9712

Optimizing antibiotic prescribing across the surgical pathway (before, during, and after surgery) is a key aspect of tackling important drivers of antimicrobial resistance and simultaneously decreasing the burden of infection at the global level. In the UK alone, 10 million patients undergo surgery every year, which is equivalent to 60% of the annual hospital admissions having a surgical intervention. The overwhelming majority of surgical procedures require effectively limited delivery of antibiotic prophylaxis to prevent infections. Evidence from around the world indicates that antibiotics for surgical prophylaxis are administered ineffectively, or are extended for an inappropriate duration of time postoperatively. Ineffective antibiotic prophylaxis can contribute to the development of surgical site infections (SSIs), which represent a significant global burden of disease. The World Health Organization estimates SSI rates of up to 50% in postoperative surgical patients (depending on the type of surgery), with a particular problem in low- and middle-income countries, where SSIs are the most frequently reported healthcare-associated infections. Across European hospitals, SSIs alone comprise 19.6% of all healthcare-acquired infections. Much of the scientific research in infection management in surgery is related to infection prevention and control in the operating room, surgical prophylaxis, and the management of SSIs, with many studies focusing on infection within the 30-day postoperative period. However it is important to note that SSIs represent only one of the many types of infection that can occur postoperatively. This article provides an overview of the surgical pathway and considers infection management and antibiotic prescribing at each step of the pathway. The aim was to identify the implications for research and opportunities for system improvement.

Journal article

Castro Sanchez EM, Iwami M, Ahmad R, Holmes Aet al., 2017, Articulating citizen participation in national policies for addressing antimicrobial resistance in European countries - an updated analysis, ECCMID 2017, Publisher: European Society of Clinical Microbiology and Infectious Diseases

Conference paper

Alividza V, Mariano V, Steel S, Holmes A, Castro Sanchez EMet al., 2017, Investigating the impact of poverty on colonization/infection with drug-resistant organisms in humans: a scoping review, ECCMID 2017

Poster

Lebcir R, Demir E, Ahmad R, Vasilakis C, Southern Det al., 2017, A Discrete Event Simulation model to evaluate the use of community services in the treatment of patients with Parkinson's disease in the United Kingdom, BMC Health Services Research, Vol: 17, ISSN: 1472-6963

Background: The numberof people affected byParkinson’s disease (PD) is increasing in the United Kingdom driven by populationageing. The treatment of the disease is complex, resource intensive and currently there is no known cure to PD. The National Health Service (NHS), the public organisation delivering healthcare in the UK, is under financial pressures. There is a need to find innovative ways to improve the operational and financial performance of treating PD patients. The use of community services is a new and promising way of providing treatment and care to PD patients a reduced cost than hospitalcare. The aim of this study is to evaluate the potentialoperational and financial benefits, which could be achieved through increased integration of community services in the delivery of treatment and care to PD patients in the UKwithout compromising care quality. Methods:A Discrete Event Simulation modelwas developed to represent the PD care structure including patients’ pathways, treatment modes, and the mix of resources required to treat PD patients. The model was parametrised with data from a large NHS Trust in the UKand validated using informationfrom the same trust.Four possible scenarios involving increased use of community services were simulated on the model.Results:Shifting more patients with PD from hospital treatment to community services will reduce the number of visits of PD patients to hospitalsby about 25%and the number of PD doctors and nurses required to treat these patientsby around 32%. Hospital based treatment costsand overall should decrease by26% leading to overall savings of 10% in the total cost of treating PD patients.

