Post Detail

Overview

In a significant step toward advancing patient safety and combating antimicrobial resistance (AMR) in South Asia, a landmark five-day initiative was successfully conducted for Phuntsholing General Hospital, a key secondary healthcare facility in Bhutan. This activity marked a robust integration of Antimicrobial Stewardship (AMS), Infection Prevention and Control (IPC), and Diagnostic Stewardship, three critical pillars of effective and sustainable healthcare delivery.

The initiative combined a high-impact two-day multidisciplinary training workshop with a focus on behavioural change, strengthening clinical practices, and establishing data-driven quality improvement strategies and  a three-day surgical prophylaxis audit .

1. Multidisciplinary Training Workshop (Days 1–2)

The workshop convened more than 25 healthcare professionals from a broad range of disciplines, including clinicians, surgeons, nurses, pharmacists, laboratory personnel, and hospital administrators, creating a valuable platform for cross-disciplinary dialogue and collaborative learning. This convergence of expertise fostered a unified approach to stewardship within the clinical environment, breaking silos and promoting shared responsibility across departments. Training focused on three key areas: Antimicrobial Stewardship (AMS), with an emphasis on improving surgical antibiotic prophylaxis (SAP) through protocol review and alignment of practices with international standards; Infection Prevention and Control (IPC), which included hands-on training in hand hygiene auditing, data collection, and compliance monitoring; and Diagnostic Stewardship, which addressed blood culture contamination and reinforced the importance of standardized patient bedside specimen collection protocols

Strategic Technical Guidance and Behavioural Insights

A major highlight of the workshop was the strategic guidance and technical presentations delivered by international stewardship advisors. These sessions grounded the discussions in evidence-based practices, real-world case studies, and WHO-endorsed tools, providing participants with a clear vision for integrated stewardship success. Equally impactful was the sharing of findings from the COM-B behavioural survey conducted among hospital staff prior to the training. This behaviour change model (Capability, Opportunity, Motivation – Behaviour) was used to assess the facility’s readiness and challenges in adopting an integrated approach to AMS, IPC, and diagnostic stewardship.

Key insights from the COM-B analysis revealed:

• Strong individual and collective motivation among stakeholders to improve stewardship practices, driven by a shared recognition of AMR as a pressing threat to patient safety and care quality.
• Gaps in capability, particularly around technical protocols for surgical prophylaxis and audit methodologies.
• Variable opportunity for implementation, highlighting system-level constraints such as workflow integration, documentation processes, and feedback mechanisms.

Stakeholders at Phuntsholing General Hospital demonstrated exceptionally high motivation to drive change. Participants openly reflected on the barriers and proposed innovative, context-appropriate solutions, showing a deep commitment to behavioural transformation as a key lever for improving clinical quality.

Building on the momentum generated during the training sessions, an in-depth analysis was conducted to review surgical antibiotic prophylaxis (SAP) prescription patterns and recent hand hygiene audit results. This critical exercise enabled the identification of actionable gaps in clinical practices and workflow. Findings highlighted inconsistencies in the timing and duration of SAP administration, as well as variation in hand hygiene compliance across departments. These insights laid the foundation for evidence-based decision-making and helped define key performance indicators to benchmark progress moving forward.

Three priority indicators were established:

Correct timing and appropriate duration of SAP, improved hand hygiene compliance across all clinical areas, and institutionalization of behaviour change interventions, using insights from the COM-B model to ensure interventions are both practical and sustainable. To address the identified gaps, the facility leadership empowered by the high level of motivation and ownership from the staff, collaboratively developed tailored solutions. These included targeted educational updates, revised workflow procedures, feedback mechanisms, and behaviourally informed nudges designed to improve adherence to best practices. Leadership involvement ensured the changes were realistic, context-appropriate, and included clear accountability from the start.

2. Surgical Prophylaxis Point Prevalence Survey (Days 3–5)

To reinforce training outcomes and create a baseline for quality improvement, a three-day point prevalence survey (PPS) was carried out, focusing on surgical prophylaxis prescribing practices. This practical exercised  aimed to build staff capacity in data collection and interpretation while also providing a snapshot of current prescribing practices.

The NAPS (National Antimicrobial Prescribing Survey) methodology, developed by the partner organization, National Center for Antimicrobial Stewardship (NCAS) was used to assess prescribing patterns across surgical departments. Involving trained staff in real-time data collection reinforced the antimicrobial stewardship principles introduced during the workshop and promoted local engagement and accountability.

3. Follow-Up and Action Plan

The initiative concluded with a forward-looking action planning session, where all stakeholders came together to co-create a site-specific improvement roadmap. This roadmap was grounded in behavioural science, informed by the data collected, and aligned with global AMR and quality-of-care strategies.

The agreed-upon interventions included:

• Finalization and adoption of a revised SAP protocol, ensuring clarity and standardization across surgical teams.
• Institutionalization of routine hand hygiene audits, supported by structured feedback loops and performance dashboards.
• Implementation of COM-B-informed behaviour change strategies, such as targeted messaging, peer champions, and workflow adaptations.

This collaborative planning session was designed to ensure the initiative would not remain a one-off training event, but instead develop into a sustained improvement journey, led and owned by the facility itself.

Next Steps: November 2025 Milestone Review

A formal follow-up visit is scheduled for November 2025, to review progress against the defined indicators. This milestone represents a critical opportunity to assess implementation challenges, provide ongoing mentorship, and refine interventions based on real-world learning. It also sets the stage for continued technical collaboration and potential scale-up to other facilities across the country.

Why This Matters Globally

This initiative illustrates how low- and middle-income countries (LMICs) such as Bhutan are taking proactive leadership in operationalizing integrated stewardship frameworks that directly align with global strategies to combat antimicrobial resistance. By combining clinical capacity building, behavioural science, and real-time data collection, this approach exemplifies an adaptable, scalable, and contextually appropriate model of stewardship excellence.

Phuntsholing General Hospital’s commitment to change, backed by evidence, collaboration, and innovation offers a compelling blueprint for other healthcare facilities worldwide aiming to preserve antimicrobial effectiveness, improve surgical outcomes, and embed quality into routine care.

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