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JAC Advance Access originally published online on December 6, 2007
Journal of Antimicrobial Chemotherapy 2008 61(2):442-451; doi:10.1093/jac/dkm462
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© The Author 2007. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
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Original research

Identifying barriers to the rapid administration of appropriate antibiotics in community-acquired pneumonia

Gavin Barlow1, Dilip Nathwani2, Elizabeth Myers2, Frank Sullivan3, Nicola Stevens2, Rebecca Duffy3 and Peter Davey3,*

1 Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Cottingham, East Yorkshire, UK 2 Ninewells Hospital and Medical School, Tayside University Hospitals NHS Trust, Dundee, UK 3 Health Informatics Centre, Mackenzie Building, Kirsty Semple Way, University of Dundee, Dundee, UK

Received 18 July 2007; returned 11 October 2007; revised 21 October 2007; accepted 29 October 2007

* Corresponding author. E-mail: p.g.davey{at}chs.dundee.ac.uk

Background: Despite multiple guidelines for management of community-acquired pneumonia (CAP), barriers to guideline use are rarely evaluated.

Methods: We performed quantitative and qualitative surveys of junior doctors before implementation of a CAP management pathway. After implementation, we identified patient-related determinants of pathway adherence by multivariate analysis.

Results: We surveyed 83 (77%) of the 108 junior doctors working in acute medicine between August 2001 and July 2002 and selected 8 for in-depth interview. We identified five main themes that influence pathway adherence. First, education (recognized to be insufficient on antimicrobial therapy) and experience: increasing clinical experience was associated with greater knowledge of pathway content, but decreasing likelihood of consulting the pathway. Second, attitudes to CAP: doctors recognized that they had not treated CAP with respect early on. Third, work intensity and lack of senior support were barriers to good practice. Fourth, guideline factors: they need to be simple enough to be easy to use while containing enough information to be useful. Fifth, CAP is sometimes difficult to diagnose on admission. Notably, when given three clinical scenarios only six (7%) of respondents assessed CAP severity correctly. In the intervention study, early administration of antibiotics was associated (P < 0.05) with indicators of increased severity of illness (pulse, respiratory rate, oxygenation and temperature) in addition to being admitted to the intervention hospital (P < 0.001).

Conclusions: Some of the identified barriers could be overcome by undergraduate and postgraduate education. However, equally important are organizational barriers that can only be overcome by systems redesign.

Keywords: quality improvement , implementation , guidelines , care pathway


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