Journal article

Iwami M, Ahmad R, Castro Sanchez E, Birgand G, Johnson AP, Holmes AHet al., 2017, Capacity of English NHS hospitals to monitor quality in infection prevention and control using a new European framework: a multi-level qualitative analysis., BMJ Open, Vol: 7, ISSN: 2044-6055

Objective: (1) To assess the extent to which current English national regulations/policies/guidelines and local hospital practices align with indicators suggested by a European review of effective strategies for infection prevention and control (IPC); (2) to examine the capacity of local hospitals to report on the indicators and current use of data to inform IPC management and practice. Design: A national and local-level analysis of the 27 indicators was conducted. At the national level, documentary review of regulations/policies/guidelines was conducted. At the local level: a) documentary review of 14 hospitals to determine the capacity to report on performance; b) qualitative interviews with three senior managers from five hospitals and direct observation of hospital wards to identify gaps in use of these indicators to improve IPC management and practice.Setting: Two acute English National Health Service (NHS) trusts and one NHS foundation trust (14 hospitals).Participants: Three senior managers from five hospitals for qualitative interviews.Primary and secondary outcome measures: As primary outcome measures, a ‘Red-Amber-Green’ (RAG) rating was developed reflecting how well the indicators were included in national documents or their availability at local organisational level. The current use of the indicators to inform IPC management and practice was also assessed. Secondary outcome measure includes the assessment of gaps across national and local levels by comparing the RAG rating results.ResultsNational regulations/policies/guidelines largely cover the suggested European indicators. The ability of individual hospitals to report some of the indicators at ward level varies across staff groups, which may mask required improvements. A reactive use of staffing-related indicators was observed rather than the suggested prospective strategic approach for IPC management.ConclusionsFor effective patient safety and infection prevention in English hospitals, ro

Journal article

Castro Sanchez EM, Iwami M, Ahmad R, Holmes Aet al., 2016, Application of novel outcome evaluation criteria to UK social marketing campaigns focused on infections, FIS/HIS 2016

Conference paper

Rawson T, Moore L, Hernandez B, Castro Sanchez E, Charani E, Georgiou P, Ahmad R, Holmes Aet al., 2016, Patient engagement with infection management in secondary care: a qualitative investigation of current experiences, BMJ Open, Vol: 6, ISSN: 2044-6055

Objective To understand patient engagement with decision-making for infection management in secondary care and the consequences associated with current practices.Design A qualitative investigation using in-depth focus groups.Participants Fourteen members of the public who had received antimicrobials from secondary care in the preceding 12 months in the UK were identified for recruitment. Ten agreed to participate. All participants had experience of infection management in secondary care pathways across a variety of South-East England healthcare institutes. Study findings were subsequently tested through follow-up focus groups with 20 newly recruited citizens.Results Participants reported feelings of disempowerment during episodes of infection in secondary care. Information is communicated in a unilateral manner with individuals ‘told’ that they have an infection and will receive an antimicrobial (often unnamed), leading to loss of ownership, frustration, anxiety and ultimately distancing them from engaging with decision-making. This poor communication drives individuals to seek information from alternative sources, including online, which is associated with concerns over reliability and individualisation. Failures in communication and information provision by clinicians in secondary care influence individuals’ future ideas about infections and their management. This alters their future actions towards antimicrobials and can drive prescription non-adherence and loss to follow-up.Conclusions Current infection management and antimicrobial prescribing practices in secondary care fail to engage patients with the decision-making process. Secondary care physicians must not view infection management episodes as discrete events, but as cumulative experiences which have the potential to shape future patient behaviour and understanding of antimicrobial use.

Journal article

Holmes A, Castro-Sánchez E, Ahmad R, 2016, Guidelines in infection prevention: Current challenges and limitations, British Journal of Health Care Management, Vol: 22, Pages: 440-443, ISSN: 1358-0574

Journal article

Holmes A, Dixon-Woods M, Ahmad R, Brewster E, Castro Sanchez EM, Secci F, Zingg Wet al., 2015, Infection prevention and control: lessons from acute care in England. Towards a whole health economy approach, Infection prevention and control: lessons from acute care in England, Publisher: Health Foundation

