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

Laura M Hamill,Megan F Baxter,Melina Kreutz,Kerina J Denny,Julia Bonnett,Gerben Keijzers

doi:10.3390/antibiotics10070843

Laura M Hamill, Megan F Baxter + Show 4 more

Open Access

https://doi.org/10.3390/antibiotics10070843

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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.

Highlights

Antimicrobial resistance (AMR) has been declared a global health crisis and if not tackled could cause up to 10 million deaths worldwide per year by 2050 [1]
This study describes the novel concept of decision-making in antibiotic prescription, in contrast with most studies which focus on the act of prescribing
We found that nearly twothirds of clinicians who prescribe antibiotic medication decide this themselves, mostly with the support of endorsed guidelines

Summary

Introduction

Antimicrobial resistance (AMR) has been declared a global health crisis and if not tackled could cause up to 10 million deaths worldwide per year by 2050 [1]. While appropriate and timely antibiotic therapy saves lives [2,3,4] the misuse and overuse of antimicrobials accelerates the development of AMR and threatens our ability to treat infectious diseases, resulting in prolonged illness, disability, death, and increasing health care costs [5]. Antimicrobial prescriptions in particular have shown greater incidence of prescription errors than other prescribing events, especially when prescribed by junior doctors. It has been estimated by the Institute of Medicine that medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths [8]. All clinicians should espouse caution and critical thinking when prescribing antimicrobials

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