Determinants of antibiotic prescribing for upper respiratory tract infections in an emergency department with good primary care access: a qualitative analysis
Determinants of antibiotic prescribing for upper respiratory tract infections in an emergency department with good primary care access: a qualitative analysis
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DOI：
10.1017/s095026881800331x
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发表时间：
2019-01-01
影响因子：
4.2
通讯作者：
Chow, A.
中科院分区：
文献类型：
--
作者：
Chan, Y. Y.;Bin Ibrahim, M. A.;Chow, A.
上呼吸道感染（URTI）占急诊科（ED）的主要就诊人数。有必要阐明在时间紧迫的ED中抗生素处方的决定因素-尽管初级保健诊所非常容易获得，但初级保健的流行选择。在新加坡的成人艾德，有目的地抽样医生（n = 9）进行半结构化的深入访谈。所有的访谈进行了分析，使用主题分析和进一步解释使用社会生态模型来解释处方的决定因素。主题包括：（1）对临床知识和判断的依赖，（2）患者相关因素，（3）患者-医生关系因素，（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病例时高度依赖他们的临床知识和判断，很少干预同行的临床决策。尽管部门规范不为URTI开抗生素，但当面临患者诊断的不确定性时，医生会开抗生素，治疗免疫功能低下或患有合并症的老年患者，以及需要抗生素的患者，特别是在时间限制下。参与者倾向于基于当地流行病学的抗生素处方指南，但认为医院处方政策是临床判断的障碍。与会者强调，需要加强公众教育，提高对适当使用抗生素和管理上呼吸道感染的认识。组织实践规范强烈影响医生的抗生素处方决定，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。
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.