College of Nursing, University of Colorado-Denver, Anschutz Medical Campus, Aurora, Colorado, United States.
Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States.
Appl Clin Inform. 2020 Aug;11(4):589-597. doi: 10.1055/s-0040-1715893. Epub 2020 Sep 9.
This study was aimed to explore the intersection between organizational environment, workflow, and technology in pediatric emergency departments (EDs) and how these factors impact antibiotic prescribing decisions.
Semistructured interviews with 17 providers (1 fellow and 16 attending faculty), and observations of 21 providers (1 physician assistant, 5 residents, 3 fellows, and 12 attendings) were conducted at three EDs in the United States. We analyzed interview transcripts and observation notes using thematic analysis.
Seven themes relating to antibiotic prescribing decisions emerged as follows: (1) professional judgement, (2) cognition as a critical individual resource, (3) decision support as a critical organizational resource, (4) patient management with imperfect information, (5) information-seeking as a primary task, (6) time management, and (7) broad process boundaries of antibiotic prescribing.
The emerging interrelated themes identified in this study can be used as a blueprint to design, implement, and evaluate clinical decision support (CDS) systems that support antibiotic prescribing in EDs. The process boundaries of antibiotic prescribing are broader than the current boundaries covered by existing CDS systems. Incongruities between process boundaries and CDS can under-support clinicians and lead to suboptimal decisions. We identified two incongruities: (1) the lack of acknowledgment that the process boundaries go beyond the physical boundaries of the ED and (2) the lack of integration of information sources (e.g., accessibility to prior cultures on an individual patient outside of the organization).
Significant opportunities exist to improve appropriateness of antibiotic prescribing by considering process boundaries in the design, implementation, and evaluation of CDS systems.
本研究旨在探讨儿科急诊环境、工作流程和技术之间的交叉点，以及这些因素如何影响抗生素处方决策。
在美国的三家急诊室对 17 名医护人员（1 名研究员和 16 名主治医生）进行了半结构化访谈，并对 21 名医护人员（1 名医生助理、5 名住院医师、3 名研究员和 12 名主治医生）进行了观察。我们使用主题分析对访谈记录和观察记录进行了分析。
出现了七个与抗生素处方决策相关的主题，分别是：（1）专业判断；（2）认知是一种关键的个体资源；（3）决策支持是一种关键的组织资源；（4）在不完善的信息下进行患者管理；（5）作为主要任务的信息寻求；（6）时间管理；（7）抗生素处方的广泛流程边界。
本研究中出现的相互关联的主题可以作为设计、实施和评估支持急诊抗生素处方的临床决策支持（CDS）系统的蓝图。抗生素处方的流程边界比现有 CDS 系统涵盖的当前边界更广泛。流程边界和 CDS 之间的不匹配会削弱临床医生的支持，导致决策不佳。我们确定了两个不匹配：（1）缺乏对流程边界超出急诊物理边界的认识；（2）缺乏信息源的整合（例如，在组织之外访问个体患者的先前培养物）。
通过在 CDS 系统的设计、实施和评估中考虑流程边界，有很大的机会提高抗生素处方的适当性。
