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Talkhan H, Stewart D, McIntosh T, Ziglam H, Abdulrouf PV, Al-Hail M, Diab M, Cunningham S. Exploring determinants of antimicrobial prescribing behaviour using the Theoretical Domains Framework. Res Social Adm Pharm 2024; 20:401-410. [PMID: 38320948 DOI: 10.1016/j.sapharm.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Few theoretically-based, qualitative studies have explored determinants of antimicrobial prescribing behaviour in hospitals. Understanding these can promote successful development and implementation of behaviour change interventions (BCIs). OBJECTIVE (s): To use the Theoretical Domains Framework (TDF) to explore determinants of clinicians' antimicrobial prescribing behaviour, identifying barriers (i.e., impediments) and facilitators to appropriate antimicrobial practice. METHODS Semi-structured interviews with purposively-sampled doctors and pharmacists with a wide range of specialties and expertise in Hamad Medical Corporation hospitals in Qatar. Interviews based on previous quantitative research and the TDF were audio-recorded, transcribed and independently analysed by two researchers using the TDF as an initial coding framework. RESULTS Data saturation was achieved after interviewing eight doctors and eight pharmacists. Inter-related determinants of antimicrobial prescribing behaviour linked to ten TDF domains were identified as barriers and facilitators that may contribute to inappropriate or appropriate antimicrobial prescribing. The main barriers identified were around hospital guidelines and electronic system deficiencies (environmental context and resources); knowledge gaps relating to guidelines and appropriate prescribing (knowledge); restricted roles/responsibilities of microbiologists and pharmacists (professional role and identity); challenging antimicrobial prescribing decisions (memory, attention and decision processes); and professional hierarchies and poor multidisciplinary teamworking (social influences). Key facilitators included guidelines compliance (goals and intentions), and participants' beliefs about the consequences of appropriate or inappropriate prescribing. Further education and training, and some changes to guidelines including their accessibility were also considered essential. CONCLUSIONS Antimicrobial prescribing behaviour in hospitals is a complex process influenced by a broad range of determinants including specific barriers and facilitators. The in-depth understanding of this complexity provided by this work may support the development of an effective BCI to promote appropriate antimicrobial stewardship.
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Affiliation(s)
- Hend Talkhan
- School of Pharmacy and Life Sciences, Robert Gordon University, UK.
| | - Derek Stewart
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar.
| | - Trudi McIntosh
- School of Pharmacy and Life Sciences, Robert Gordon University, UK.
| | - Hisham Ziglam
- Infectious Diseases Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.
| | | | - Moza Al-Hail
- Pharmacy Department, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar.
| | - Mohammad Diab
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar.
| | - Scott Cunningham
- School of Pharmacy and Life Sciences, Robert Gordon University, UK.
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2
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He K, Iwaniuk M, Goretsky MJ, Cina RA, Saito JM, Hall B, Grant C, Cohen ME, Newland JG, Ko CY, Rangel SJ. Procedure-level Misutilization of Antimicrobial Prophylaxis in Pediatric Surgery: Implications for Improved Stewardship and More Effective Infection Prevention. J Pediatr Surg 2023; 58:1116-1122. [PMID: 36914463 DOI: 10.1016/j.jpedsurg.2023.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 02/10/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND The objective of this study was to quantify prophylaxis misutilization to identify high-priority procedures for improved stewardship and SSI prevention. METHODS This was a multicenter analysis including 90 hospitals participating in the NSQIP-Pediatric Antibiotic Prophylaxis Collaborative from 6/2019 to 6/2020. Prophylaxis data were collected from all hospitals and misutilization measures were developed from consensus guidelines. Overutilization included use of overly broad-spectrum agents, continuation of prophylaxis >24 h after incision closure, and use in clean procedures without implants. Underutilization included omission (clean-contaminated cases), use of inappropriately narrow-spectrum agents, and administration post-incision. Procedure-level misutilization burden was estimated by multiplying NSQIP-derived misutilization rates by case volume data obtained from the Pediatric Health Information System database. RESULTS 9861 patients were included. Overutilization was most commonly associated with overly broad-spectrum agents (14.0%), unindicated utilization (12.6%), and prolonged duration (8.4%). Procedure groups with the greatest overutilization burden included small bowel (27.2%), cholecystectomy (24.4%), and colorectal (10.7%). Underutilization was most commonly associated with post-incision administration (6.2%), inappropriate omission (4.4%), and overly narrow-spectrum agents (4.1%). Procedure groups with the greatest underutilization burden included colorectal (31.2%), gastrostomy (19.2%), and small bowel (11.1%). CONCLUSION A relatively small number of procedures account for a disproportionate burden of antibiotic misutilization in pediatric surgery. TYPE OF STUDY Retrospective Cohort. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Katherine He
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | | | - Michael J Goretsky
- Department of Surgery, Children's Hospital of the King's Daughters, Norfolk, VA, USA
| | - Robert A Cina
- Department of Surgery, The Medical University of South Carolina, Charlestown, SC, USA
| | - Jacqueline M Saito
- Department of Surgery, Washington University St. Louis School of Medicine and BJC Healthcare, St. Louis, MO, USA
| | - Bruce Hall
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, Washington University St. Louis School of Medicine and BJC Healthcare, St. Louis, MO, USA
| | | | | | - Jason G Newland
- Department of Pediatrics, Washington University St. Louis School of Medicine, St. Louis, MO, USA
| | | | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA.
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3
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Vo C, Geoffrion AV, Mohamed ZA, Morin JN, Lagacé-Nadon S, Routhier A, Chapados S, Desaulniers PL, David PM, Ang A. Impact of individualized feedback letters on adherence to surgical antibiotic prophylaxis guidelines: an interrupted time series study (FEEDBACK-ASAP). Am J Infect Control 2022; 51:440-445. [PMID: 35760143 DOI: 10.1016/j.ajic.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Surgical antibiotic prophylaxis (SAP) has been proved to decrease the rate of surgical site infections (SSI), but compliance to SAP guidelines remains suboptimal. AIM This study evaluated the impact of periodically sending individualized feedback letters to surgeons and anesthesiologists on their compliance rate to SAP guidelines. METHODS A total of 1491 surgeries were evaluated by retrospective chart review during the pre-intervention period and 668 surgeries were evaluated by prospective chart review during the per-intervention period. Finally, 295 letters were sent to 64 surgeons and 45 anesthesiologists. Compliance rate was assessed as an outcome composed of: indication for SAP, choice of antibiotic agent, antibiotic dose, postoperative duration, timing of the preoperative dose and intraoperative redosing. An interrupted time series design was used to assess a difference on compliance rates before and during the intervention period. FINDINGS Sending individualized feedback letters to surgeons and anesthesiologists did not significantly improve the overall compliance to local SAP guidelines. CONCLUSION Individualized feedback letters could be part of future interventions directed at improving compliance to SAP guidelines, but are likely insufficient by themselves to provide significant results.
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Affiliation(s)
- Chloé Vo
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada; Pharmacy Department, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Aurélie Vintze Geoffrion
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada; Pharmacy Department, Centre intégré de santé et de services sociaux des Laurentides, Québec, Canada
| | - Zahra Abow Mohamed
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada; Pharmacy Department, Centre intégré universitaire de santé et de services sociaux du Centre-Ouest-de-l'Île-de-Montréal, Montréal, Québec, Canada
| | - Jean-Noël Morin
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada; Pharmacy Department, Centre intégré universitaire de santé et de services sociaux de l'Est de l'Île-de-Montréal, Montréal, Québec, Canada
| | - Sarah Lagacé-Nadon
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada; Pharmacy Department, Centre intégré de santé et de services sociaux de Lanaudière, Québec, Canada
| | - Annie Routhier
- Pharmacy Department, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Sandra Chapados
- Pharmacy Department, Centre intégré de santé et de services sociaux de la Montérégie-Ouest, Québec, Canada
| | | | | | - Anita Ang
- Pharmacy Department, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
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Ratnesh K, Kumar P, Arya A. Incidence of Surgical Site Infections and Surgical Antimicrobial Prophylaxis in JNMC, Bhagalpur, India. JOURNAL OF PHARMACY AND BIOALLIED SCIENCES 2022; 14:S868-S871. [PMID: 36110734 PMCID: PMC9469243 DOI: 10.4103/jpbs.jpbs_30_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/26/2022] [Indexed: 11/04/2022] Open
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5
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Menz BD, Charani E, Gordon DL, Leather AJM, Moonesinghe SR, Phillips CJ. Surgical Antibiotic Prophylaxis in an Era of Antibiotic Resistance: Common Resistant Bacteria and Wider Considerations for Practice. Infect Drug Resist 2021; 14:5235-5252. [PMID: 34908856 PMCID: PMC8665887 DOI: 10.2147/idr.s319780] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/19/2021] [Indexed: 01/19/2023] Open
Abstract
The increasing incidence of antimicrobial resistance (AMR) presents a global crisis to healthcare, with longstanding antimicrobial agents becoming less effective at treating and preventing infection. In the surgical setting, antibiotic prophylaxis has long been established as routine standard of care to prevent surgical site infection (SSI), which remains one of the most common hospital-acquired infections. The growing incidence of AMR increases the risk of SSI complicated with resistant bacteria, resulting in poorer surgical outcomes (prolonged hospitalisation, extended durations of antibiotic therapy, higher rates of surgical revision and mortality). Despite these increasing challenges, more data are required on approaches at the institutional and patient level to optimise surgical antibiotic prophylaxis in the era of antibiotic resistance (AR). This review provides an overview of the common resistant bacteria encountered in the surgical setting and covers wider considerations for practice to optimise surgical antibiotic prophylaxis in the perioperative setting.
