Hostname: page-component-8448b6f56d-c47g7 Total loading time: 0 Render date: 2024-04-17T22:58:52.236Z Has data issue: false hasContentIssue false
  • English
  • Français

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

Published online by Cambridge University Press:  10 May 2016

Larissa May ,
Glencora Gudger ,
Paige Armstrong ,
Gillian Brooks ,
Pamela Hinds ,
Rahul Bhat ,
Gregory J. Moran ,
Lisa Schwartz ,
Sara E. Cosgrove  and
Eili Y. Klein
...Show all authors
Larissa May*
Affiliation:
Department of Emergency Medicine, George Washington University, Washington, DC
Glencora Gudger
Affiliation:
Department of Emergency Medicine, George Washington University, Washington, DC
Paige Armstrong
Affiliation:
Department of Emergency Medicine, George Washington University, Washington, DC
Gillian Brooks
Affiliation:
Department of Emergency Medicine, George Washington University, Washington, DC
Pamela Hinds
Affiliation:
Children’s National Health System, Department of Nursing Research, Quality Outcomes Center for Translational Research, and Department of Pediatrics, George Washington University, Washington, DC
Rahul Bhat
Affiliation:
Department of Emergency Medicine, Georgetown University, Washington, DC
Gregory J. Moran
Affiliation:
Department of Emergency Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, California
Lisa Schwartz
Affiliation:
Department of Clinical Research and Leadership, George Washington University School of Medicine and Health Sciences, Washington, DC
Sara E. Cosgrove
Affiliation:
Department of Medicine, Division of Infectious Diseases, Johns Hopkins Medical Institutions, Baltimore, Maryland
Eili Y. Klein
Affiliation:
Center for Advanced Modeling, Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
Richard E. Rothman
Affiliation:
Department of Emergency Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
Cynthia Rand
Affiliation:
Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
*
Department of Emergency Medicine, George Washington University Medical Faculty Associates, 2120 L Street, NW, Suite 450, Washington, DC 20037 (larissa.may@gmail.com).
Get access Rights & Permissions [Opens in a new window]

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

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 35 , Issue 9 , 01 September 2014 , pp. 1114 - 1125
Copyright
© 2014 by The Society for Healthcare Epidemiology of America. All rights reserved.

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Lieberman, JM. Appropriate antibiotic use and why it is important: the challenges of bacterial resistance. Pediatr Infect Dis J 2003;22:1143–1151.Google Scholar
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):584–599.CrossRefGoogle Scholar
3. Karras, D. Antibiotic misuse in the emergency department. Acad Emerg Med 2006;13(3):331–333.Google Scholar
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):1135–1141.Google Scholar
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.CrossRefGoogle ScholarPubMed
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):631–639.CrossRefGoogle ScholarPubMed
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;20:697–702.Google Scholar
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;11:371–377.CrossRefGoogle ScholarPubMed
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;56:575–582.Google Scholar
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):302–310.Google Scholar
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):181–185.Google Scholar
12. Jick, TD. Mixing qualitative and quantitative methods: triangulation in action. Admin Sci Q 1979:602–611.Google Scholar
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):1451–1456.CrossRefGoogle ScholarPubMed
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):714–718.CrossRefGoogle ScholarPubMed
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):8–13.CrossRefGoogle ScholarPubMed
16. Tversky, A, Kahneman, D. Judgment under uncertainty: heuristics and biases. Science 1974;185(4157):1124–1131.Google Scholar
17. Bettinghaus, EP. Health promotion and the knowledge-attitude-behavior continuum. Prev Med 1986;15(5):475–491.Google Scholar
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):1458–1465.Google Scholar
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;53:651–662.CrossRefGoogle ScholarPubMed
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;58:840–843.CrossRefGoogle ScholarPubMed
21. Shehab, N, Patel, PR, Srinivisan, A, Budnitz, DS. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis 2008;47:735–743.Google Scholar
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):213–220.Google Scholar
23. Shapiro, E. Injudicious antibiotic use: an unforeseen consequence of the emphasis on patient satisfaction? Clin Ther 2002;24(1):197–204.Google Scholar
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):520–523.Google Scholar
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):405–411.Google Scholar
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.CrossRefGoogle ScholarPubMed
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):267–275.Google Scholar
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):II2–II45 Google Scholar
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.Google Scholar
30. Wanderer, JP, Sandberg, WS, Ehrenfeld, JM. Real-time alerts and reminders using information systems. Anesthesiol Clin 2011;29(3):389–396.Google Scholar
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.Google Scholar