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Multisite Exploration of Clinical Decision Making for Antibiotic Use by Emergency Medicine Providers Using Quantitative and Qualitative Methods

  • Larissa May (a1), Glencora Gudger (a1), Paige Armstrong (a1), Gillian Brooks (a1), Pamela Hinds (a2), Rahul Bhat (a3), Gregory J. Moran (a4), Lisa Schwartz (a5), Sara E. Cosgrove (a6), Eili Y. Klein (a7), Richard E. Rothman (a8) and Cynthia Rand (a9)...

Extract

Objectives.

To explore current practices and decision making regarding antimicrobial prescribing among emergency department (ED) clinical providers.

Methods

We conducted a survey of ED providers recruited from 8 sites in 3 cities. Using purposeful sampling, we then recruited 21 providers for in-depth interviews. Additionally, we observed 10 patient-provider interactions at one of the ED sites. SAS 9.3 was used for descriptive and predictive statistics. Interviews were audio recorded, transcribed, and analyzed using a thematic, constructivist approach with consensus coding using NVivo 10.0. Field and interview notes collected during the observational study were aligned with themes identified through individual interviews.

Results

Of 150 survey respondents, 76% agreed or strongly agreed that antibiotics are overused in the ED, while half believed they personally did not overprescribe. Eighty-nine percent used a smartphone or tablet in the ED for antibiotic prescribing decisions. Several significant differences were found between attending and resident physicians. Interview analysis identified 42 codes aggregated into the following themes: (1) resource and environmental factors that affect care; (2) access to and quality of care received outside of the ED consult; (3) patient-provider relationships; (4) clinical inertia; and (5) local knowledge generation. The observational study revealed limited patient understanding of antibiotic use. Providers relied heavily upon diagnostics and provided limited education to patients. Most patients denied a priori expectations of being prescribed antibiotics.

Conclusions

Patient, provider, and healthcare system factors should be considered when designing interventions to improve antimicrobial stewardship in the ED setting.

Infect Control Hosp Epidemiol 2014;35(9):1114-1125

Copyright

Corresponding author

Department of Emergency Medicine, George Washington University Medical Faculty Associates, 2120 L Street, NW, Suite 450, Washington, DC 20037 (larissa.may@gmail.com).