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Affiliation(s)
- Bradley D Menz
- SA Pharmacy, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Esmita Charani
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, London, UK
| | - David L Gordon
- Flinders Health & Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Division of Medicine, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Andrew J M Leather
- Centre for Global Health and Health Partnerships, School of Population Health and Environmental Science, Kings College London, London, UK
| | - S Ramani Moonesinghe
- Centre for Perioperative Medicine, UCL Division of Surgery and Interventional Science, London, UK.,UCL Hospitals NIHR Biomedical Research Centre, London, UK
| | - Cameron J Phillips
- SA Pharmacy, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia.,Flinders Health & Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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6
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Fésüs A, Benkő R, Matuz M, Kungler-Gorácz O, Fésüs MÁ, Bazsó T, Csernátony Z, Kardos G. The Effect of Pharmacist-Led Intervention on Surgical Antibacterial Prophylaxis (SAP) at an Orthopedic Unit. Antibiotics (Basel) 2021; 10:antibiotics10121509. [PMID: 34943721 PMCID: PMC8698705 DOI: 10.3390/antibiotics10121509] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 11/16/2022] Open
Abstract
Perioperative antibiotic use is a common reason for antibiotic misuse. Evidence suggests that adherence to SAP guidelines may improve outcomes. The purpose of this study was to analyze the impact of pharmacist-led antibiotic stewardship interventions on SAP guideline compliance. The study was conducted at an Orthopedic Department of a tertiary care medical center. SAP compliance and antibiotic exposure in the pre-intervention and intervention period was compared using chi-square, Fisher exact, and Mann-Whitney tests, as appropriate. Prophylactic antibiotic use in orthopedic joint arthroplasties (overall guideline adherence: agent, dose, frequency, duration), clinical outcomes (length of stay-LOS, number of surgical site infections-SSIs), antibiotic exposure and direct antibiotic costs were compared between pre-intervention and intervention periods. Significant improvement in mean SAP duration (by 42.9%, 4.08 ± 2.08 vs. 2.08 ± 1.90 days, p ˂ 0.001), and overall guideline adherence regarding antibiotic use (by 56.2%, from 2% to 58.2%, p ˂ 0.001) were observed. A significant decrease was observed in antibiotic exposure in SAP (by 41%, from 6.07 ± 0.05 to 3.58 ± 4.33 DDD/patient, p ˂ 0.001), average prophylactic antibiotic cost (by 54.8%, 9278.79 ± 6094.29 vs. 3598.16 ± 3354.55 HUF/patient), and mean LOS (by 37.2%, from 11.22 ± 6.96 to 7.62 ± 3.02 days, p < 0.001); and a slight decrease in the number of confirmed SSIs was found between the two periods (by 1.8%, from 3% to 1.2%, p = 0.21). Continuous presence of the clinical pharmacist led to significant improvement in SAP guideline adherence, which was accompanied by decreased antibiotic exposure and cost.
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Affiliation(s)
- Adina Fésüs
- Central Clinical Pharmacy, Clinical Center, University of Debrecen, H-4032 Debrecen, Hungary; (A.F.); (O.K.-G.)
- Department of Pharmacodynamics, Faculty of Pharmacy, University of Debrecen, H-4032 Debrecen, Hungary
- Doctoral School of Pharmaceutical Sciences, University of Debrecen, H-4032 Debrecen, Hungary
| | - Ria Benkő
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Szeged, H-6725 Szeged, Hungary; (R.B.); (M.M.)
- Central Pharmacy, Albert Szent Györgyi Medical Center, University of Szeged, H-6725 Szeged, Hungary
- Department of Emergency Medicine, Albert Szent Györgyi Medical Center, University of Szeged, H-6725 Szeged, Hungary
| | - Mária Matuz
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Szeged, H-6725 Szeged, Hungary; (R.B.); (M.M.)
- Central Pharmacy, Albert Szent Györgyi Medical Center, University of Szeged, H-6725 Szeged, Hungary
| | - Orsolya Kungler-Gorácz
- Central Clinical Pharmacy, Clinical Center, University of Debrecen, H-4032 Debrecen, Hungary; (A.F.); (O.K.-G.)
- Doctoral School of Pharmaceutical Sciences, University of Debrecen, H-4032 Debrecen, Hungary
- Department of Metagenomics, University of Debrecen, H-4032 Debrecen, Hungary
| | - Márton Á. Fésüs
- Department of Traumatology and Hand Surgery, Faculty of Medicine, University of Debrecen, H-4031 Debrecen, Hungary;
| | - Tamás Bazsó
- Department of Orthopedic Surgery, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary; (T.B.); (Z.C.)
| | - Zoltán Csernátony
- Department of Orthopedic Surgery, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary; (T.B.); (Z.C.)
| | - Gábor Kardos
- Department of Metagenomics, University of Debrecen, H-4032 Debrecen, Hungary
- Correspondence:
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7
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Cheoun ML, Heo J, Kim WH. Antimicrobial Resistance: KAP of Healthcare Professionals at a Tertiary-Level Hospital in Nepal. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10062. [PMID: 34639365 PMCID: PMC8532001 DOI: 10.3390/ijerph181910062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022]
Abstract
Although increasing antimicrobial resistance (AMR) is a substantial threat worldwide, low- and middle-income countries, including Nepal, are especially vulnerable. It is also known that healthcare providers (HCPs) are the major determinants of antimicrobial misuse. A cross-sectional, self-administered survey was conducted among 160 HCPs to assess the knowledge, attitudes, and practices (KAP) of Nepali HCPs regarding AMR and its use. Descriptive statistics and nonparametric tests were performed to evaluate KAP dimensions and investigate subgroup differences. HCPs scored higher on theoretical than practical knowledge. Regarding practical knowledge, men scored higher than women (p < 0.01), and physicians scored higher than nurses (p < 0.001). Participants aged < 25 years scored lower on practical knowledge than older participants (p < 0.001), while those with <3 years work experience scored lower than those with >6 years (p < 0.05). Participants from the medical department scored higher on practical knowledge than those from the surgical department (p < 0.01). AMR control was more accepted in the medical than in the surgical department (p < 0.001). Regarding practices, women and nurses scored higher than men (p < 0.001) and physicians (p < 0.01), respectively. An educational intervention that is tailored to the sociodemographic and professional characteristics of HCPs is necessary to reduce the gap between theoretical and practical knowledge and improve their attitudes and practices.