Report

Ahmad R, Iwami M, Castro-Sanchez E, Husson F, Taiyari K, Zingg W, Holmes Aet al., 2015, Defining the user role in infection control, Journal of Hospital Infection, Vol: 92, Pages: 321-327, ISSN: 1532-2939

BackgroundHealth policy initiatives continue to recognize the valuable role of patients and the public in improving safety, advocating the availability of information as well as involvement at the point of care. In infection control, there is a limited understanding of how users interpret the plethora of publicly available information about hospital performance, and little evidence to support strategies that include reminding healthcare staff to adhere to hand hygiene practices.AimTo understand how users define their own role in patient safety, specifically in infection control.MethodsThrough group interviews, self-completed questionnaires and scenario evaluation, user views of 41 participants (15 carers and 26 patients with recent experience of inpatient hospital care in London, UK) were collected and analysed. In addition, the project's patient representative performed direct observation of the research event to offer inter-rater reliability of the qualitative analysis.FindingsUsers considered evidence of systemic safety-related failings when presented with hospital choices, and did not discount hospitals with high (‘red’ flagged) rates of meticillin-resistant Staphylococcus aureus. Further, users considered staff satisfaction within the workplace over and above user satisfaction. Those most dissatisfied with the care they received were unlikely to ask staff, ‘Have you washed your hands?’ConclusionThis in-depth qualitative analysis of views from a relatively informed user sample shows ‘what matters’, and provides new avenues for improvement initiatives. It is encouraging that users appear to take a holistic view of indicators. There is a need for strategies to improve dimensions of staff satisfaction, along with understanding the implications of patient satisfaction.

Journal article

Holmes A, Castro-Sánchez E, Ahmad R, 2015, Guidelines in infection prevention: Current challenges and limitations, British Journal of Health Care Management, Vol: 21, Pages: 275-277, ISSN: 1358-0574

Journal article

Kyratsis Y, Ahmad R, Hatzaras K, Iwami M, Holmes AHet al., 2014, Making sense of evidence in management decisions: the role of research-based knowledge on innovation adoption and implementation in health care., Health Services and Delivery Research, Vol: 2, ISSN: 2050-4357

Background: Although innovation can improve patient care, implementing new ideas is often challenging.Previous research found that professional attitudes, shaped in part by health policies and organisationalcultures, contribute to differing perceptions of innovation ‘evidence’. However, we still know little abouthow evidence is empirically accessed and used by organisational decision-makers when innovationsare introduced.Aims and objectives: We aimed to investigate the use of different sources and types of evidence ininnovation decisions to answer the following questions: how do managers make sense of evidence? Whatrole does evidence play in management decision-making when adopting and implementing innovations inhealth care? How do wider contextual conditions and intraorganisational capacity influence research useand application by health-care managers?Methods: Our research design comprised multiple case studies with mixed methods. We investigatedtechnology adoption and implementation in nine acute-care organisations across England. We employedstructured survey questionnaires, in-depth interviews and documentary analysis. The empirical setting wasinfection prevention and control. Phase 1 focused on the espoused use of evidence by 126 non-clinicaland clinical hybrid managers. Phase 2 explored the use of evidence by managers in specific technologyexamples: (1) considered for adoption; (2) successfully adopted and implemented; and (3) rejectedor discontinued.Findings: (1) Access to, and use of, evidence types and sources varied greatly by profession. Cliniciansreported a strong preference for science-based, peer-reviewed, published evidence. All groups called uponexperiential knowledge and expert opinion. Nurses overall drew upon a wider range of evidence sourcesand types. Non-clinical managers tended to sequentially prioritise evidence on cost from national-levelsources, and local implementation trials. (2) A sizeable proportion of professionals from all g

Journal article

Ahmad R, Kyratsis Y, Holmes A, 2012, When the user is not the chooser: learning from stakeholder involvement in technology adoption decisions in infection control, Journal of Hospital Infection, Vol: 81, Pages: 163-168

Journal article

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