Table 2.

Thematic construction of medical physicians’ decision pathway for the management of acute infections in secondary care

No.	Theme	Supporting quotation
1	Bayesian process	“It’s like Bayesian model where you refine your likelihood of diagnoses based on every new quantum of information you get, so you start off with the physiological parameters, then your differential is refined based on blood results and further refined based on the microbiology.” [Specialist Trainee, clinical pharmacology & therapeutics]
2	Physiological parameters	“So the first thing I do is look at the vital signs and basically make sure that the patient is haemodynamically stable” [Consultant, acute medicine] “Bearing in mind that most patients have a multitude of different things going on and it could be an infection or it could be many other things, the temperature would be the first thing you would look at” [Consultant, gastroenterology/acute medicine]
3	Localise/confirm infection	“So basically history and then examine them [the patient], and then reaching a diagnosis” [On-rotation, acute medicine/stroke] “Access the patient clinically if I suspect infection and then I would try to determine where the infection is coming from” [Consultant, acute medicine/endocrinology]
4	Investigations	“Determine where the infection is coming from, where the source is and take appropriate cultures and do further investigations as indicated” [Consultant, acute medicine/endocrinology] “The other secondary tests, such as inflammatory markers, give us an idea of whether there really is sepsis or whether there is some other pathology” [Consultant, respiratory 1]
5	Determine severity	“I would still want to be assessing the severity and particularly looking for evidence of sepsis” [Consultant, respiratory 2] “If someone is clinically well and may have an infection I probably would rather wait because they may not need antibiotics at all. It could be a viral infection. So it very much depends on the clinical picture and medical context” [Consultant, acute medicine/endocrinology]
6	Initiate treatment	“We use local policy guidelines, so when I am assessing a patient I am thinking – Okay where is the focus? And also, if I know where it is [the focus], what antibiotics specifically does my hospital use?” [On-rotation, respiratory/general medicine] “I think if it isn’t clearly in the guideline or I am not sure, if it doesn’t easily fit into the guideline, I am going to say [to my juniors], okay speak to microbiology and see what they think” [Consultant, respiratory 1]
7	Review & refine	“Look at the patient and make sure that they are getting better, the temperature is resolving, and their clinical symptoms and signs are improving” [Consultant, acute medicine] “Whoever has [initially] seen the patient will make the initial decision on differential diagnosis and required treatment. Thereafter, it will be the consultant review who will say yes I agree or not, and does the treatment also adhere to Trust policy? So it is very algorithmic” [Consultant, acute medicine/endocrinology]