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Affiliation(s)
- Mee-Lang Cheoun
- JW LEE Center for Global Medicine, Seoul National University College of Medicine, 71 Ihwajang-gil, Jongno-gu, Seoul 03087, Korea;
| | - Jongho Heo
- JW LEE Center for Global Medicine, Seoul National University College of Medicine, 71 Ihwajang-gil, Jongno-gu, Seoul 03087, Korea;
- National Assembly Futures Institute, 1 Uisadang-daero, Seoul 07233, Korea
| | - Woong-Han Kim
- JW LEE Center for Global Medicine, Seoul National University College of Medicine, 71 Ihwajang-gil, Jongno-gu, Seoul 03087, Korea;
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea
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Sabharwal P, Sidhu GK, Bloria SD, Chauhan R. Perioperative antibiotics administration: Who will take the onus? J Anaesthesiol Clin Pharmacol 2021; 37:134. [PMID: 34103842 PMCID: PMC8174433 DOI: 10.4103/joacp.joacp_436_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 12/31/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
| | | | - Summit Dev Bloria
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Rajeev Chauhan
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
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9
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van Mun LAM, Bosman SJE, de Vocht J, de Kort J, Schouten J. Barriers and Facilitators in Perioperative Antibiotic Prophylaxis: A Mixed-Methods Study in a Small Island Setting. Antibiotics (Basel) 2021; 10:462. [PMID: 33921814 PMCID: PMC8073237 DOI: 10.3390/antibiotics10040462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 11/16/2022] Open
Abstract
Few studies have addressed antibiotic guideline adherence in small island settings, such as Aruba. This study aimed to evaluate the appropriateness of perioperative antibiotic prophylaxis (PAP) and identify barriers for PAP guideline adherence. A mixed-methods study was carried out at the operating theatre (OT) in the Dr. Horacio E. Oduber Hospital (HOH) in Aruba. First, a prospective audit was performed on the appropriateness of guideline-derived quality indicators (QIs). Then, interviews based on the Flottorp framework were conducted to identify barriers for guideline adherence. Finally, a survey was distributed to verify the outcomes of the interviews. The appropriateness of QIs was measured: correct indication (50.6%); antimicrobial agent (30.8%); dose (94.4%); timing (55.0%); route of administration (100%); duration (89.5%); and redosing (95.7%). The overall appropriateness was 34.9%. The main barriers discovered were poor knowledge about PAP and the guidelines and professional interactions regarding PAP, specifically poor communication and lack of clarity about responsibilities regarding PAP. This study was the first to evaluate the appropriateness and to identify barriers for PAP guideline adherence in a small island hospital. The overall appropriateness of PAP was poor with just 34.9%. Future interventions should be focused on communication, education and awareness of the possibility to consult an ID physician or microbiologist.
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Affiliation(s)
- Liza A. M. van Mun
- Radboud Center for Infectious Diseases (RCI), RadboudUMC, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands; (J.d.V.); (J.S.)
| | - Sabien J. E. Bosman
- Radboud Center for Infectious Diseases (RCI), RadboudUMC, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands; (J.d.V.); (J.S.)
| | - Jessica de Vocht
- Radboud Center for Infectious Diseases (RCI), RadboudUMC, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands; (J.d.V.); (J.S.)
| | - Jaclyn de Kort
- Department of Internal Medicine, Dr. Horacio E. Oduber Hospital, Dr. Horacio E. Oduber Boulevard #1, Oranjestad, Aruba;
| | - Jeroen Schouten
- Radboud Center for Infectious Diseases (RCI), RadboudUMC, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands; (J.d.V.); (J.S.)
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10
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Hassan S, Chan V, Stevens J, Stupans I. Factors that influence adherence to surgical antimicrobial prophylaxis (SAP) guidelines: a systematic review. Syst Rev 2021; 10:29. [PMID: 33453730 PMCID: PMC7811740 DOI: 10.1186/s13643-021-01577-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 01/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Despite the extensive research that has been conducted to date, practice often differs from established guidelines and will vary between individuals and organisations. It has been noted that the global uptake of local and international surgical antimicrobial prophylaxis (SAP) guidelines is poor with limited research investigating factors that affect guideline adherence. The purpose of this systematic review was to determine the reported barriers and enablers to the adherence of SAP guidelines. METHODS A search of the literature was performed using four electronic databases (CINAHL, EMBASE, PubMed and SCOPUS) for articles published in the English language from January 1998 to December 2018. Articles were included if they were solely related to SAP and discussed the barriers or enablers to SAP guideline adherence. Articles that assessed the adherence to a range of infection control measures or discussed adherence to antibiotic treatment guidelines rather than SAP guidelines were excluded from this review. Barriers and enablers were mapped to the Theoretical Domains Framework (TDF). The Mixed Methods Appraisal Tool was used to assess the quality of included studies. RESULTS A total of 1489 papers were originally retrieved, with 48 papers meeting the eligibility criteria. Barriers and enablers were mapped to 11 out of 14 TDF domains: knowledge, skills, social/professional role and identity, beliefs about capabilities, beliefs about consequences, reinforcement, memory, attention and decision processes, environmental context and resources, social influences, emotion and behavioural regulation. Barriers were further categorised into personal or organisational barriers, while enablers were arranged under commonly trialled interventions. CONCLUSIONS There are numerous factors that can determine the uptake of SAP guidelines. An identification and understanding of these factors at a local level is required to develop tailored interventions to enhance guideline adherence. Interventions, when used in combination, can be considered as a means of improving guideline use.
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Affiliation(s)
- Sarah Hassan
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia.
| | - Vincent Chan
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
| | - Julie Stevens
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Ieva Stupans
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
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Parker H, Frost J, Britten N, Robinson S, Mattick K. Understanding surgical antimicrobial prescribing behaviour in the hospital setting: a systematic review and meta-ethnography protocol. Syst Rev 2020; 9:236. [PMID: 33038928 PMCID: PMC7548039 DOI: 10.1186/s13643-020-01477-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/08/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Surgical specialities use extensive amounts of antimicrobials, and misuse has been widely reported, making them a key target for antimicrobial stewardship initiatives. Interventions informed by, and tailored to, a clear understanding of the contextual barriers to appropriate antimicrobial use are more likely to successfully improve practice. However, this approach has been under utilised. Our aim is to synthesise qualitative studies on surgical antimicrobial prescribing behaviour (APB) in hospital settings to explain how and why contextual factors act and interact to influence APB amongst surgical teams. We will develop new theory to advance understanding and identify knowledge gaps to inform further research. METHODS The meta-ethnography will follow the seven-phase method described by Noblit and Hare. We will conduct a comprehensive search using eight databases (AMED, CINAHL, EMBASE, MEDLINE, MEDLINE-in-process, Web of Science, Cochrane Library and PsycINFO) with no date restrictions; forwards and backwards citation searches; and contacting first authors of relevant papers. Studies will be dual screened and included if they use recognised qualitative methods and analysis; focus on contextual factors associated with surgical APB within hospital settings; are available in full in English; and are relevant to the research question. Any disagreements between reviewers will be resolved through discussion to reach consensus. Included studies will be read repeatedly to illuminate key concepts and the relationship between key concepts across studies. Then, key concepts will be sorted into conceptual categories or 'piles' which will be further abstracted to form a conceptual framework explaining surgical APB. During the synthesis, emerging interpretations will be discussed with stakeholders (including authors of included studies where possible; surgical and stewardship practitioners; and patient representatives) to ensure new knowledge is meaningful. DISCUSSION This research has several strengths: (1) the protocol has been written with reference to established guidance maximising rigour and transparency; (2) the multi-disciplinary research team bring varied interpretative repertoires and relevant methodological skills; and (3) stakeholders will be involved to ensure that findings are relevant, and disseminated via suitable channels, to support improved patient care. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020184343.
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Affiliation(s)
- Hazel Parker
- Pharmacy Department, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK.
| | - Julia Frost
- South Cloisters, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Nicky Britten
- South Cloisters, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Sophie Robinson
- South Cloisters, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Karen Mattick
- South Cloisters, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
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Pough K, Bhakta R, Maples H, Honeycutt M, Vijayan V. Evaluation of Pediatric Surgical Site Infections Associated with Colorectal Surgeries at an Academic Children's Hospital. Healthcare (Basel) 2020; 8:healthcare8020091. [PMID: 32283686 PMCID: PMC7348892 DOI: 10.3390/healthcare8020091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/04/2020] [Accepted: 04/05/2020] [Indexed: 01/22/2023] Open
Abstract
Appropriate use of antibiotic prophylaxis (AP) is a key measure for the prevention of surgical site infections (SSI) in colorectal surgeries; however, despite the presence of national and international guidelines, compliance with AP recommendations remains low. The purpose of this study is to evaluate compliance with recommendations for the use of AP in children undergoing colorectal surgeries and to evaluate the effectiveness of antibiotics in the prevention of SSI. We collected demographic and clinical characteristics of patients who underwent colorectal surgeries, as well as microbiological and antimicrobial susceptibility data for patients who developed SSI. AP data were collected and compared with national guidelines. Antibiotic dosing and duration were most frequently in concordance with national guidelines, while antibiotic timing and selection had the lowest rates of compliance. Twelve of the 192 colorectal procedures evaluated resulted in SSI. Only 2 of the 12 children with SSI received appropriate AP for all four categories evaluated. Eight cases that resulted in SSI were due to organisms not covered by the recommended AP. We identified multiple areas for the improvement of AP in children undergoing colorectal surgery. A multidisciplinary approach to development of standardized protocols, educational interventions, and EHR-based algorithms may facilitate or improve appropriate AP use.
