Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, National Institute for Health Research, Imperial College London.
Department of Health Sciences, University of Leicester, United Kingdom.
Clin Infect Dis. 2019 Jun 18;69(1):12-20. doi: 10.1093/cid/ciy844.
Cultural and social determinants influence antibiotic decision-making in hospitals. We investigated and compared cultural determinants of antibiotic decision-making in acute medical and surgical specialties.
An ethnographic observational study of antibiotic decision-making in acute medical and surgical teams at a London teaching hospital was conducted (August 2015-May 2017). Data collection included 500 hours of direct observations, and face-to-face interviews with 23 key informants. A grounded theory approach, aided by Nvivo 11 software, analyzed the emerging themes. An iterative and recursive process of analysis ensured saturation of the themes. The multiple modes of enquiry enabled cross-validation and triangulation of the findings.
In medicine, accepted norms of the decision-making process are characterized as collectivist (input from pharmacists, infectious disease, and medical microbiology teams), rationalized, and policy-informed, with emphasis on de-escalation of therapy. The gaps in antibiotic decision-making in acute medicine occur chiefly in the transition between the emergency department and inpatient teams, where ownership of the antibiotic prescription is lost. In surgery, team priorities are split between 3 settings: operating room, outpatient clinic, and ward. Senior surgeons are often absent from the ward, leaving junior staff to make complex medical decisions. This results in defensive antibiotic decision-making, leading to prolonged and inappropriate antibiotic use.
In medicine, the legacy of infection diagnosis made in the emergency department determines antibiotic decision-making. In surgery, antibiotic decision-making is perceived as a nonsurgical intervention that can be delegated to junior staff or other specialties. Different, bespoke approaches to optimize antibiotic prescribing are therefore needed to address these specific challenges.
文化和社会决定因素影响医院的抗生素决策。我们调查并比较了急性内科和外科专业中抗生素决策的文化决定因素。
对伦敦一所教学医院的急性内科和外科团队的抗生素决策进行了民族志观察研究（2015 年 8 月至 2017 年 5 月）。数据收集包括 500 小时的直接观察和 23 名关键信息提供者的面对面访谈。采用扎根理论方法，借助 Nvivo 11 软件分析了新出现的主题。分析过程的迭代和递归确保了主题的饱和度。多种查询模式使研究结果得到了交叉验证和三角验证。
在医学领域，决策过程中的公认规范被描述为集体主义（来自药剂师、传染病和医学微生物学团队的投入）、合理化和政策知情，强调减少治疗的强度。急性内科中抗生素决策的差距主要发生在急诊科和住院部之间的过渡阶段，此时抗生素处方的所有权丧失。在外科领域，团队的优先级在三个环境之间划分：手术室、门诊和病房。高级外科医生经常不在病房，这使得初级工作人员需要做出复杂的医疗决策。这导致了防御性的抗生素决策，导致抗生素的使用时间延长且不合理。
在医学领域，急诊科做出的感染诊断决定了抗生素决策。在外科领域，抗生素决策被视为一种非外科干预，可以委托给初级工作人员或其他专业人员。因此，需要采用不同的、定制的方法来优化抗生素的使用，以解决这些特定的挑战。
