Identifying barriers to the rapid administration of appropriate antibiotics in community-acquired pneumonia.
BACKGROUND
Despite multiple guidelines for management of community-acquired pneumonia (CAP), barriers to guideline use are rarely evaluated.


METHODS
We performed quantitative and qualitative surveys of junior doctors before implementation of a CAP management pathway. After implementation, we identified patient-related determinants of pathway adherence by multivariate analysis.


RESULTS
We surveyed 83 (77%) of the 108 junior doctors working in acute medicine between August 2001 and July 2002 and selected 8 for in-depth interview. We identified five main themes that influence pathway adherence. First, education (recognized to be insufficient on antimicrobial therapy) and experience: increasing clinical experience was associated with greater knowledge of pathway content, but decreasing likelihood of consulting the pathway. Second, attitudes to CAP: doctors recognized that they had not treated CAP with respect early on. Third, work intensity and lack of senior support were barriers to good practice. Fourth, guideline factors: they need to be simple enough to be easy to use while containing enough information to be useful. Fifth, CAP is sometimes difficult to diagnose on admission. Notably, when given three clinical scenarios only six (7%) of respondents assessed CAP severity correctly. In the intervention study, early administration of antibiotics was associated (P < 0.05) with indicators of increased severity of illness (pulse, respiratory rate, oxygenation and temperature) in addition to being admitted to the intervention hospital (P < 0.001).


CONCLUSIONS
Some of the identified barriers could be overcome by undergraduate and postgraduate education. However, equally important are organizational barriers that can only be overcome by systems redesign.
Barlow
Gavin
G
Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Cottingham, East Yorkshire, UK.
Nathwani
Dilip
D
Myers
Elizabeth
E
Sullivan
Frank
F
Stevens
Nicola
N
Duffy
Rebecca
R
Davey
Peter
P
D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D001291:Attitude of Health Personnel; D015331:Cohort Studies; D017714:Community-Acquired Infections / Q000188:drug therapy* / Q000453:epidemiology; D018849:Controlled Clinical Trials as Topic / Q000639:trends; D003625:Data Collection / Q000379:methods; D019983:Guideline Adherence / Q000639:trends; D006801:Humans; D008875:Middle Aged; D010819:Physician's Role; D011014:Pneumonia / Q000188:drug therapy* / Q000453:epidemiology; D013997:Time Factors
D000900:Anti-Bacterial Agents