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Q&A: Differences in antibiotic prescribing between acute medical and surgical specialties
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Antibiotic decision-making in hospitals is largely influenced by cultural and social determinants within specialties, signifying a need for individualized interventions to improve antibiotic prescribing, according to researchers.
In an ethnographic study, Esmita Charani, PhD, MSc, MPharm, a research pharmacist in the United Kingdom’s National Institute for Health Research, and colleagues compared antibiotic decision-making between acute medical and surgical teams and found certain differences in the process.
In medicine, they found that antibiotic decisions are informed by input from a collective team, including pharmacists, infectious disease specialists and medical microbiology teams. The process is rational, informed by policy and emphasizes the de-escalation of therapy, but there are gaps in the transition of patients from the emergency department to inpatient rooms, Charani and colleagues reported.
In surgery, they researchers found that complex antibiotic decision-making is often left to junior staff who make defensive decisions that lead to prolonged and inappropriate antibiotic use.
Infectious Disease News spoke with Charani about the factors behind these differences and why it is important to understand them. – by Marley Ghizzone
How does the culture differ between acute medical and surgical teams?
The medical and surgical specialties display differing values, social norms and priorities in relation to antibiotic decision-making. Ownership for antibiotic decision-making is unclear and vague at different phases in the patient pathway in these two specialties. In medicine, ambiguity in ownership occurs in the interphase between the accident and emergency and the acute-care medical team handover. In surgery, the ambiguity lies within the surgical teams, who tend to work in isolation from other specialties. The surgeons consider antibiotic prescribing decisions not to be a primary focus for them, and they will readily delegate it to nonsurgical doctors. In surgery, gaps in multidisciplinary input and absences of the senior team from wards amplify the lack of ownership of antibiotic prescriptions. The medical teams adopt an interdisciplinary, collectivist and policy-informed model that includes pharmacist input into the antibiotic decision-making process. These observed and reported differences in practice translate into measurable differences in the antibiotic indicators between medicine and surgery.
There is variation in the observed norms, values and behaviors in medicine and surgery. Time is more restricted in surgical teams, and communication is often via phones or messaging applications. Members of the senior team are often absent from the wards because they must be in the operating theater or clinics.
How do these differences influence antibiotic prescribing?
The medical teams practice a much more policy-informed antibiotic decision making. The antibiotic decision-making in surgery is often defensive and aims to prevent infectious complications in patients who have undergone surgery or are in hospital for a long period of time. The patients in the surgical pathway may be prescribed antibiotics unnecessarily and for longer periods of time.
Why is it important to understand these differences?
Culture, at the specialty level and within organizations, is an important determinant of behaviors of health care professionals and antibiotic decision-making. At organizational level and within specialties, leaders and champions have a role in establishing the prevailing culture.
Is there a problem that needs to be solved? If so, what is the solution?
To address specialty-level variation in behaviors and antibiotic prescribing, there needs to be contextually developed interventions. The ownership of the antibiotic prescriptions needs to be clear, perhaps by using clinical pharmacists, exemplified in the medical specialty, or through engagement with medical colleagues in surgery.
Why an ethnographic study?
Most of the published studies on antibiotic prescribing in hospitals focus on quantitative methodologies, and try to answer what interventions work, and what their effect size is. The question of why an intervention might or might not work, and more importantly how professional health care behaviors and culture within organizations, teams, and specialties might affect antibiotic prescribing decision-making and/or intervention size and effect remain unanswered. Understanding the context in which antibiotic decisions are made is crucial to the development of targeted and sustainable quality improvement interventions that optimize antibiotic use and improve patient outcomes. Therefore, the first step should be a better understanding of how and why culture and team dynamics affect antibiotic decision-making. This qualitative study aimed to provide an understanding and explanation for how culture and team dynamics within organizations and specialties affect antibiotic decision-making. Using ethnography provided a fresh understanding of antibiotic decision-making behaviors in the context of medical and surgical specialties by studying professional health care behaviors within the context in which they work, in other words, their day-to-day clinical environment. Additionally, it enabled them to project their experiences and voice into the research.
Reference:
Charani E, et al. Clin Infect Dis. 2018;doi:10.1093/cid/ciy844.
Disclosures: Charani reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.