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Affiliation(s)
- Kimberly Pough
- Department of Pharmacy Practice, Arkansas Children’s Hospital, Little Rock, AR 72202, USA;
- Department of Pharmacy Practice, St. Christopher’s Hospital for Children, Philadelphia, PA 19134, USA
- Correspondence:
| | - Rima Bhakta
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Holly Maples
- Department of Pharmacy Practice, Arkansas Children’s Hospital, Little Rock, AR 72202, USA;
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Michele Honeycutt
- Department of Infection Prevention and Hospital Epidemiology, Arkansas Children’s Hospital, Little Rock, AR 72202, USA;
| | - Vini Vijayan
- Division of Infectious Diseases, Department of Pediatrics, Valley Children’s Hospital, Madera, CA 93636, USA;
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Alamrew K, Tadesse TA, Abiye AA, Shibeshi W. Surgical Antimicrobial Prophylaxis and Incidence of Surgical Site Infections at Ethiopian Tertiary-Care Teaching Hospital. Infect Dis (Lond) 2019; 12:1178633719892267. [PMID: 31819472 PMCID: PMC6882032 DOI: 10.1177/1178633719892267] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 11/09/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are infections that develop within 30 days after an operation or surveillance of surgical wound infection implementation within 90 days after surgery when an implant is placed. The objective of this study was to assess preoperative and postoperative antimicrobial use in St. Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia. METHODS A hospital-based cross-sectional study was undertaken in surgery wards of SPHMMC for 4 months by reviewing 413 patients' charts. All patients 13 years and older who were admitted and underwent different types of surgical procedures were included in the study. Epi info 7 was used for data entry, and then data were exported to Statistical Package for Social Sciences (SPSS) version 20.0 software for analysis. Descriptive analyses were computed and rate of SSI was calculated in this study. Moreover, bivariate analysis was done to examine the relationship between the outcome variable and predictor variables with a value of P < .2 retained for subsequent multivariate analyses using multiple logistic regressions. P value of <.05 was considered as statistically significant. RESULTS Out of 413 patients, 152 (36.8%) were operated for general surgery, and the remaining were for other types of surgeries. Most of the patients, 196 (79.7%), were managed by a single surgical antibiotic agent, followed by 2 agents (20.3%) for surgical prophylaxis indication. Surgical site infections occurred in 46 (11.1%) patients before discharge from the hospital. In those patients who need treatment for SSIs, almost half of them (49.5%) received combination therapy of ceftriaxone and metronidazole. Emergency surgical cases were 2.647 times more likely to develop SSIs than the elective surgical cases (adjusted odds ratio [AOR] = 2.647; 95% confidence interval [CI] = 1.406-4.983; P = .003). Patients who did not receive antibiotic prophylaxis were 2.572 times more likely to develop SSIs compared to those who received antibiotic prophylaxis (AOR = 2.572; 95% CI = 1.02-6.485; P = .045). Clean-contaminated and contaminated types of wound were a protective factor against SSI in our study. CONCLUSIONS This study indicated that most of the patients (72.1%) received surgical antimicrobial prophylaxis. The overall incidence rate of SSIs was 11.1% in the studied hospital. Ceftriaxone was the most commonly used drug. Being not receiving prophylaxis, wound class, and surgery types were significantly associated with the development of SSI.
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Affiliation(s)
- Kerebih Alamrew
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tamrat Assefa Tadesse
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alfoalem Araba Abiye
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Workineh Shibeshi
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Charani E, de Barra E, Rawson TM, Gill D, Gilchrist M, Naylor NR, Holmes AH. Antibiotic prescribing in general medical and surgical specialties: a prospective cohort study. Antimicrob Resist Infect Control 2019; 8:151. [PMID: 31528337 PMCID: PMC6743118 DOI: 10.1186/s13756-019-0603-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/30/2019] [Indexed: 12/02/2022] Open
Abstract
Background Qualitative work has described the differences in prescribing practice across medical and surgical specialties. This study aimed to understand if specialty impacts quantitative measures of prescribing practice. Methods We prospectively analysed the antibiotic prescribing across general medical and surgical teams for acutely admitted patients. Over a 12-month period (June 2016 – May 2017) 659 patients (362 medical, 297 surgical) were followed for the duration of their hospital stay. Antibiotic prescribing across these cohorts was assessed using Chi-squared or Wilcoxon rank-sum, depending on normality of data. The t-test was used to compare age and length of stay. A logistic regression model was used to predict escalation of antibiotic therapy. Results Surgical patients were younger (p < 0.001) with lower Charlson Comorbidity Index scores (p < 0.001). Antibiotics were prescribed for 45% (162/362) medical and 55% (164/297) surgical patients. Microbiological results were available for 26% (42/164) medical and 29% (48/162) surgical patients, of which 55% (23/42) and 48% (23/48) were positive respectively. There was no difference in the spectrum of antibiotics prescribed between surgery and medicine (p = 0.507). In surgery antibiotics were 1) prescribed more frequently (p = 0.001); 2) for longer (p = 0.016); 3) more likely to be escalated (p = 0.004); 4) less likely to be compliant with local policy (p < 0.001) than medicine. Conclusions Across both specialties, microbiology investigation results are not adequately used to diagnose infections and optimise their management. There is significant variation in antibiotic decision-making (including escalation patterns) between general surgical and medical teams. Antibiotic stewardship interventions targeting surgical specialties need to go beyond surgical prophylaxis. It is critical to focus on of review the patients initiated on therapeutic antibiotics in surgical specialties to ensure that escalation and continuation of therapy is justified.
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Affiliation(s)
- E Charani
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
| | - E de Barra
- 2Royal College of Surgeons in Ireland, RCSI Education & Research Centre, Beaumont Hospital, Beaumont, Dublin 9, Ireland
| | - T M Rawson
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
| | - D Gill
- 3Department of Biostatistics and Epidemiology, School of Public Health, Imperial College London, London, W2 1PG UK
| | - M Gilchrist
- Department of Pharmacy, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London, W12 1NY UK
| | - N R Naylor
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
| | - A H Holmes
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
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15
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Wæhle HV, Harthug S, Søfteland E, Sevdalis N, Smith I, Wiig S, Aase K, Haugen AS. Investigation of perioperative work processes in provision of antibiotic prophylaxis: a prospective descriptive qualitative study across surgical specialties in Norway. BMJ Open 2019; 9:e029671. [PMID: 31230033 PMCID: PMC6596935 DOI: 10.1136/bmjopen-2019-029671] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/05/2019] [Accepted: 05/17/2019] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Surgical site infections are known postoperative complications, yet the most preventable of healthcare-associated infections. Correct provision of surgical antibiotic prophylaxis (SAP) is crucial. Use of the WHO Safe Surgical Checklist (SSC) has been reported to improve provision of SAP, and reduce infections postoperatively. To understand possible mechanisms and interactions generating such effects, we explored the underlying work processes of SAP provision and SSC performance at the intersection of perioperative procedures and actual team working. DESIGN An ethnographic study including observations and in-depth interviews. A combination of deductive and inductive content analysis of the data was conducted. SETTING Operating theatres with different surgical specialities, in three Norwegian hospitals. PARTICIPANTS Observations of perioperative team working (40 hours) and in-depth interviews of 19 experienced perioperative team members were conducted. Interview participants followed a maximum variation purposive sampling strategy. RESULTS Analysis identified provision of SAP as a process of linked activities; sequenced, yet disconnected in time and space throughout the perioperative phase. Provision of SAP was handled in relation to several interactive factors: preparation and administration, prescription accuracy, diversity of prescription order systems, patient-specific conditions and changes in operating theatre schedules. However, prescription checks were performed either as formal SSC reviews of SAP items or as informal checks of relevant documents. In addition, use of cognitive reminders and clinical experiences were identified as mechanisms used to enable administration of SAP within the 60 min timeframe described in the SSC. CONCLUSION Provision of SAP was identified as a complex process. Yet, a key element in provision of SAP was the given 60 min. timeframe of administration before incision, provided in the SSC. Thus, the SSC seems beneficial in supporting timely SAP administration practice by either being a cognitive tool and/or as a cognitive intervention.
