Antimicrobial Prescribing in the Emergency Department; Who Is Calling the Shots?

Abstract

Objective: Inappropriate antimicrobial prescribing in the emergency department (ED) can lead to poor outcomes. It is unknown how often the prescribing clinician is guided by others, and whether prescriber factors affect appropriateness of prescribing. This study aims to describe decision making, confidence in, and appropriateness of antimicrobial prescribing in the ED. Methods: Descriptive study in two Australian EDs using both questionnaire and medical record review. Participants were clinicians who prescribed antimicrobials to patients in the ED. Outcomes of interest were level of decision-making (self or directed), confidence in indication for prescribing and appropriateness (5-point Likert scale, 5 most confident). Appropriateness assessment of the prescribing event was by blinded review using the National Antibiotic Prescribing Survey appropriateness assessment tool. All analyses were descriptive. Results: Data on 88 prescribers were included, with 61% making prescribing decisions themselves. The 39% directed by other clinicians were primarily guided by more senior ED and surgical subspecialty clinicians. Confidence that antibiotics were indicated (Likert score: 4.20, 4.35 and 4.35) and appropriate (Likert score: 4.07, 4.23 and 4.29) was similar for juniors, mid-level and senior prescribers, respectively. Eighty-five percent of prescriptions were assessed as appropriate, with no differences in appropriateness by seniority, decision-making or confidence. Conclusions: Over one-third of prescribing was guided by senior ED clinicians or based on specialty advice, primarily surgical specialties. Prescriber confidence was high regardless of seniority or decision-maker. Overall appropriateness of prescribing was good, but with room for improvement. Future qualitative research may provide further insight into the intricacies of prescribing decision-making.

Impact of antibiotic allergy labels on timely and appropriate antibiotics for sepsis in the emergency department

“…In our study we observed a high rate of appropriate empirical antibiotic prescribing (94.4%). This rate is higher than in other published Australian studies, including 85% appropriateness in a Queensland ED, 28 and 75.7% appropriateness in the 2019 NAPS (involving 377 Australian hospitals). 29 We hypothesize this observed difference in our cohort compared with other published studies is due to the early involvement of EM pharmacists in the sepsis alert response and local ED sepsis guidelines including first-/second-/third-line options to guide empirical therapy in the presence of AALs.…”

Effect and sustainability of a stepwise implemented multidisciplinary antimicrobial stewardship programme in a university hospital emergency department

“… 19 Antibiotic prescribing in the ED is complex and not every decision is guided by seniors or ID specialists. 20 Moreover, the analysed infectious diseases entities in this study are not typically surgical. The picture could be different for specific surgical diagnoses like appendicitis or cholecystitis.…”

How Clinicians Decide? Exploring Complexity of Antibiotic Prescribing in Emergency Departments Using Video-Reflexive Ethnography

“…Building on our previous research on challenges and potential improvements to antibiotic prescribing in EDs (Denny et al, 2019; Hamill et al, 2021), we sought to examine clinical communication around antibiotic treatment decisions as they unfolded at the point of care. Furthermore, as no prior studies used VRE to explore antibiotic prescribing practices, we assessed the acceptability of video-reflexive methods among clinicians working in a complex ED environment.…”