Multisite exploration of clinical decision making for antibiotic use by emergency medicine providers using quantitative and qualitative methods

Infect Control Hosp Epidemiol. 2014 Sep;35(9):1114-25. doi: 10.1086/677637. Epub 2014 Jul 23.


Objectives: 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.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Aged
  • Anti-Bacterial Agents*
  • Attitude of Health Personnel*
  • Decision Making*
  • Decision Support Techniques
  • Emergency Service, Hospital / statistics & numerical data*
  • Female
  • Health Care Surveys
  • Health Knowledge, Attitudes, Practice
  • Humans
  • Inappropriate Prescribing / psychology*
  • Inappropriate Prescribing / statistics & numerical data
  • Interviews as Topic
  • Male
  • Middle Aged
  • Physician-Patient Relations
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Qualitative Research
  • United States


  • Anti-Bacterial Agents