Hostname: page-component-cd9895bd7-gbm5v Total loading time: 0 Render date: 2024-12-30T17:15:33.439Z Has data issue: false hasContentIssue false
  • English
  • Français

Perioperative antimicrobial decision making: Focused ethnography study in orthopedic and cardiothoracic surgeries in an Australian hospital

Published online by Cambridge University Press:  18 March 2020

Trisha N. Peel Open the ORCID record for Trisha N. Peel [Opens in a new window] ,
Eliza Watson ,
Kelly Cairns ,
Ho Yin (Ashley) Lam ,
Heidi Zhangrong Li ,
Ganan Ravindran ,
Jayan Seneviratne ,
David Daly ,
Susan Liew  and
David McGiffin
...Show all authors
Trisha N. Peel*
Affiliation:
Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
Eliza Watson
Affiliation:
Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
Kelly Cairns
Affiliation:
Department of Pharmacy, Alfred Health, Melbourne, Victoria, Australia
Ho Yin (Ashley) Lam
Affiliation:
Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
Heidi Zhangrong Li
Affiliation:
Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
Ganan Ravindran
Affiliation:
Medical Students, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
Jayan Seneviratne
Affiliation:
Medical Students, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
David Daly
Affiliation:
Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
Susan Liew
Affiliation:
Department of Orthopaedic Surgery, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
David McGiffin
Affiliation:
Department of Cardiothoracic Surgery, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
Paul Myles
Affiliation:
Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
Darshini Ayton
Affiliation:
Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
*
Author for correspondence: Trisha N. Peel, E-mail: Trisha.Peel@monash.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

Antimicrobial use in the surgical setting is common and frequently inappropriate. Understanding the behavioral context of antimicrobial use is a critical step to developing stewardship programs.

Design:

In this study, we employed qualitative methodologies to describe the phenomenon of antimicrobial use in 2 surgical units: orthopedic surgery and cardiothoracic surgery.

Setting:

This study was conducted at a public, quaternary, university-affiliated hospital.

Participants:

Healthcare professionals from the 2 surgical unit teams participated in the study.

Methods:

We used focused ethnographic and face-to-face semi-structured interviews to observe antimicrobial decision-making behaviors across the patient’s journey from the preadmission clinic to the operating room to the postoperative ward.

Results:

We identified 4 key themes influencing decision making in the surgical setting. Compartmentalized communication (theme 1) was observed with demarcated roles and defined pathways for communication (theme 2). Antimicrobial decisions in the operating room were driven by the most senior members of the team. These decisions, however, were delegated to more junior members of staff in the ward and clinic environment (theme 3). Throughout the patient’s journey, communication with the patient about antimicrobial use was limited (theme 4).

Conclusions:

