Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge,Tan Tock Seng Hospital,Singapore,Singapore.
Department of Emergency Medicine,Tan Tock Seng Hospital,Singapore,Singapore.
Epidemiol Infect. 2019 Jan;147:e111. doi: 10.1017/S095026881800331X.
Upper respiratory tract infections (URTIs) account for substantial attendances at emergency departments (EDs). There is a need to elucidate determinants of antibiotic prescribing in time-strapped EDs - popular choices for primary care despite highly accessible primary care clinics. Semi-structured in-depth interviews were conducted with purposively sampled physicians (n = 9) in an adult ED in Singapore. All interviews were analysed using thematic analysis and further interpreted using the Social Ecological Model to explain prescribing determinants. Themes included: (1) reliance on clinical knowledge and judgement, (2) patient-related factors, (3) patient-physician relationship factors, (4) perceived practice norms, (5) policies and treatment guidelines and (6) patient education and awareness. The physicians relied strongly on their clinical knowledge and judgement in managing URTI cases and seldom interfered with their peers' clinical decisions. Despite departmental norms of not prescribing antibiotics for URTIs, physicians would prescribe antibiotics when faced with uncertainty in patients' diagnoses, treating immunocompromised or older patients with comorbidities, and for patients demanding antibiotics, especially under time constraints. Participants had a preference for antibiotic prescribing guidelines based on local epidemiology, but viewed hospital policies on prescribing as a hindrance to clinical judgement. Participants highlighted the need for more public education and awareness on the appropriate use of antibiotics and management of URTIs. Organisational practice norms strongly influenced antibiotic prescribing decisions by physicians, who can be swayed by time pressures and patient demands. Clinical decision support tools, hospital guidelines and patient education targeting at individual, interpersonal and community levels could reduce unnecessary antibiotic use.
上呼吸道感染 (URTI) 在急诊科 (ED) 的就诊中占很大比例。需要阐明在时间紧迫的 ED 中决定开抗生素处方的因素 - 尽管初级保健诊所高度普及，但 ED 仍然是初级保健的热门选择。在新加坡的一家成人 ED 中，对有目的地抽样的医生（n=9）进行了半结构式深入访谈。使用主题分析对所有访谈进行分析，并使用社会生态模型进一步解释处方决定因素。主题包括：（1）依赖临床知识和判断，（2）患者相关因素，（3）医患关系因素，（4）感知的实践规范，（5）政策和治疗指南，（6）患者教育和意识。医生在管理 URTI 病例时强烈依赖他们的临床知识和判断，很少干预他们同事的临床决策。尽管部门规范规定不治疗 URTI 开具抗生素，但当患者的诊断不确定、治疗免疫功能低下或患有合并症的老年患者时，以及当患者要求使用抗生素时，即使在时间紧迫的情况下，医生也会开抗生素。参与者倾向于使用基于当地流行病学的抗生素处方指南，但认为医院的处方政策会干扰临床判断。参与者强调需要对抗生素的合理使用和 URTI 的管理进行更多的公众教育和意识提高。组织实践规范强烈影响医生的抗生素处方决策，医生可能会受到时间压力和患者需求的影响。针对个人、人际和社区层面的临床决策支持工具、医院指南和患者教育可以减少不必要的抗生素使用。
