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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
Seasonal influenza is a significant cause of morbidity and mortality in the United States each year. Healthcare worker (HCW) influenza vaccination is associated with both decreased absenteeism among employees and improved outcomes among patients. However, HCW influenza vaccine uptake remains suboptimal. The objective of this study was to characterize HCWs' understanding of and response to a stringent vaccination policy.
Design, Setting, and Participants.
A survey of 928 hospital staff at a tertiary academic medical center in Baltimore during the 2008-2009 influenza season.
Of those surveyed, 75% (n = 695) completed the survey; 623 respondents reported regular patient contact, and 91% of those reported vaccination in the current influenza season. However, only 60% reported consistently receiving the vaccine every year. Of those who were vaccinated, 8% (n = 48) reported being vaccinated for the first time during that influenza season. A significant proportion (42%) of respondents were unaware of the major change in hospital policy regarding vaccination. Influences on the decision to be vaccinated varied significantly between those who are regularly vaccinated and those with inconsistent vaccination habits. Attitudes toward hospital policy varied significantly by race and clinical role.
Although 91% of respondents with regular patient contact reported being vaccinated for influenza in the 2008–2009 season, only 60% reported consistent annual vaccination. Misinformation regarding hospital policies is widespread. Improvements in vaccination rates will likely require multifaceted, targeted efforts focused on specific influences on less adherent groups. The identified variability in influences on the decision to be vaccinated suggests possible targets for future interventions.
Intensive care units (ICUs) are potential high-risk areas for the transmission of respiratory viruses such as influenza. An influenza pandemic is expected to result in a dramatic surge of critically ill patients, and ICU healthcare workers (HCW) are likely to be at high risk of infection.
To characterize the knowledge, attitudes, and expected behaviors of ICU HCWs concerning the risk of and response to an influenza pandemic.
Design, Participants, and Setting.
A survey was distributed to 292 HCWs (ie, internal medicine house staff, pulmonary and critical care fellows and faculty members, nurses, and respiratory care professionals) at 2 hospitals in Baltimore, Maryland.
Of the 292 HCWs, 256 (88%) completed the survey. Just over one-half of the respondents believed there is at least a 45% chance of an influenza pandemic within the next 5 years. However, only 41% reported knowing how to protect themselves during an outbreak. Despite this common belief that a pandemic is likely in the near future, 59% of those surveyed reported only minimal knowledge of the risks of and protective strategies for an influenza pandemic, and 20% reported being unlikely to report to work during a pandemic or being unsure about whether they would do so. The odds of reporting to work varied on the basis of race and responsibility for child care.
ICU HCWs reported having minimal knowledge concerning the risk of and response to an influenza pandemic, even though more that one-half of HCWs expect that a pandemic will occur in the near future. This finding in a high-risk setting is of concern, given that lack of knowledge among HCWs may result in increased nosocomial transmission to HCWs and patients. Interventions to improve knowledge of pandemics and understanding of risks among ICU HCWs are essential.
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