Form #5 Form #5 ED Physician Pre-implementation Questionnaire

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Emergency Department Provider Pre-Intervention Questionnaire

1. What is your clinical training background (e.g. residencies and fellowships in what fields)

2. How long have you been in practice as an attending physician?

3. How long have you been working in the BWH ED?

4. Have you used antibiograms in the emergency department setting? Yes/No

   • In the last month?

   • In the last year?

5. We have several questions about antibiograms usefulness in the ED and generally

• In your opinion, on a scale of 1 to 5 with ‘1’ indicating very minimal usefulness and ‘5’ very useful, how useful are antibiograms in the emergency department setting for selecting the most effective antibiotic for a particular infection or organism? __________. Please explain.

• In your opinion, on a scale of 1 to 5 with ‘1’ indicating very minimal usefulness and ‘5’ very useful, how useful are antibiograms, in general, for selecting the most effective antibiotic for a particular infection or organism? ___________ Please explain.

6. Have you used antibiograms at another health care setting? Yes/No

• What setting?

  1. Hospital Ward or ICU

  2. Home Health

  3. Clinic

  4. Other _______________

• In your opinion, on a scale of 1 to 5 with ‘1’ indicating very minimal usefulness and ‘5’ very useful, how useful are antibiograms in the setting noted above for selecting the most effective antibiotic for a particular infection or organism? __________. Please explain.

7. If you are currently using antibiograms or have used them in the past, please answer the following:

• How is the information communicated to you?

  1. Online (webpage, hospital internet)

  2. Email

  3. Posted in paper form in clinical area

  4. Mail

  5. Other _____________

• Is this method of communication convenient and efficient? Yes/No

• How could communication of antibiograms be improved? __________________________________

8. In your opinion, how well do you feel that you know the antibiotic sensitivity/resistance pattern of common infections in local nursing homes?

• Response coded on 5-point Likert scale with”1” indicating very well to “5” indicating very poorly.

9. If an antibiogram were easily available for the nursing home of an ED patient you were caring for, would you review it prior to prescribing antibiotics? YES / NO

   • Explain: ­­­­­­­­­­_________________________________

10. The most significant barrier to using antibiograms in the ED is:

______________________________________

Public reporting burden for this collection of information is estimated to average 10 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

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