Understanding the management of common infections in out-of-hours primary care

Problem

Regardless of a slow downward trend in general practice antibiotic consumption, from 2015-2019 usage out-of-hours has increased. Despite specific interactional challenges faced by primary healthcare professionals working out-of-hours, compared to the general practice in-hours setting, out-of-hours has received little research attention. Currently there are no antimicrobial prescribing guidelines specific to out-of-hours, and out-of-hours clinicians receive less stewardship training interventions relative to other groups. The aims of this study were: a) to understand how the social interactional context might influence antibiotic prescribing outcomes in out-of-hours patient consultations; and b) to develop antimicrobial stewardship training for the management of common infections based on our findings.

Approach

This was an observational study. Two out-of-hours providers serving populations across the South and West of England were recruited as study partners and 66 clinicians self-selected to participate. Audio and video-recordings of patient consultations for common infections (68 advice calls, 86 primary care centre appointments and 66 home visits), case records and survey data were collected between March 2019-March 2020. We aimed for a maximum variation sample to include all patient groups, all primary care centres (busy and less busy centres, and those serving neighbourhoods with different levels of deprivation); all seasons; weekday evenings, weekends and bank holidays. Anonymised case records for all patient contacts were also collected over the same 12-month period. All recordings were transcribed, and an evidence-informed coding framework was developed and applied to track three main prescribing outcomes: no antibiotic; delayed antibiotic; or immediate antibiotic.

Findings

For the 220 recorded consultations, 60% of patients were female with a mean age of 41.6 years (32.3 sd). The three main categories of common infections presented were respiratory (45.0%), urinary (21.4%) and skin (14.1%). Overall, antibiotics were prescribed 50.9% of the time (85.1% urinary; 53.4% skin; 50.6% respiratory). Only 4.6% were delayed or back-up prescriptions. Four communication-related themes from our content coding (managing patient expectations, recommending self-care, delayed prescribing and safety-netting) were developed as e-learning modules. To ensure their acceptability and maximise their potential for changing behaviour, module development was supplemented by 21 semi-structured interviews with out-of-hours clinicians and refined by remote group ‘Think Aloud’ sessions with eight out-of-hours clinicians and feedback from wider stakeholder groups including patients.

Consequences

Common interactional dilemmas were faced by out-of-hours clinicians, with high rates of prescribing for common infections compared to general practice. Drawing on current guidelines, prior research and our own systematic observations with stakeholder input, we have produced four credible evidence-based training modules for clinicians. These modules are the basis for a new e-Learning for Healthcare (eLfH) programme, ‘Antimicrobial Stewardship Out of Hours’, hosted by Health Education England. The platform has over one million registered users so the potential to inform clinical education, practice and future stewardship interventions is significant.