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Affiliation(s)
- Hilde Valen Wæhle
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Stig Harthug
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Eirik Søfteland
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service & Population Research Department, King's College, London, UK
| | - Ingrid Smith
- Department of Essential Medicines and Health Products, World Health Organization, Geneve, Switzerland
| | - Siri Wiig
- Centre for Resilience in Healthcare (SHARE), Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Karina Aase
- Centre for Resilience in Healthcare (SHARE), Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Arvid Steinar Haugen
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
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Chan JOS, Baysari MT, Carland JE, Sandaradura I, Moran M, Day RO. Barriers and facilitators of appropriate vancomycin use: prescribing context is key. Eur J Clin Pharmacol 2018; 74:1523-1529. [PMID: 30056569 DOI: 10.1007/s00228-018-2525-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 07/16/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE Audit studies reveal frequent non-compliance with dosing and monitoring guidelines for vancomycin. This study aimed to qualitatively explore the barriers and facilitators of compliance with vancomycin dosing and monitoring guidelines. METHODS Interviews were conducted with 16 prescribers in a large tertiary teaching hospital in Sydney, Australia. Questions explored knowledge, attitudes, and perceived complexities associated with vancomycin use. Interviews were analysed using thematic analysis. RESULTS Prescribers reported utilising vancomycin guidelines, citing familiarity with guidelines, a positive perception of guidelines, awareness of poor guideline compliance, and assistance from specialist staff as facilitators of the uptake of guideline recommendations. Barriers existing within the prescribing environment such as the prescribing culture, a lack of time, and poor communication and coordination of therapeutic drug monitoring processes were identified as hindrances to guideline compliance. CONCLUSIONS The provision of guidelines may not be sufficient in ensuring appropriate prescribing and monitoring of vancomycin when barriers relating to the prescribing environment exist. Developing interventions targeted toward these barriers, such as having dedicated phlebotomists for vancomycin blood sampling, fostering better handover processes, and educating staff on poorly understood aspects of guidelines, is likely to improve the uptake of guideline recommendations for vancomycin and other medications requiring therapeutic drug monitoring.
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Affiliation(s)
- Joanne Oi Sze Chan
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia.
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.
| | | | - Jane Ellen Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Indy Sandaradura
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia
| | - Maria Moran
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Richard Osborne Day
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
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Vos RJ, Van Putte BP, Kloppenburg GTL. Prevention of deep sternal wound infection in cardiac surgery: a literature review. J Hosp Infect 2018; 100:411-420. [PMID: 29885873 DOI: 10.1016/j.jhin.2018.05.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 05/31/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Deep sternal wound infection (DSWI) is a dreaded complication of cardiac surgery with considerable consequences in terms of mortality, morbidity and treatment costs. In addition to standard surgical site infection prevention guidelines, multiple specific measures in the prevention of DSWI have been developed and evaluated in the past decades. This review focuses on these specific measures to prevent DSWI. METHODS An extensive literature search was performed to assess interventions in the prevention of DSWI. Articles describing results of a randomized controlled trial were categorized by type of intervention. Results were yielded and, if possible, pooled. RESULTS From a total of 743 articles found, 48 randomized controlled trials were selected. Studies were divided into 12 categories, containing pre-, peri- and postoperative preventive measures. Specific measures shown to be effective were: antibiotic prophylaxis with a first-generation cephalosporin for at least 24 h, application of local gentamicin before chest closure, sternal closure with figure-of-eight steel wires, and postoperative chest support using a corset or vest. CONCLUSION This study identified several measures that prevent DSWI after cardiac surgery that are not frequently applied in current practice. It is recommended that the guidelines on prevention of surgical site infection in cardiac surgery should be updated.
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Affiliation(s)
- R J Vos
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, The Netherlands.
| | - B P Van Putte
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - G T L Kloppenburg
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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18
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Antibiotic Prophylaxis for Breast Oncosurgery in a Setting With a High Prevalence of Multidrug-Resistant Bacteria: Common Sense Infection Control Measures Are More Important Than Prolonged Antibiotics. Infect Control Hosp Epidemiol 2018; 39:498-500. [PMID: 29436315 DOI: 10.1017/ice.2017.313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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19
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Pollmann AS, Bailey JG, Davis PJB, Johnson PM. Antibiotic use among older adults on an acute care general surgery service. Can J Surg 2017; 60:388-393. [PMID: 28930045 DOI: 10.1503/cjs.004317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Antibiotics play an important role in the treatment of many surgical diseases that affect older adults, and the potential for inappropriate use of these drugs is high. Our objective was to describe antibiotic use among older adults admitted to an acute care surgery service at a tertiary care teaching hospital. METHODS Detailed data regarding diagnosis, comorbidities, surgery and antibiotic use were retrospectively collected for patients 70 years and older admitted to an acute care surgery service. We evaluated antibiotic use (perioperative prophylaxis and treatment) for appropriateness based on published guidelines. RESULTS During the study period 453 patients were admitted to the acute care surgery service, and 229 underwent surgery. The most common diagnoses were small bowel obstruction (27.2%) and acute cholecystitis (11.0%). In total 251 nonelective abdominal operations were performed, and perioperative antibiotic prophylaxis was appropriate in 49.5% of cases. The most common prophylaxis errors were incorrect timing (15.5%) and incorrect dose (12.4%). Overall 206 patients received treatment with antibiotics for their underlying disease process, and 44.2% received appropriate first-line drug therapy. The most common therapeutic errors were administration of second- or third-line antibiotics without indication (37.9%) and use of antibiotics when not indicated (12.1%). There was considerable variation in the duration of treatment for patients with the same diagnoses. CONCLUSION Inappropriate antibiotic use was common among older patients admitted to an acute care surgery service. Quality improvement initiatives are needed to ensure patients receive optimal care in this complex hospital environment.
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Affiliation(s)
- André S Pollmann
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Pollmann, Bailey, Davis, Johnson); and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS (Bailey, Davis, Johnson)
| | - Jon G Bailey
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Pollmann, Bailey, Davis, Johnson); and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS (Bailey, Davis, Johnson)
| | - Philip J B Davis
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Pollmann, Bailey, Davis, Johnson); and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS (Bailey, Davis, Johnson)
| | - Paul M Johnson
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Pollmann, Bailey, Davis, Johnson); and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS (Bailey, Davis, Johnson)
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20
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Hardefeldt LY, Browning GF, Thursky KA, Gilkerson JR, Billman-Jacobe H, Stevenson MA, Bailey KE. Cross-sectional study of antimicrobials used for surgical prophylaxis by bovine veterinary practitioners in Australia. Vet Rec 2017; 181:426. [PMID: 28893972 DOI: 10.1136/vr.104375] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 07/25/2017] [Accepted: 08/04/2017] [Indexed: 11/04/2022]
Abstract
Antimicrobials are widely used in veterinary practices, but there has been no investigation of antimicrobial classes used or the appropriateness of their use in bovine practice. This study investigated antimicrobial use for surgical prophylaxis in bovine practice in Australia. A cross-sectional study of veterinarian antimicrobial usage patterns was conducted using an online questionnaire. Information solicited included respondent's details, the frequency with which antimicrobials were used for specific surgical conditions (including the dose, timing and duration of therapy) and details of practice antimicrobial use policies and sources of information about antimicrobials. In total, 212 members of the Australian veterinary profession working in bovine practice completed the survey. Antimicrobials were always or frequently used by more than 75 per cent of respondents in all scenarios. Generally, antimicrobial drug choice was appropriate for the reported surgical conditions. Procaine penicillin and oxytetracycline accounted for 93 per cent of use. However, there was a wide range of doses used, with underdosing and inappropriate timing of administration being common reasons for inappropriate prophylactic treatment. There was very low use of critically important antimicrobials (3.3 per cent of antimicrobials reported). Antimicrobial use guidelines need to be developed and promoted to improve the responsible use of antimicrobials in bovine practice.