Approaches to decision making in surgery are highly structured. Although this structure appears to facilitate smooth flow of responsibility, more junior members of the staff may be disempowered. In addition, opportunities for shared decision making with patients were limited. Antimicrobial stewardship programs need to recognize the hierarchal structure as well as opportunities to engage the patient in shared decision making.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 41 , Issue 6 , June 2020 , pp. 645 - 652
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Australian Commission on Safety and Quality in Health Care. Antimicrobial Prescribing Practice in Australian Hospitals: Results of the 2017 National Antimicrobial Prescribing Survey. Darlinghurst, Australia: Australian Commission on Safety and Quality in Health Care; 2018.Google Scholar
Bailly, P, Lallemand, S, Thouverez, M, Talon, D.Multicentre study on the appropriateness of surgical antibiotic prophylaxis. J Hosp Infect 2001;49:135–138.CrossRefGoogle ScholarPubMed
Cusini, A, Rampini, SK, Bansal, V, et al.Different patterns of inappropriate antimicrobial use in surgical and medical units at a tertiary care hospital in Switzerland: a prevalence survey. PLoS One 2010;5:e14011.CrossRefGoogle Scholar
Branch-Elliman, W, O’Brien, W, Strymish, J, Itani, K, Wyatt, C, Gupta, K.Association of duration and type of surgical prophylaxis with antimicrobial-associated adverse events. JAMA Surg 2019;154:590–598.10.1001/jamasurg.2019.0569CrossRefGoogle ScholarPubMed
Weiser, TG, Haynes, AB, Molina, G, et al.Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet 2015;385(suppl 2):S11.10.1016/S0140-6736(15)60806-6CrossRefGoogle ScholarPubMed
Australian Institute of Health and Welfare. Australia’s Hospitals 2015–16 at a Glance. Canberra, Australia: Australian Institute of Health and Welfare; 2017.Google Scholar
World Health Organization. Global Action Plan on Antimicrobial Resistance. Geneva, Switzerland: WHO; 2015.Google Scholar
Government, Australian. Implementation Plan: Australia’s First National Antimicrobial Resistance Strategy 2015–2019. Canberra, Australia: Departments of Health and Agriculture and Water Resources; 2016.Google Scholar
Review on Antimicrobial Resistance. Antimicrobial Resistance: Tackling a Crisis for the Health and Wealth of Nations. London: UK Government and Wellcome Trust; 2014.Google Scholar
The White House. National action plan for combating antibiotic-resistant bacteria. Centers for Disease Control and Prevention website. https://www.cdc.gov/drugresistance/pdf/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf. Published 2015. Accessed October 22, 2019.Google Scholar
Bikker, AP, Atherton, H, Brant, H, et al.Conducting a team-based multi-sited focused ethnography in primary care. BMC Med Res Methodol 2017;17:139.CrossRefGoogle ScholarPubMed
Goodson, L, Vassar, M.An overview of ethnography in healthcare and medical education research. J Educ Eval Health Professions 2011;8:4.10.3352/jeehp.2011.8.4CrossRefGoogle ScholarPubMed
Charani, E, Tarrant, C, Moorthy, K, Sevdalis, N, Brennan, L, Holmes, AH.Understanding antibiotic decision making in surgery-a qualitative analysis. Clin Microbiol Infect 2017;23:752–760.10.1016/j.cmi.2017.03.013CrossRefGoogle ScholarPubMed
Charani, E, Ahmad, R, Rawson, TM, Castro-Sanchez, E, Tarrant, C, Holmes, AH.The differences in antibiotic decision-making between acute surgical and acute medical teams: an ethnographic study of culture and team dynamics. Clin Infect Dis 2019;69:12–20.CrossRefGoogle ScholarPubMed
Tong, A, Sainsbury, P, Craig, J.Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349–357.CrossRefGoogle ScholarPubMed
Charani, E, Castro-Sanchez, E, Sevdalis, N, et al.Understanding the determinants of antimicrobial prescribing within hospitals: the role of “prescribing etiquette.” Clin Infect Dis 2013;57:188–196.CrossRefGoogle ScholarPubMed
Broom, JK, Broom, AF, Kirby, ER, Post, JJ.How do professional relationships influence surgical antibiotic prophylaxis decision making? A qualitative study. Am J Infect Control 2018;46:311–315.10.1016/j.ajic.2017.09.004CrossRefGoogle ScholarPubMed
Everitt, DE, Soumerai, SB, Avorn, J, Klapholz, H, Wessels, M.Changing surgical antimicrobial prophylaxis practices through education targeted at senior department leaders. Infect Control Hosp Epidemiol 1990;11:578–583.CrossRefGoogle ScholarPubMed
Broom, A, Kirby, E, Gibson, AF, Post, JJ, Broom, J. Myth, manners, and medical ritual: defensive medicine and the fetish of antibiotics. Qualitat Health Res 2017;27:1994–2005.CrossRefGoogle ScholarPubMed
