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The differences in antibiotic decision-making between acute surgical and acute medical teams: An ethnographic study of culture and team dynamics

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Title: The differences in antibiotic decision-making between acute surgical and acute medical teams: An ethnographic study of culture and team dynamics
Authors: Charani, E
Ahmad, R
Rawson, T
Castro-Sanchez, E
Tarrant, C
Holmes, A
Item Type: Journal Article
Abstract: Background Cultural and social determinants influence antibiotic decision-making in hospitals. We investigated and compared cultural determinants of antibiotic decision-making in acute medical and surgical specialties. Methods An ethnographic observational study of antibiotic decision-making in acute medical and surgical teams at a London teaching hospital was conducted (August 2015–May 2017). Data collection included 500 hours of direct observations, and face-to-face interviews with 23 key informants. A grounded theory approach, aided by Nvivo 11 software, analyzed the emerging themes. An iterative and recursive process of analysis ensured saturation of the themes. The multiple modes of enquiry enabled cross-validation and triangulation of the findings. Results In medicine, accepted norms of the decision-making process are characterized as collectivist (input from pharmacists, infectious disease, and medical microbiology teams), rationalized, and policy-informed, with emphasis on de-escalation of therapy. The gaps in antibiotic decision-making in acute medicine occur chiefly in the transition between the emergency department and inpatient teams, where ownership of the antibiotic prescription is lost. In surgery, team priorities are split between 3 settings: operating room, outpatient clinic, and ward. Senior surgeons are often absent from the ward, leaving junior staff to make complex medical decisions. This results in defensive antibiotic decision-making, leading to prolonged and inappropriate antibiotic use. Conclusions In medicine, the legacy of infection diagnosis made in the emergency department determines antibiotic decision-making. In surgery, antibiotic decision-making is perceived as a nonsurgical intervention that can be delegated to junior staff or other specialties. Different, bespoke approaches to optimize antibiotic prescribing are therefore needed to address these specific challenges.
Issue Date: 1-Jul-2019
Date of Acceptance: 28-Sep-2018
URI: http://hdl.handle.net/10044/1/65028
DOI: https://doi.org/10.1093/cid/ciy844
ISSN: 1058-4838
Publisher: Oxford University Press (OUP)
Start Page: 12
End Page: 20
Journal / Book Title: Clinical Infectious Diseases
Volume: 69
Issue: 1
Copyright Statement: © 2018 The Author(s). Published by Oxford University Press for the Infectious Diseases Society of America. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
Sponsor/Funder: ESRC
National Institute for Health Research
National Institute for Health Research
Economic & Social Research Council (ESRC)
Funder's Grant Number: KMRF-2015-04-007
Keywords: antimicrobial decision-making
team dynamics
06 Biological Sciences
11 Medical and Health Sciences
Publication Status: Published
Online Publication Date: 2018-11-15
Appears in Collections:Department of Infectious Diseases