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Affiliation(s)
- Laura Y Hardefeldt
- Faculty of Veterinary and Agricultural Sciences, Asia-Pacific Centre for Animal Health, University of Melbourne, Parkville, Victoria, Australia.,National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Carlton, Victoria, Australia
| | - Glenn F Browning
- Faculty of Veterinary and Agricultural Sciences, Asia-Pacific Centre for Animal Health, University of Melbourne, Parkville, Victoria, Australia.,National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Carlton, Victoria, Australia
| | - Karin A Thursky
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Carlton, Victoria, Australia
| | - James R Gilkerson
- Faculty of Veterinary and Agricultural Sciences, Asia-Pacific Centre for Animal Health, University of Melbourne, Parkville, Victoria, Australia
| | - Helen Billman-Jacobe
- Faculty of Veterinary and Agricultural Sciences, Asia-Pacific Centre for Animal Health, University of Melbourne, Parkville, Victoria, Australia.,National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Carlton, Victoria, Australia
| | - Mark A Stevenson
- Faculty of Veterinary and Agricultural Sciences, Asia-Pacific Centre for Animal Health, University of Melbourne, Parkville, Victoria, Australia
| | - Kirsten E Bailey
- Faculty of Veterinary and Agricultural Sciences, Asia-Pacific Centre for Animal Health, University of Melbourne, Parkville, Victoria, Australia.,National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Carlton, Victoria, Australia
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21
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Hardefeldt LY, Browning GF, Thursky K, Gilkerson JR, Billman-Jacobe H, Stevenson MA, Bailey KE. Antimicrobials used for surgical prophylaxis by equine veterinary practitioners in Australia. Equine Vet J 2017; 50:65-72. [PMID: 28608525 DOI: 10.1111/evj.12709] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 06/02/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antimicrobials are widely used in Australian veterinary practices, but no investigation into the classes of antimicrobials used, or the appropriateness of use in horses, has been conducted. OBJECTIVES The aim of the study was to describe antimicrobial use for surgical prophylaxis in equine practice in Australia. STUDY DESIGN Cross-sectional questionnaire survey. METHODS An online questionnaire was used to document antimicrobial usage patterns. Information solicited in the questionnaire included demographic details of the respondents, the frequency with which antimicrobials were used for specific surgical conditions (including the dose, timing and duration of therapy) and practice antimicrobial use policies and sources of information about antimicrobials and their uses. RESULTS A total of 337 members of the Australian veterinary profession completed the survey. Generally, the choice of antimicrobial was appropriate for the specified equine surgical condition, but the dose and duration of therapy varied greatly. While there was poor optimal compliance with British Equine Veterinary Association guidelines in all scenarios (range 1-15%), except removal of a nonulcerated dermal mass (42%), suboptimal compliance (compliant antimicrobial drug selection but inappropriate timing, dose or duration of therapy) was moderate for all scenarios (range 48-68%), except for an uninfected contaminated wound over the thorax, where both optimal and suboptimal compliance was very poor (1%). Veterinarians practicing at a university hospital had higher odds of compliance than general practice veterinarians (Odds ratio 3.2, 95% CI, 1.1-8.9, P = 0.03). MAIN LIMITATIONS Many survey responses were collected at conferences which may introduce selection bias, as veterinarians attending conferences may be more likely to have been exposed to contemporary antimicrobial prescribing recommendations. CONCLUSIONS Antimicrobial use guidelines need to be developed and promoted to improve the responsible use of antimicrobials in equine practice in Australia. An emphasis should be placed on antimicrobial therapy for wounds and appropriate dosing for procaine penicillin.
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Affiliation(s)
- L Y Hardefeldt
- Asia-Pacific Centre for Animal Health, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia.,National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Carlton, Victoria, Australia
| | - G F Browning
- Asia-Pacific Centre for Animal Health, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia.,National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Carlton, Victoria, Australia
| | - K Thursky
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Carlton, Victoria, Australia
| | - J R Gilkerson
- Asia-Pacific Centre for Animal Health, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - H Billman-Jacobe
- Asia-Pacific Centre for Animal Health, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia.,National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Carlton, Victoria, Australia
| | - M A Stevenson
- Asia-Pacific Centre for Animal Health, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - K E Bailey
- Asia-Pacific Centre for Animal Health, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia.,National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Carlton, Victoria, Australia
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22
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de Jonge SW, Gans SL, Atema JJ, Solomkin JS, Dellinger PE, Boermeester MA. Timing of preoperative antibiotic prophylaxis in 54,552 patients and the risk of surgical site infection: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e6903. [PMID: 28723736 PMCID: PMC5521876 DOI: 10.1097/md.0000000000006903] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The aim of the study was to assess the effect of timing of preoperative surgical antibiotic prophylaxis (SAP) on surgical site infection (SSI) and compare the different timing intervals.The benefit of routine use of SAP prior to surgery has long been recognized. However, the optimal timing has not been defined. For the purpose of developing recommendations for the World Health Organization guideline for SSI prevention, a systematic review and meta-analysis of all relevant evidence was conducted.Major medical databases were searched from 1990 to 2016. The primary outcome was SSI after preoperative-SAP comparing different timing intervals. Adjusted odds ratios (OR) with 95% confidence intervals (CI) were extracted and pooled for each comparison with a random effects model.Fourteen papers with 54,552 patients were included in this review. In a quantitative analysis, there was no significant difference when SAP was administered 120-60 minutes prior to incision compared to administration 60-0 minutes prior to incision. Studies investigating different timing intervals within the last 60 minutes time frame reported contradictive results. The risk of SSI almost doubled when SAP was administered after first incision (OR:1.89; 95%CI:[1.05-3.40]) and was 5 times higher when administered more than 120 minutes prior to incision (OR5.26; 95%CI:[3.29-8.39]).Administration of antibiotic prophylaxis more than 120 minutes before incision or after incision is associated a higher risk of surgical site infections than administration less than 120 minutes before incision. Within this 120-minute time frame prior to incision, no differential effects could be identified. The broadly accepted recommendation to administer prophylaxis within a 60-minute time frame prior to incision could not be substantiated.
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Affiliation(s)
| | - Sarah L. Gans
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Jasper J. Atema
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Joseph S. Solomkin
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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Charani E, Ahmad R, Tarrant C, Birgand G, Leather A, Mendelson M, Moonesinghe SR, Sevdalis N, Singh S, Holmes A. Opportunities for system level improvement in antibiotic use across the surgical pathway. Int J Infect Dis 2017; 60:29-34. [PMID: 28483725 DOI: 10.1016/j.ijid.2017.04.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/19/2017] [Accepted: 04/25/2017] [Indexed: 12/16/2022] Open
Abstract
Optimizing antibiotic prescribing across the surgical pathway (before, during, and after surgery) is a key aspect of tackling important drivers of antimicrobial resistance and simultaneously decreasing the burden of infection at the global level. In the UK alone, 10 million patients undergo surgery every year, which is equivalent to 60% of the annual hospital admissions having a surgical intervention. The overwhelming majority of surgical procedures require effectively limited delivery of antibiotic prophylaxis to prevent infections. Evidence from around the world indicates that antibiotics for surgical prophylaxis are administered ineffectively, or are extended for an inappropriate duration of time postoperatively. Ineffective antibiotic prophylaxis can contribute to the development of surgical site infections (SSIs), which represent a significant global burden of disease. The World Health Organization estimates SSI rates of up to 50% in postoperative surgical patients (depending on the type of surgery), with a particular problem in low- and middle-income countries, where SSIs are the most frequently reported healthcare-associated infections. Across European hospitals, SSIs alone comprise 19.6% of all healthcare-acquired infections. Much of the scientific research in infection management in surgery is related to infection prevention and control in the operating room, surgical prophylaxis, and the management of SSIs, with many studies focusing on infection within the 30-day postoperative period. However it is important to note that SSIs represent only one of the many types of infection that can occur postoperatively. This article provides an overview of the surgical pathway and considers infection management and antibiotic prescribing at each step of the pathway. The aim was to identify the implications for research and opportunities for system improvement.
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Affiliation(s)
- E Charani
- NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infection, Imperial College London, Department of Medicine, London, UK.
| | - R Ahmad
- NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infection, Imperial College London, Department of Medicine, London, UK
| | - C Tarrant
- Department of Health Sciences, University of Leicester, Centre for Medicine, Leicester, UK
| | - G Birgand
- NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infection, Imperial College London, Department of Medicine, London, UK
| | - A Leather
- King's Centre for Global Health & Health Partnerships, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, UK
| | - M Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Groote Schuur Hospital Observatory, Cape Town, South Africa
| | - S R Moonesinghe
- Centre for Anaesthesia Critical Care and Pain Medicine, University College London Hospitals, London, UK()
| | - N Sevdalis
- Centre for Implementation Science, Institute of Psychiatry, King's College London, Denmark Hill, UK
| | - S Singh
- School of Medicine, Amrita University, Tamilnadu, Kochi, India
| | - A Holmes
- NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infection, Imperial College London, Department of Medicine, London, UK
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Giusti A, Spila Alegiani S, Ciofi Degli Atti ML, Colaceci S, Raschetti R, Arace P, Spiazzi R, Raponi M. Surgical antibiotic prophylaxis in children: a mixed method study on healthcare professionals attitudes. BMC Pediatr 2016; 16:203. [PMID: 27919244 PMCID: PMC5139116 DOI: 10.1186/s12887-016-0739-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/26/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Qualitative and quantitative research investigating determinants of adherence to clinical guidelines (GLs) on surgical antibiotic prophylaxis (SAP) are scarce. We conducted a mixed-method study aimed at investigating barriers and at describing attitudes of healthcare professionals (HCPs) regarding SAP in three Italian children's hospitals. METHODS The study comprised two sequential phases: 1) collection of qualitative data through focus groups; 2) conduction of a survey on HCPs attitudes towards SAP. Focus groups were carried out in each hospital with a theoretical convenience sample of 10-15 HCPs. Categorical analysis was conducted. Emerging categories and additional topics derived by literature search were used to develop the survey questionnaire, which included 13 questions expressed through a 4-point Likert scale. Members of surgical teams were invited by e-mail to fill in the questionnaire. We summed up the points assigned to each 4-point Likert scale response and calculated a cumulative score expressing overall concordance to expected HCPs attitudes on SAP. We conducted univariate and multivariate analysis to evaluate the relationship among characteristics of respondents and concordance with expected attitudes. RESULTS The main categories identified in the qualitative phase included determinants of general adherence to GLs (e.g., relevance of clinical judgment), individual determinants (e.g., poor knowledge on hospital data) and organizational/structural determinants (e.g., patient flows). A total of 357 HCPs participated in the survey (response rate: 82.1%). Among respondents, 75% reported that SAP should be performed with first or second-generation cephalosporins, 44% that 2-3 days of antibiotic administration are useful as a precaution after surgery, 32% that SAP is needed for all surgical procedures. At multivariate analysis, professional category (physicians vs nurses; OR: 3.31; 95%CI: 1.88-5.82), and hospital (hospital 1 and 2 vs hospital 3; ORs: 2.79, 95%CI: 1.22-6.36; 2.40, 95%CI: 1.30-4.43, respectively) were significantly and independently associated with higher concordance with expected attitudes on SAP. CONCLUSIONS Results from this study were useful to identify obstacles to appropriate SAP use in children. In our setting, findings support that a quality-improvement intervention should take into account local contexts, with development of hospital policies, education on SAP recommendations, and dissemination of data on adherence to recommendations.
