Optimising the design and prospective implementation of a test result review app to support antimicrobial stewardship in emergency departments – A qualitative study

Every year, millions of people walk into emergency departments around the world, often carrying an infection that needs to be treated immediately. Doctors must make quick decisions about which antibiotics to prescribe, often before they know exactly which bacteria is causing the illness. This is a necessary gamble, but it carries a hidden risk. When a patient leaves the hospital, their test results might still be waiting in the wings. If those results arrive later and show that the bacteria is resistant to the medicine the patient is taking, or that a different drug would work better, someone needs to find that information and act on it. If this follow-up is delayed or missed, the patient might suffer from ineffective treatment, and the bacteria could learn to survive the drugs meant to kill it, a growing global problem known as antimicrobial resistance.

To solve this, researchers are turning to technology. They are building digital tools designed to help doctors and nurses manage the flood of test results that come in after a patient has gone home. The goal is to create a system that automatically flags when a prescribed antibiotic does not match the bacteria found in a test, prompting a quick phone call or a change in medication. However, technology alone is not enough. A tool that does not fit into the chaotic, fast-paced rhythm of an emergency room will simply be ignored. This is where the work of a team from the Commonwealth Scientific and Industrial Research Organisation and Queensland Children's Hospital becomes vital. They set out to understand exactly how doctors and nurses currently handle these pending results, and how to design a new app that actually helps them rather than adding to their burden.

The researchers focused their study on the emergency department of a large children's hospital in Brisbane, Australia. They knew that the people who would use this new tool were already stretched thin, managing high volumes of patients and complex cases. To understand the real-world challenges, the team did not just ask questions in a quiet office. They went to the hospital, walked through the emergency department, and sat down with the people doing the work. They spoke with eight experienced clinicians, including five nurse practitioners and three senior medical officers, who are responsible for reviewing test results and deciding on follow-up care. The researchers listened to stories about their daily routines, watched how they navigated different computer systems, and asked them to try out a prototype of the new app using simulated patient cases.

The current process the team observed was a collaborative but fragile effort. When a patient leaves the emergency department, the doctor who treated them is responsible for checking their own test results. However, because shifts change and doctors are often busy with new patients, a safety net was built into the system: nurse practitioners review a shared pool of results from all the doctors, acting as a backup to catch anything that might have been missed. This process involves checking the results, deciding if the antibiotics need to change, calling the patient or their family, and documenting everything in the hospital's electronic records. The researchers found that this workflow was under immense pressure. Clinicians described feeling overwhelmed by the sheer number of results, the difficulty of finding specific information buried in long notes, and the mental fatigue of trying to remember which patients needed a call. They also noted that the systems they used did not always talk to each other, forcing them to log in and out of different programs to piece together a patient's story.

When the team introduced the prototype app, the clinicians saw its potential but also pointed out exactly where it needed to change to fit their lives. The app was designed to automatically compare the bacteria found in a test with the antibiotic the patient was prescribed. If the bacteria was resistant to the drug, the app would flag it in red. The clinicians liked this visual cue, as it would help them spot problems quickly. However, they were clear that the app could not create more work. If the app showed a list of patients that they then had to manually check again in the main hospital system, it would be useless. They insisted that the app needed to be integrated directly into the hospital's existing electronic medical records so that signing off on a result in the app would also update the main system. They also asked for more specific details, such as the exact count of bacteria growth or whether the patient had a history of similar infections, to help them make better decisions.

The researchers used a structured approach to turn these conversations into a plan. They analyzed the interviews to identify the specific factors that would help or hinder the app's success. They found that the most important things were not just about the technology itself, but about how it fit into the hospital's culture and physical environment. The clinicians needed the tool to be adaptable to their specific roles, simple to use without training, and capable of reducing the time they spent searching for information. The team also realized that for the app to work, the hospital needed to support the people using it. This meant having leaders within the emergency department who could champion the new tool, training staff on how to use it, and ensuring that the technology team was ready to fix any connection issues between the app and the hospital's computers.

The study concluded that the path forward requires a careful, step-by-step approach. The researchers recommended that before the app is rolled out to everyone, it should be tested in a small pilot trial with a few key users. This would allow the team to see how the tool works in real time, gather feedback, and make adjustments. They emphasized that the design must be tailored to the local context, meaning the app might look and function differently in this children's hospital compared to an adult hospital. The team also highlighted the need for strong relationships between the IT department, hospital management, and the clinical staff to ensure that the technical requirements are met and that the staff feels supported. By focusing on these human and organizational factors alongside the technology, the researchers believe they can create a system that truly supports doctors and nurses in their critical work of keeping patients safe and fighting antibiotic resistance.

This work represents a shift in how medical technology is developed. Instead of building a tool in a lab and hoping it fits, the researchers worked alongside the people who would use it from the very beginning. They listened to the specific complaints about high workloads and confusing systems, and they used those insights to shape the design. The result is a plan for an app that is not just a piece of software, but a partner in the daily workflow of an emergency department. By addressing the real barriers to adoption, such as the need for seamless integration and clear visual cues, the team is laying the groundwork for a future where test results are reviewed faster, antibiotics are used more wisely, and patients receive the right care at the right time.