Understanding antibiotic decision making in surgery - a qualitative analysis

OBJECTIVE: To investigate the characteristics and culture of antibiotic decision making in the surgical specialty. METHODS: A qualitative study including ethnographic observation and face to face interviews with participants from six surgical teams at a teaching hospital in London was conducted. Over a three month period: 1) thirty ward rounds (WRs) (100 hours) were observed, 2) face-to-face follow up interviews took place with thirteen key informants, 3) multidisciplinary meetings on the management of surgical patients and daily practice on wards were observed. Applying these methods provided rich data for characterising the antibiotic decision making in surgery and enabled cross-validation and triangulation of the findings. Data from the interview transcripts and the observational notes were coded and analysed iteratively until saturation was reached. RESULTS: The surgical team is in a state of constant flux with individuals having to adjust to the context in which they work. The demands placed on the team to be in the operating room, and to address the surgical needs of the patient means that the responsibility for antibiotic decision making is uncoordinated and diffuse. Antibiotic decision making is considered by surgeons as a secondary task, commonly delegated to junior members of their team and occurs in the context of disjointed communication. CONCLUSION: There is lack of clarity around medical decision making for treating infections in surgical patients. The result is sub-optimal and uncoordinated antimicrobial management. Developing the role of a perioperative clinician may help improve patient level outcomes and optimise decision making.