Increasing antimicrobial resistance has been identified as a global threat to health. To arrest such threat, a variety of measures have been implemented to improve the quality of antimicrobial prescribing. But whilst increasing prescriber knowledge has proven easier to achieve, maintaining adequate engagement with recommended prescribing behaviours remains harder to accomplish due to psychological and behavioural influences. In other clinical settings, the use of serious electronic games coupled with the application of game mechanics have been successfully employed to resolve similar behavioural challenges, allowing players to experience complicated clinical scenarios and gain technical skills without any negative consequences on patients. In 2013 we proposed to investigate if a serious smartphone prescribing game would be effective in supporting and encouraging the prudent use of antimicrobials in acute care.
In collaboration with a commercial game company, we developed a series of virtual patients that presented signs and symptoms of different infectious pathologies including community- and healthcare-acquired pneumonia, viral and bacterial meningitis, urinary tract infection, influenza, cellulitis and C. difficile colitis, among others. Players gradually receive clinical information for each patient to help them decide the diagnosis and management for the case, and can opt to prescribe oral antibiotics, broad- or narrow-spectrum intravenous (IV) antibiotics, request further tests or discharge the patient without any treatment. Timely and accurate diagnosis and clinical management are rewarded by the scoring algorithm, whilst too conservative or hurried decisions are penalised. Recognising the social interactions that occur during a prescribing decision and the impact of such decisions on different professional groups, we include behavioural nudges offered by professionals, patients and hospital management, depending on each player’s performance.
We used several gamification elements to focus players’ mind on desired antimicrobial prescribing behaviours and to highlight any unintended consequences. The user interface can be personalized and timers and scores, together with increasing case difficulty were introduced to sustain engagement with the game. Immediate feedback after each case and tailored messages informed players about their performance. Delayed consequences of prescribing decisions were explicit for players; for example, using IV antibiotics too frequently results in cannula-site infections which will reappear as follow-up cases, increasing players workload.
The game (which can be downloaded here) from was launched on 6th May to coincide with the international patient safety day promoted by the World Health Organization. The concept and progress were recently presented at the 16th International Conference on Infectious Diseases in Cape Town (South Africa) and the European Congress of Clinical Microbiology and Infectious Diseases in Barcelona (Spain), attracting much interest as no other research group has developed a similar initiative.
Sustaining appropriate prescribing behaviours remains a challenge for antimicrobial stewardship initiatives worldwide. Serious games delivered on mobile devices can complement the experiential learning of prescribers. Games can be useful to reinforce desired behaviours, elicit the relationships between different professional groups involved in prescribing decision-making, and highlight any unintended consequences of antimicrobial prescribing. Serious games may be an affordable and feasible solution to address the behavioural and social influences on prescribing.
Enrique Castro Sánchez
Academic Research Nurse
National Centre for Infection Prevention and Management