Understanding decisions about antibiotic prescribing in ICU: an application of the Necessity Concerns Framework

, INHALE WP2 Study Group (2021) Understanding decisions about antibiotic prescribing in ICU: an application of the Necessity Concerns Framework. BMJ Quality and Safety. ISSN 2044-5415

[img]
Preview
PDF (Published_Version) - Published Version
Available under License Creative Commons Attribution Non-commercial.

Download (520kB) | Preview

Abstract

Background: Antibiotics are extensively prescribed in intensive care units (ICUs), yet little is known about how antibiotic-related decisions are made in this setting. We explored how beliefs, perceptions and contextual factors influenced ICU clinicians' antibiotic prescribing. Methods: We conducted 4 focus groups and 34 semistructured interviews with clinicians involved in antibiotic prescribing in four English ICUs. Focus groups explored factors influencing prescribing, whereas interviews examined decision-making processes using two clinical vignettes. Data were analysed using thematic analysis, applying the Necessity Concerns Framework. Results: Clinicians' antibiotic decisions were influenced by their judgement of the necessity for prescribing/not prescribing, relative to their concerns about potential adverse consequences. Antibiotic necessity perceptions were strongly influenced by beliefs that antibiotics would protect patients from deterioration and themselves from the ethical and legal consequences of undertreatment. Clinicians also reported concerns about prescribing antibiotics. These generally centred on antimicrobial resistance; however, protecting the individual patient was prioritised over these societal concerns. Few participants identified antibiotic toxicity concerns as a key influencer. Clinical uncertainty often complicated balancing antibiotic necessity against concerns. Decisions to start or continue antibiotics often represented € erring on the side of caution' as a protective response in uncertainty. This approach was reinforced by previous experiences of negative consequences ( € being burnt') which motivated prescribing € just in case' of an infection. Prescribing decisions were also context-dependent, exemplified by a lower perceived threshold to prescribe antibiotics out-of-hours, input from external team members and local prescribing norms. Conclusion: Efforts to improve antibiotic stewardship should consider clinicians' desire to protect with a prescription. Rapid molecular microbiology, with appropriate communication, may diminish clinicians' fears of not prescribing or of using narrower-spectrum antibiotics.

Item Type: Article
Uncontrolled Keywords: antibiotic management,critical care,decision making,qualitative research,health policy ,/dk/atira/pure/subjectarea/asjc/2700/2719
Faculty \ School: Faculty of Medicine and Health Sciences > Norwich Medical School
Related URLs:
Depositing User: LivePure Connector
Date Deposited: 27 May 2021 00:09
Last Modified: 16 Sep 2021 11:11
URI: https://ueaeprints.uea.ac.uk/id/eprint/80119
DOI: 10.1136/bmjqs-2020-012479

Actions (login required)

View Item View Item