Assessment of factors that influence timely administration of initial antibiotic dose using collaborative process mapping at a referral hospital in Malawi: a case study of pneumonia patients

BACKGROUND: Timely initiation of antibiotics within one hour of prescription is one of the recommended antibiotic stewardship interventions when managing patients with pneumonia in the emergency department. Effective implementation of this intervention depends on effective communication, a well-established coordination process and availability of resources. Understanding what may influence this aspect of care by using process mapping is an important component when planning for improvement interventions. The aim of the study was to identify factors that influence antibiotic initiation following prescription in the Adult Emergency and Trauma Centre of the largest referral hospital in Malawi. METHODS: We conducted a prospective observational case study using process mapping of two purposively selected adult pneumonia patients. One of the investigators CM observed the patient from the time of arrival at the triage area to the time he/she received initial dose of antibiotics. With purposively selected members of the clinical team; we used simple questions to analyze the map and identified facilitators, barriers and potential areas for improvement. RESULTS: Both patients did not receive the first dose of antibiotic within one hour of prescription. Despite the situation being less than ideal, potential facilitators to timely antibiotic initiation were: prompt assessment and triaging; availability of different expertise, timely first review by the clinician; and blood culture collected prior to antibiotic initiation. Barriers were: long waits, lack of communication/coordinated care and competency gap. Improvements are needed in communication, multidisciplinary teamwork, education and leadership/supervision. CONCLUSION: Process mapping can have a significant impact in unveiling the system-related factors that influence timely initiation of antibiotics. The mapping exercise brought together stakeholders to evaluate and identify the facilitators and barriers. Recommendations here focused on improving communication, multidisciplinary team culture such as teamwork, good leadership and continuing professional development. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1186/s12879-018-3620-9) contains supplementary material, which is available to authorized users.