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To explore current practices and decision making regarding antimicrobial prescribing among emergency department (ED) clinical providers.
We conducted a survey of ED providers recruited from 8 sites in 3 cities. Using purposeful sampling, we then recruited 21 providers for in-depth interviews. Additionally, we observed 10 patient-provider interactions at one of the ED sites. SAS 9.3 was used for descriptive and predictive statistics. Interviews were audio recorded, transcribed, and analyzed using a thematic, constructivist approach with consensus coding using NVivo 10.0. Field and interview notes collected during the observational study were aligned with themes identified through individual interviews.
Of 150 survey respondents, 76% agreed or strongly agreed that antibiotics are overused in the ED, while half believed they personally did not overprescribe. Eighty-nine percent used a smartphone or tablet in the ED for antibiotic prescribing decisions. Several significant differences were found between attending and resident physicians. Interview analysis identified 42 codes aggregated into the following themes: (1) resource and environmental factors that affect care; (2) access to and quality of care received outside of the ED consult; (3) patient-provider relationships; (4) clinical inertia; and (5) local knowledge generation. The observational study revealed limited patient understanding of antibiotic use. Providers relied heavily upon diagnostics and provided limited education to patients. Most patients denied a priori expectations of being prescribed antibiotics.
Patient, provider, and healthcare system factors should be considered when designing interventions to improve antimicrobial stewardship in the ED setting.
Infect Control Hosp Epidemiol 2014;35(9):1114-1125
Pamela S. Hinds, Member and Director, Division of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, USA,
Jami S. Gattuso, Nursing Research Specialist, Division of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, USA,
Belinda N. Mandrell, Pediatric Nurse Practitioner, Patient Care Services, St. Jude Children's Research Hospital, Memphis, TN, USA
In the treatment of children and adolescents with leukemia, nursing care complements and extends the efforts of other members of the health-care team. The focus of nursing care is on the long-term as well as immediate needs of patients and their families, and thus includes strategies to prevent or manage complications and sequelae of the disease and its treatment. Another integral aspect of nursing care is assisting individual patients and families in achieving their developmental goals during the period of treatment and follow-up.
In this chapter, rather than describing the challenges of pediatric oncology nursing or detailing practice recommendations specific to the care of young patients with leukemia, we provide a framework within which these aspects can be addressed and apply this framework to several practice examples. This framework includes three levels of environment and seven possible treatment phases. The relationships between nursing strategies and both the level of environment and the phase of care are illustrated in examples of several major concerns that can arise in the treatment of childhood leukemia. For convenience, we have based our examples primarily on the treatment of childhood acute lymphoblastic leukemia (ALL), but the same principles apply to other leukemias in children. Whenever possible, we have focused on the results of nursing research and their application to practice.
An environmental model
The nursing care of a child or adolescent with leukemia extends beyond a set of symptoms or specific treatment and disease-related events.
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