How Clinicians Decide? Exploring Complexity of Antibiotic Prescribing in Emergency Departments Using Video-Reflexive Ethnography.

Antibiotic overprescribing is a global issue that significantly contributes to increased antimicrobial resistance. Strengthening antimicrobial prescribing practices should be considered a priority. The emergency department (ED) represents a setting where antibiotics are frequently prescribed, but the determinants that influence prescribing choices are complex and multifaceted. We conducted an exploratory qualitative study to investigate the contextual factors that influence antibiotic prescribing choices among clinicians in the ED. The study employed video-reflexive ethnography (VRE) to capture prospective clinical decision-making in situated practice. Data collection involved fieldwork observations, video observations, and delivery of facilitated group reflexive sessions, where clinicians viewed a selection of recorded video snippets relating to antibiotic prescribing. Study was conducted across two EDs within the same health service in Australia. A total of 29 clinical conversations focusing on antibiotic prescribing were recorded. Additionally, 34 clinicians participated in group reflexive sessions. Thematic analysis from the transcribed data yielded four themes: 'importance of clinical judgment', 'usability of prescribing guidelines', 'managing patient expectations', and 'context-dependent disruptions'. Our findings provide insights into the challenges faced by clinicians in navigating complex ED environment, utilising electronic decision-support tools and engaging in discussions about patient treatments with senior clinicians. The findings also indicate that VRE is useful in visualising full complexity of the ED setting, and in initiating meaningful discussions among clinical teams. Integrating the use of VRE in everyday clinical settings can potentially facilitate the implementation of pragmatic solutions for delivering effective antibiotic stewardship practices.

Appropriateness of antibiotic prescribing in the Emergency Department.

Background: Antibiotics are some of the most commonly prescribed drugs in the Emergency Department (ED) and yet data describing the overall appropriateness of antibiotic prescribing in the ED is scarce. Objectives: To describe the appropriateness of antibiotic prescribing in the ED. Methods: A retrospective, observational study of current practice. All patients who presented to the ED during the study period and were prescribed at least one antibiotic were included. Specialists from Infectious Disease, Microbiology and Emergency Medicine and a Senior Pharmacist assessed antibiotic appropriateness against evidence-based guidelines. Results: A total of 1019 (13.6%) of patient presentations involved the prescription of at least one antibiotic. Of these, 640 (62.8%) antibiotic prescriptions were assessed as appropriate, 333 (32.7%) were assessed as inappropriate and 46 (4.5%) were deemed to be not assessable. Adults were more likely to receive an inappropriate antibiotic prescription than children (36.9% versus 22.9%; difference 14.1%, 95% CI 7.2%-21.0%). Patients who met quick Sepsis-related Organ Failure Assessment (qSOFA) criteria were more likely to be prescribed inappropriate antibiotics (56.7% versus 36.1%; difference 20.5%, 95% CI, 2.4%-38.7%). There was no difference in the incidence of appropriate antibiotic prescribing based on patient gender, disposition (admitted/discharged), reason for antibiotic administration (treatment/prophylaxis) or time of shift (day/night). Conclusions: Inappropriate administration of antibiotics can lead to unnecessary adverse events, treatment failure and antimicrobial resistance. With over one in three antibiotic prescriptions in the ED being assessed as inappropriate, there is a pressing need to develop initiatives to improve antibiotic prescribing to prevent antibiotic-associated patient and community harms.

Association of Empiric Antibiotic Regimen Discordance With 30-Day Mortality in Neonatal and Pediatric Bloodstream Infection-A Global Retrospective Cohort Study.

BACKGROUND: While there have been studies in adults reporting discordant empiric antibiotic treatment associated with poor outcomes, this area is relatively unexplored in children and neonates despite evidence of increasing resistance to recommended first-line treatment regimens. METHODS: Patient characteristics, antibiotic treatment, microbiology, and 30-day all-cause outcome from children <18 years with blood-culture-confirmed bacterial bloodstream infections (BSI) were collected anonymously using REDCap™ through the Global Antibiotic Prescribing and Resistance in Neonates and Children network from February 2016 to February 2017. Concordance of early empiric antibiotic treatment was determined using European Committee on Antimicrobial Susceptibility Testing interpretive guidelines. The relationship between concordance of empiric regimen and 30-day mortality was investigated using multivariable regression. RESULTS: Four hundred fifty-two children with blood-culture-positive BSI receiving early empiric antibiotics were reported by 25 hospitals in 19 countries. Sixty percent (273/452) were under the age of 2 years. S. aureus, E. coli, and Klebsiella spp. were the most common isolates, and there were 158 unique empiric regimens prescribed. Fifteen percent (69/452) of patients received a discordant regimen, and 7.7% (35/452) died. Six percent (23/383) of patients with concordant regimen died compared with 17.4% (12/69) of patients with discordant regimen. Adjusting for age, sex, presence of comorbidity, unit type, hospital-acquired infections, and Gram stain, the odds of 30-day mortality were 2.9 (95% confidence interval: 1.2-7.0; P = 0.015) for patients receiving discordant early empiric antibiotics. CONCLUSIONS: Odds of mortality in confirmed pediatric BSI are nearly 3-fold higher for patients receiving a discordant early empiric antibiotic regimen. The impact of improved concordance of early empiric treatment on mortality, particularly in critically ill patients, needs further evaluation.

Recognition, response and outcomes of sepsis: A dual site retrospective observational study.

OBJECTIVES: To describe clinical recognition, response and outcomes of patients with sepsis. METHODS: A retrospective, observational study was undertaken at two hospitals. Inclusion criteria were: adult patients admitted via the Emergency Department (ED) between 1 January and 30 April 2014 allocated a primary ICD-10-AM discharge from hospital code related to sepsis. Recognition of sepsis was considered based on the presence of clinical documentation that reflects the Sepsis Kills criteria being met. Response to sepsis was considered based on the presence of clinical documentation where the patient received a response consistent with the 'Sepsis Six' strategies. Outcomes pertained to response to sepsis (e.g. time to antibiotics) and ED measures (e.g. time to be seen, ED length of stay). Sub-group analysis considered location where sepsis was recognised (ED/ward). RESULT: In total, 96 patients met the inclusion criteria; most were admitted under general medicine (37%) followed by intensive care (18%). Sepsis was recognised in the ED for most patients (n = 64), with a history of fevers/rigors the most common (60%) indication of infection. Regarding response and ED outcomes for this group, the median time from triage nurse assessment i) to being seen by the treating clinician was 19 min; ii) to sepsis recognition was 27 min; and iii) to antibiotics was 181 min; 35% received antibiotics within 60 min from recognition. Those recognised in the ED had a longer ED stay than those where sepsis was recognised on the ward (336 min vs. 225 min, p = 0.013). CONCLUSIONS: Sepsis can develop at various stages throughout the patient's journey. In this small sample, ED recognition was associated with longer ED stay, likely due to more interventions. Whilst guidelines recommend antibiotics be administered within 60 min of triage, this was not achieved for most patients. Given the dynamic nature of sepsis, future indicators may focus on time from recognition rather than time from triage.