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Perioperative antimicrobial decision making: Focused ethnography study in orthopedic and cardiothoracic surgeries in an Australian hospital

Published online by Cambridge University Press:  18 March 2020

Trisha N. Peel Open the ORCID record for Trisha N. Peel [Opens in a new window] ,
Eliza Watson ,
Kelly Cairns ,
Ho Yin (Ashley) Lam ,
Heidi Zhangrong Li ,
Ganan Ravindran ,
Jayan Seneviratne ,
David Daly ,
Susan Liew  and
David McGiffin
...Show all authors
Trisha N. Peel*
Affiliation:
Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
Eliza Watson
Affiliation:
Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
Kelly Cairns
Affiliation:
Department of Pharmacy, Alfred Health, Melbourne, Victoria, Australia
Ho Yin (Ashley) Lam
Affiliation:
Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
Heidi Zhangrong Li
Affiliation:
Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
Ganan Ravindran
Affiliation:
Medical Students, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
Jayan Seneviratne
Affiliation:
Medical Students, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
David Daly
Affiliation:
Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
Susan Liew
Affiliation:
Department of Orthopaedic Surgery, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
David McGiffin
Affiliation:
Department of Cardiothoracic Surgery, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
Paul Myles
Affiliation:
Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
Darshini Ayton
Affiliation:
Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
*
Author for correspondence: Trisha N. Peel, E-mail: [email protected]
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Abstract

Objective:

Antimicrobial use in the surgical setting is common and frequently inappropriate. Understanding the behavioral context of antimicrobial use is a critical step to developing stewardship programs.

Design:

In this study, we employed qualitative methodologies to describe the phenomenon of antimicrobial use in 2 surgical units: orthopedic surgery and cardiothoracic surgery.

Setting:

This study was conducted at a public, quaternary, university-affiliated hospital.

Participants:

Healthcare professionals from the 2 surgical unit teams participated in the study.

Methods:

We used focused ethnographic and face-to-face semi-structured interviews to observe antimicrobial decision-making behaviors across the patient’s journey from the preadmission clinic to the operating room to the postoperative ward.

Results:

We identified 4 key themes influencing decision making in the surgical setting. Compartmentalized communication (theme 1) was observed with demarcated roles and defined pathways for communication (theme 2). Antimicrobial decisions in the operating room were driven by the most senior members of the team. These decisions, however, were delegated to more junior members of staff in the ward and clinic environment (theme 3). Throughout the patient’s journey, communication with the patient about antimicrobial use was limited (theme 4).

Conclusions:

Approaches to decision making in surgery are highly structured. Although this structure appears to facilitate smooth flow of responsibility, more junior members of the staff may be disempowered. In addition, opportunities for shared decision making with patients were limited. Antimicrobial stewardship programs need to recognize the hierarchal structure as well as opportunities to engage the patient in shared decision making.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 41 , Issue 6 , June 2020 , pp. 645 - 652
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.

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