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

Background Antimicrobial stewardship is increasingly important to ensure appropriate antibiotics use and reduce antimicrobial resistance. In Emergency Department (ED), test results are often pending at discharge, particularly microbiology findings that may require follow-up action. Delays in reviewing these results can lead to ineffective treatment and inappropriate antibiotic use and contribute to antimicrobial resistance. While decision support tools can support test result management, few solutions are tailored to the ED workflows, and challenges remain in seamless integration and clinician acceptance. This study involved co-designing a test result review app with clinicians in an ED of a paediatric hospital, building on an existing research prototype which cross-references microbiology results with prescribed antibiotics to prioritize identification of drug-bug mismatches and support timely follow-up. Methods We conducted semi-structured interviews with clinicians responsible for test result review. The aims were to map the current review workflow, identify design requirements, and understand factors influencing the app implementation to enable strategy identification. Five interview sessions were held with five nurse practitioners and three paediatric senior medical officers in the ED. Scenario-based evaluation of the prototype were also conducted during the sessions. Data were analysed using thematic analysis to identify workflow characteristics and design considerations. Factors influencing implementation were coded using the CFIR (Consolidated Framework for Implementation Research) and subsequently mapped to the ERIC (Expert Recommendation for Implementation Change) framework to generate implementation strategies. Results The study revealed key activities in the test result review workflow, including checking and assessing results, escalation and consultation, antibiotic review and adjustments, documentation in result review pools and Integrated Electronic Medical Record (ieMR), sign-off and patient follow-up. Current challenges included high result volumes, lack of function tools such as prioritization, incomplete documentation, navigation burdens across medical systems, and the workload of follow-up. Participants viewed the proof-of-concept positively and provided design feedback across functions, features, usability and integration. Ten CFIR-based influencing factors were identified, covering innovation suitability, adaptability, design, relative advantage, complexity, information technology infrastructure, work infrastructure, local conditions, communications and tension for change. Resulting ERIC recommended key strategies included: adapt and tailor to context, develop stakeholder interrelations and use evaluative and iterative strategies. Conclusion The study generated detailed design considerations for further development of the test result review app and identified key implementation influencing factors and strategies using established implementation science frameworks. These findings will inform the next steps, including technology refinements, stakeholder workshops to map optimal workflows, and development of actionable implementation strategies for a pilot trial.