title: Multisite exploration of clinical decision making for antibiotic use by emergency medicine providers using quantitative and qualitative methods.
abstract: OBJECTIVE
  To explore current practices and decision making regarding antimicrobial prescribing among emergency department (ED) clinical providers.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  Patient, provider, and healthcare system factors should be considered when designing interventions to improve antimicrobial stewardship in the ED setting.
authors.affiliation: Department of Emergency Medicine, George Washington University, Washington, DC.
authors.forename: Larissa
authors.initials: L
authors.lastname: May
authors.forename: Glencora
authors.initials: G
authors.lastname: Gudger
authors.forename: Paige
authors.initials: P
authors.lastname: Armstrong
authors.forename: Gillian
authors.initials: G
authors.lastname: Brooks
authors.forename: Pamela
authors.initials: P
authors.lastname: Hinds
authors.forename: Rahul
authors.initials: R
authors.lastname: Bhat
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Moran
authors.forename: Lisa
authors.initials: L
authors.lastname: Schwartz
authors.forename: Sara E
authors.initials: SE
authors.lastname: Cosgrove
authors.forename: Eili Y
authors.initials: EY
authors.lastname: Klein
authors.forename: Richard E
authors.initials: RE
authors.lastname: Rothman
authors.forename: Cynthia
authors.initials: C
authors.lastname: Rand
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents; D001291:Attitude of Health Personnel; D003657:Decision Making; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D057970:Inappropriate Prescribing / Q000523:psychology* / Q000706:statistics & numerical data; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D036301:Qualitative Research; D014481:United States
chemical_list: D000900:Anti-Bacterial Agents
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