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Affiliation(s)
- Angela Giusti
- National Centre for Epidemiology, Surveillance and Health Promotion, National Institute of Health, Rome, Italy
| | - Stefania Spila Alegiani
- National Centre for Epidemiology, Surveillance and Health Promotion, National Institute of Health, Rome, Italy
| | | | - Sofia Colaceci
- National Centre for Epidemiology, Surveillance and Health Promotion, National Institute of Health, Rome, Italy
| | - Roberto Raschetti
- National Centre for Epidemiology, Surveillance and Health Promotion, National Institute of Health, Rome, Italy
| | - Pasquale Arace
- Medical Direction, Ospedale Santobono Pausilipon, Naples, Italy
| | - Raffaele Spiazzi
- Medical Direction, Children's Hospital AO Spedali Civili, Brescia, Italy
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Parker HM, Mattick K. The determinants of antimicrobial prescribing among hospital doctors in England: a framework to inform tailored stewardship interventions. Br J Clin Pharmacol 2016; 82:431-40. [PMID: 27038778 DOI: 10.1111/bcp.12953] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 03/08/2016] [Accepted: 03/28/2016] [Indexed: 01/15/2023] Open
Abstract
AIM Little is known about the determinants of antimicrobial prescribing behaviour (APB), how they vary between hospital prescribers or the mechanism by which interventions are effective. Yet, interventions based on a sound theoretical understanding of APB are more likely to be successful in changing outcomes. This study sought to quantify the potential determinants of APB among hospital doctors in south-west England. METHODS This multicentre, quantitative study employed a closed answer questionnaire to garner hospital doctors' views on factors influencing their APB. Underlying constructs within the data were identified using exploratory factor analysis and subsequent pairwise comparisons assessed for variance between groups of prescribers. RESULTS The questionnaire was completed by 301 doctors across four centres (response rate ≥ 74%) and three key factors were identified: autonomy, guidelines adherence and antibiotic awareness. The internal consistency for the questionnaire scale and for each factor subscale was good (α ≥ 0.7). Subgroup analysis identified significant differences between groups of prescribers: autonomy scores increased with grade until at the specialist trainee level (P ≤ 0.009), foundation doctors scored higher for guidelines adherence than consultants (P = 0.004) and specialist trainees (P = 0.003) and United Kingdom trained doctors scored higher than those trained abroad for antibiotic awareness (P < 0.0005). Scores did not vary significantly between doctors from different centres. CONCLUSION Autonomy, guidelines adherence and antibiotic awareness were identified as important factors relevant to APB, which vary with experience and training. A theoretical framework is offered to facilitate development of more effective, tailored interventions to change APBs.
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Affiliation(s)
- Hazel M Parker
- Pharmacy Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Karen Mattick
- Centre for Research in Professional Learning, Graduate School of Education, University of Exeter, Exeter, UK
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Empowering patients in the hospital as a new approach to reducing the burden of health care-associated infections: The attitudes of hospital health care workers. Am J Infect Control 2016; 44:263-8. [PMID: 26607433 DOI: 10.1016/j.ajic.2015.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 10/02/2015] [Accepted: 10/06/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Any approach promoting a culture of safety and the prevention of health care-associated infections (HCAIs) should involve all stakeholders, including by definition the patients themselves. This qualitative study explored the knowledge and attitudes of health care workers toward the concept of patient empowerment focused on improving infection control practices. METHODS Semi-structured interviews were undertaken with 29 staff from a large hospital in Sydney, Australia. RESULTS There was virtually unanimous agreement among the participants that patients should be thought of as a stakeholder and should have a role in the prevention of HCAI. However, the degree of patient responsibility and level of system engagement varied. Although very few had previously been exposed to the concept of empowerment, they were accepting of the idea and were surprised that hospitals had not yet adopted the concept. However, they felt that a lack of support, busy workloads, and negative attitudes would be key barriers to the implementation of any empowerment programs. CONCLUSION Although the World Health Organization has recommended that patients have a role in encouraging hand hygiene as a means of preventing infection, patient engagement remains an underused method. By extending the concept of patient empowerment to a range of infection prevention opportunities, the positive impact of this intervention will not only extend to the patient but to the system itself.
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Durando P, Bassetti M, Orengo G, Crimi P, Battistini A, Bellina D, Talamini A, Tiberio G, Alicino C, Iudici R, Sticchi C, Ansaldi F, Rossi A, Rosso R, Viscoli C, Icardi G. Adherence to international and national recommendations for the prevention of surgical site infections in Italy: results from an observational prospective study in elective surgery. Am J Infect Control 2012; 40:969-72. [PMID: 22418605 DOI: 10.1016/j.ajic.2011.11.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 11/22/2011] [Accepted: 11/22/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND An observational prospective study of the perioperative procedures for prevention of surgical site infections (SSIs) was carried out in a tertiary referral teaching hospital in Liguria, Italy, to evaluate their adherence to international and national standards. METHODS A 1-month survey was performed in all surgical departments, monitored by turns by trained survey teams. Data regarding presurgical patient preparation and intraoperative infection control practices were collected. RESULTS A total of 717 elective interventions were actively monitored in 703 patients who underwent surgery. Hair-shaving was performed mainly using a razor (92%) by the nurses (72.8%) on the day before the operation (83.5%). All of the patients showered, either with a common detergent (87%) or with an antiseptic solution (13%). Antimicrobial prophylaxis was administered properly in 75.7% of the patients at induction of anaesthesia; however, according to current Italian guidelines, inappropriate prophylaxis was provided in 55.2% patients. Appropriate antisepsis of the incision area was done in 97.4% of the operations, and nearly 90% of the interventions lasted less than the respective 75th percentile. The doors of the operating theatres were mostly open during the duration of the operation in 36.3% of the cases. CONCLUSIONS This review of infection control policies identified significant opportunities for improving the safety and the quality of routine surgical practice.
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Affiliation(s)
- Paolo Durando
- Department of Health Sciences, University of Genoa, Genoa, Italy.
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Understanding physician antibiotic prescribing behaviour: a systematic review of qualitative studies. Int J Antimicrob Agents 2012; 41:203-12. [PMID: 23127482 DOI: 10.1016/j.ijantimicag.2012.09.003] [Citation(s) in RCA: 315] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 09/02/2012] [Indexed: 11/23/2022]
Abstract
Inappropriate prescription has been associated with mounting rates of antibiotic resistance worldwide, demanding more detailed studies into physicians' decision-making process. Accordingly, this study sought to explore physicians' perceptions of factors influencing antibiotic prescribing. A systematic search was performed for qualitative studies focused on understanding physicians' perceptions of the factors, attitudes and knowledge influencing antibiotic prescription. Of the total of 35 papers selected for review purposes, 18 solely included physicians and the remaining 17 also included patients and/or other healthcare providers. Data collection was based mainly on interviews, followed by questionnaires and focus groups, and the methodologies mainly used for data analysis were grounded theory and thematic analysis. Factors cited by physicians as having an impact on antibiotic prescribing were grouped into those that were intrinsic (group 1) and those that were extrinsic (group 2) to the healthcare professional. Among the former, physicians' attitudes, such as complacency or fear, were rated as being most influential on antibiotic prescribing, whilst patient-related factors (e.g. signs and symptoms) or healthcare system-related factors (e.g. time pressure and policies/guidelines implemented) were the most commonly reported extrinsic factors. These findings revealed that: (i) antibiotic prescribing is a complex process influenced by factors affecting all the actors involved, including physicians, other healthcare providers, healthcare system, patients and the general public; and (ii) such factors are mutually dependent. Hence, by shedding new light on the process, these findings will hopefully contribute to generating new and more effective strategies for improving antibiotic prescribing and allaying global concern about antibiotic resistance.
