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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 ([email protected]).
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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.

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