References

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1. Lieberman, JM. Appropriate antibiotic use and why it is important: the challenges of bacterial resistance. Pediatr Infect Dis J 2003;22:11431151.
2. Shlaes, DM, Gerding, DN, John, JF Jr, et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Clin Infect Dis 1997;25(3):584599.
3. Karras, D. Antibiotic misuse in the emergency department. Acad Emerg Med 2006;13(3):331333.
4. Samore, MH, Tonnerre, C, Hannah, EL, et al. Impact of outpatient antibiotic use on carriage of ampicillin-resistant Escherichia coli. Antimicrob Agents Chemother 2011;55(3):11351141.
5. Costelloe, C, Metcalfe, C, Lovering, A, Mant, D, Hay, AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096.
6. Hicks, LA, Chien, YW, Taylor, TH Jr, Haber, M, Klugman, KP; Active Bacterial Core Surveillance (ABCs) Team. Outpatient antibiotic prescribing and nonsusceptible Streptococcus pneumoniae in the United States, 1996–2003. Clin Infect Dis 2011;53(7):631639.
7. Roumie, CL, Halasa, NB, Grijalva, CG, et al. Trends in antibiotic prescribing for adults in the United States—1995 to 2002. J Gen Intern Med 2005;20:697702.
8. Kane, BG, Degutis, LC, Sayward, HK, D’Onofrio, G. Compliance with the Centers for Disease Control and Prevention recommendations for the diagnosis and treatment of sexually transmitted diseases. Acad Emerg Med 2004;11:371377.
9. Schouten, JA, Hulscher, ME, Kullberg, BJ, et al. Understanding variation in quality of antibiotic use for community-acquired pneumonia: effect of patient, professional and hospital factors. J Antimicrob Chemother 2005;56:575582.
10. May, L, Harter, K, Yadav, K, et al. Practice patterns and management strategies for purulent skin and soft-tissue infections in an urban academic ED. Am J Emerg Med 2012;30(2):302310.
11. Grover, ML, Bracamonte, JD, Kanodia, AK, et al. Assessing adherence to evidence-based guidelines for the diagnosis and management of uncomplicated urinary tract infection. Mayo Clin Proc 2007;82(2):181185.
12. Jick, TD. Mixing qualitative and quantitative methods: triangulation in action. Admin Sci Q 1979:602611.
13. Srinivasan, A, Song, X, Richards, A, Sinkowitz-Cochran, R, Cardo, D, Rand, C. A survey of knowledge, attitudes, and beliefs of house staff physicians from various specialties concerning antimicrobial use and resistance. Arch Intern Med 2004;164(13):14511456.
14. Abbo, L, Sinkowitz-Cochran, R, Smith, L, et al. Faculty and resident physicians’ attitudes, perceptions, and knowledge about antimicrobial use and resistance. Infect Control Hosp Epidemiol 2011;32(7):714718.
15. Mills, J, Bonner, A, Francis, K. Adopting a constructivist approach to grounded theory: implications for research design. Int J Nurs Pract 2006;12(1):813.
16. Tversky, A, Kahneman, D. Judgment under uncertainty: heuristics and biases. Science 1974;185(4157):11241131.
17. Bettinghaus, EP. Health promotion and the knowledge-attitude-behavior continuum. Prev Med 1986;15(5):475491.
18. Cabana, M, Rand, C, Powe, N, et al. Why don’t physicians follow clinical practice guidelines? a framework for improvement. JAMA 1999;282(15):14581465.
19. Charani, E, Edwards, R, Sevdalis, N, et al. Behavior change strategies to influence antimicrobial prescribing in acute care: a systematic review. Clin Infect Dis 2011;53:651662.
20. De Souza, V, MacFarlane, A, Murphy, AW, Hanahoe, B, Barber, A, Cormicam, M. A qualitative study of factors influencing antimicrobial prescribing by non-consultant hospital doctors. J Antimicrob Chemother 2006;58:840843.
21. Shehab, N, Patel, PR, Srinivisan, A, Budnitz, DS. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis 2008;47:735743.
22. Ong, S, Nakase, J, Moran, GJ, et al. Antibiotic use for emergency department patients with upper respiratory infections: prescribing practices, patient expectations, and patient satisfaction. Ann Emerg Med 2007;50(3):213220.
23. Shapiro, E. Injudicious antibiotic use: an unforeseen consequence of the emphasis on patient satisfaction? Clin Ther 2002;24(1):197204.
24. Cockburn, J, Pit, S. Prescribing behaviour in clinical practice: patients’ expectations and doctors’ perceptions of patients’ expectations—a questionnaire study. BMJ 1997;315(7107):520523.
25. Fenton, JJ, Jerant, AF, Bertakis, KD, Franks, P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 2012;172(5):405411.
26. Chandler, CIR, Jones, C, Boniface, G, Kaseem, J, Reyburn, H, Whitty, CJM. Guidelines and mindlines: why do clinical staff over-diagnose malaria in Tanzania? a qualitative study. Malaria J 2008;7:53.
27. May, L, Katz, R, Johnston, L, Sanza, M, Petinaux, B. Assessing physicians’ in training attitudes and behaviors during the 2009 H1N1 influenza season: a cross-sectional survey of medical students and residents in an urban academic setting. Influenza Other Respir Viruses 2010;4(5):267275.
28. Grimshaw, JM, Shirran, L, Thomas, R, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care 2001;39(8 suppl 2):II2II45
29. Leblanc, A, Légaré, F, Labrecque, M, et al. Feasibility of a randomised trial of a continuing medical education program in shared decision-making on the use of antibiotics for acute respiratory infections in primary care: the DECISION+ pilot trial. Implement Sci 2011;6:5.
30. Wanderer, JP, Sandberg, WS, Ehrenfeld, JM. Real-time alerts and reminders using information systems. Anesthesiol Clin 2011;29(3):389396.
31. Waldron, N, Dey, I, Nagree, Y, Xiao, J, Flicker, L. A multifaceted intervention to implement guideline care and improve quality of care for older people who present to the emergency department with falls. BMC Geriatr 2011;11:6.
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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