Broom, J, Broom, A, Kirby, E, Post, JJ.Improvisation versus guideline concordance in surgical antibiotic prophylaxis: a qualitative study. Infection 2018;46:541–548.CrossRefGoogle ScholarPubMed
Borg, MA.Prolonged perioperative surgical prophylaxis within European hospitals: an exercise in uncertainty avoidance? J Antimicrob Chemother 2014;69:1142–1144.10.1093/jac/dkt461CrossRefGoogle ScholarPubMed
Haynes, AB, Weiser, TG, Berry, WR, et al.A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–499.CrossRefGoogle Scholar
Treadwell, JR, Lucas, S, Tsou, AY.Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Safety 2014;23:299–318.10.1136/bmjqs-2012-001797CrossRefGoogle ScholarPubMed
Griffen, FD, Turnage, RH.Reviews of liability claims against surgeons: what have they revealed? Adv Surg 2009;43:199–209.10.1016/j.yasu.2009.02.005CrossRefGoogle ScholarPubMed
Krockow, EM, Colman, AM, Chattoe-Brown, E, et al.Balancing the risks to individual and society: a systematic review and synthesis of qualitative research on antibiotic prescribing behaviour in hospitals. J Hosp Infect 2019;101:428–439.CrossRefGoogle ScholarPubMed
Broom, A, Broom, J, Kirby, E.Cultures of resistance? A Bourdieusian analysis of doctors’ antibiotic prescribing. Soc Sci Med (1982) 2014;110:81–88.CrossRefGoogle ScholarPubMed
Broom, J, Broom, A, Kirby, E, Gibson, AF, Post, JJ.Individual care versus broader public health: a qualitative study of hospital doctors’ antibiotic decisions. Infect Dis Health 2017;22:97–104.10.1016/j.idh.2017.05.003CrossRefGoogle ScholarPubMed
McCullough, AR, Rathbone, J, Parekh, S, Hoffmann, TC, Del Mar, CB.Not in my backyard: a systematic review of clinicians’ knowledge and beliefs about antibiotic resistance. J Antimicrob Chemother 2015;70:2465–2473.CrossRefGoogle Scholar
Brink, AJ, Messina, AP, Feldman, C, Richards, GA, van den Bergh, D, Netcare Antimicrobial Stewardship Study A. From guidelines to practice: a pharmacist-driven prospective audit and feedback improvement model for peri-operative antibiotic prophylaxis in 34 South African hospitals. J Antimicrob Chemother 2017;72:1227–1234.Google ScholarPubMed
Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship in Australian Health Care 2018. Sydney, NSW: ACSQHC; 2018.Google Scholar
Popescu, I, Neudorf, K, Kossey, SN.Engaging patients in antimicrobial resistance and stewardship. Int J Health Gov 2016;21:180–193.CrossRefGoogle Scholar
Davey, P, Pagliari, C, Hayes, A.The patient’s role in the spread and control of bacterial resistance to antibiotics. Clin Microbiol Infect 2002;8(suppl 2):43–68.CrossRefGoogle ScholarPubMed
Lum, EPM, Page, K, Nissen, L, Doust, J, Graves, N.Australian consumer perspectives, attitudes and behaviours on antibiotic use and antibiotic resistance: a qualitative study with implications for public health policy and practice. BMC Pub Health 2017;17:799.CrossRefGoogle ScholarPubMed
McGuckin, M, Govednik, J.Patient empowerment and hand hygiene, 1997–2012. J Hosp Infect 2013;84:191–199.CrossRefGoogle ScholarPubMed
Sun, TB, Chao, SF, Chang, BS, Chen, TY, Gao, PY, Shyr, MH.Quality improvements of antimicrobial prophylaxis in coronary artery bypass grafting. J Surg Res 2011;167:329–335.CrossRefGoogle ScholarPubMed
Schwann, NM, Bretz, KA, Eid, S, et al.Point-of-care electronic prompts: an effective means of increasing compliance, demonstrating quality, and improving outcome. Anesth Analg 2011;113:869–876.CrossRefGoogle ScholarPubMed
Zanetti, G, Flanagan, HL Jr, Cohn, LH, Giardina, R, Platt, R.Improvement of intraoperative antibiotic prophylaxis in prolonged cardiac surgery by automated alerts in the operating room. Infect Control Hosp Epidemiol 2003;24:13–16.CrossRefGoogle ScholarPubMed
Wax, DB, Beilin, Y, Levin, M, Chadha, N, Krol, M, Reich, DL.The effect of an interactive visual reminder in an anesthesia information management system on timeliness of prophylactic antibiotic administration. Anesth Analg 2007;104:1462–1466.10.1213/01.ane.0000263043.56372.5fCrossRefGoogle Scholar
World Health Organization. World alliance for patient safety. WHO guidelines for safe surgery. Atul Gawande website. http://www.gawande.com/documents/WHOGuidelinesforSafeSurgery.pdf. Published 2018. Accessed October 22, 2019.Google Scholar
van Kasteren, ME, Mannien, J, Kullberg, BJ, et al.Quality improvement of surgical prophylaxis in Dutch hospitals: evaluation of a multi-site intervention by time series analysis. J Antimicrob Chemother 2005;56:1094–1102.CrossRefGoogle ScholarPubMed