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Lopez-Vazquez P, Vazquez-Lago JM, Figueiras A. Misprescription of antibiotics in primary care: a critical systematic review of its determinants. J Eval Clin Pract 2012; 18:473-84. [PMID: 21210896 DOI: 10.1111/j.1365-2753.2010.01610.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Antibiotic resistance is one of the principal public health problems worldwide. Currently, inappropriate use of antibiotics is regarded as the principal determinant of resistance, with most of these drugs being prescribed outside a hospital setting. This systematic review sought to identify the factors, attitudes and knowledge linked to misprescription of antibiotics. METHODS A systematic review was conducted using the MEDLINE-PubMed and EMBASE databases. The selection criteria required that papers: (1) be published in English or Spanish; (2) designate their objective as that of addressing attitudes/knowledge or other factors related with the prescribing of antibiotics; and (3) use quality and/or quantity indicators to define misprescription. The following were excluded: any paper that used qualitative methodology and any paper that included descriptive analysis only. RESULTS A total of 46 papers that met the inclusion criteria were included in the review. They were very heterogeneous and displayed major methodological limitations. Doctors' socio-demographic and personal factors did not appear to exert much influence. Complacency (fulfilling what professionals perceived as being patients'/parents' expectations) and, to a lesser extent, fear (fear of possible complications in the patient) were the attitudes associated with misprescription of antibiotics. CONCLUSIONS Before designing interventions aimed at improving the prescription and use of antibiotics, studies are needed to identify precisely which factors influence prescribing.
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Affiliation(s)
- Paula Lopez-Vazquez
- Galician Ministry of Health, Spain and PhD Candidate, Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Spain
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Charani E, Edwards R, Sevdalis N, Alexandrou B, Sibley E, Mullett D, Franklin BD, Holmes A. Behavior change strategies to influence antimicrobial prescribing in acute care: a systematic review. Clin Infect Dis 2011; 53:651-62. [PMID: 21890770 DOI: 10.1093/cid/cir445] [Citation(s) in RCA: 178] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Antimicrobial use in acute care is widely reported to be suboptimal. Inappropriate use of antimicrobials is a major contributing factor to the emergence of multidrug resistance and health care-associated infection. Addressing prescribing behavior is a key component of antimicrobial stewardship. METHODS We performed a novel systematic review of both qualitative and quantitative literature on antimicrobial prescribing behavior in acute care. We assessed the extent to which behavioral sciences and social marketing were used and whether this could be related to the effectiveness of reported outcomes. MEDLINE, Excerpta Medica Database (EMBASE), Applied Social Sciences Index and Abstracts (ASSIA), Business Source Complete, The Cochrane Library, PsychInfo, Database of Abstracts of Reviews of Effectiveness (DARE) and Health Management Information Consortium (HMIC) were searched for studies undertaken during the period January 1999-April 2011 and published in English. RESULTS Five qualitative and 5 quantitative studies met the quality criteria. Qualitative studies highlight the predominant influence of social norms, attitudes, and beliefs on antimicrobial prescribing behavior. Quantitative studies reporting interventions to optimize antimicrobial prescribing behavior do not use theoretical science or primary research to inform the design and choice of the interventions deployed. CONCLUSIONS Despite qualitative evidence demonstrating the impact of behavioral determinants and social norms on prescribing, these influences are not given due consideration in the design and evaluation of interventions. To ensure a better understanding of prescribing behaviors and to improve the quality of interventions and research in this area, the incorporation and application of behavioral sciences supported by appropriate multidisciplinary collaboration is recommended.
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Affiliation(s)
- Esmita Charani
- The National Centre for Infection Prevention and Management, Imperial College London, London, UK.
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Toma O, Suntrup P, Stefanescu A, London A, Mutch M, Kharasch E. Pharmacokinetics and Tissue Penetration of Cefoxitin in Obesity. Anesth Analg 2011; 113:730-7. [DOI: 10.1213/ane.0b013e31821fff74] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Kawanami GH, Fortaleza CMCB. Factors predictive of inappropriateness in requests for parenteral antimicrobials for therapeutic purposes: a study in a small teaching hospital in Brazil. ACTA ACUST UNITED AC 2011; 43:528-35. [PMID: 21401329 DOI: 10.3109/00365548.2011.565795] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The identification of patterns of inappropriate antimicrobial prescriptions in hospitals contributes to the improvement of antimicrobial stewardship programs (ASP). METHODS We conducted a cross-sectional study to identify predictors of inappropriateness in requests for parenteral antimicrobials (RPAs) in a teaching hospital with 285 beds. We reviewed 25% of RPAs for therapeutic purposes from y 2005. Appropriateness was evaluated according to current guidelines for antimicrobial therapy. We assessed predictors of inappropriateness through univariate and multivariate models. RPAs classified as 'appropriate' or 'probably appropriate' were selected as controls. Case groups comprised inappropriate RPAs, either in general or for specific errors. RESULTS Nine hundred and sixty-three RPAs were evaluated, 34.6% of which were considered inappropriate. In the multivariate analysis, general predictors of inappropriateness were: prescription on weekends/holidays (odds ratio (OR) 1.67, 95% confidence interval (CI) 1.20-2.28, p = 0.002), patient in the intensive care unit (OR 1.57, 95% CI 1.11-2.23, p = 0.01), peritoneal infection (OR 2.15, 95% CI 1.27-3.65, p = 0.004), urinary tract infection (OR 1.89, 95% CI 1.25-2.87, p = 0.01), combination therapy with 2 or more antimicrobials (OR 1.72, 95% CI 1.15-2.57, p = 0.008) and prescriptions including penicillins (OR 2.12, 95% CI 1.39-3.25, p = 0.001) or 1(st) generation cephalosporins (OR 1.74, 95% CI 1.01-3.00, p = 0.048). Previous consultation with an infectious diseases (ID) specialist had a protective effect against inappropriate prescription (OR 0.34, 95% CI 0.24-0.50, p < 0.001). Factors independently associated with specific prescription errors varied. However, consultation with an ID specialist was protective against both unnecessary antimicrobial use (OR 0.04, 95% CI 0.01-0.26, p = 0.001) and requests for agents with an insufficient antimicrobial spectrum (OR 0.14, 95% CI 0.03-0.30, p = 0.01). CONCLUSIONS Our results demonstrate the importance of previous consultation with an ID specialist in assuring the quality of prescriptions. Also, they highlight prescription patterns that should be approached by ASP policies.
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Affiliation(s)
- Gustavo Hideki Kawanami
- Department of Tropical Diseases and Imaging Diagnosis, Botucatu School of Medicine, São Paulo State University, UNESP, Botucatu, Brazil
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Lundine KM, Nelson S, Buckley R, Putnis S, Duffy PJ. Adherence to perioperative antibiotic prophylaxis among orthopedic trauma patients. Can J Surg 2010; 53:367-372. [PMID: 21092428 PMCID: PMC2993037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2009] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND The goal of this study was to assess whether patients receive their antibiotic prophylaxis as prescribed. We also investigated what doses and durations of antibiotics are typically ordered, which patients actually receive antibiotics and factors causing the ordered antibiotic regimen to be altered. METHODS We performed a retrospective review of 205 patient charts and sent a national survey to all surgeon members of the Canadian Orthopaedic Trauma Society (COTS) about antibiotic prophylaxis in the setting of surgical treatment for closed fractures. RESULTS In all, 93% (179 of 193) of patients received an appropriate preoperative dose of antibiotics, whereas less than 32% (58 of 181) of patients received their postoperative antibiotics as ordered. The most commonly stated reason for patients not receiving their postoperative antibiotics as ordered was patients being discharged before completing 3 postoperative doses. There was a 70% (39 of 56) response rate to the survey sent to COTS surgeons. A single dose of a first-generation cephalosporin preoperatively followed by 3 doses postoperatively is the most common practice among orthopedic trauma surgeons across Canada, but several surgeons give only preoperative prophylaxis. CONCLUSION Adherence to multidose postoperative antibiotic regimens is poor. Meta-analyses have failed to demonstrate the superiority of multidose regimens over single-dose prophylaxis. Single-dose preoperative antibiotic prophylaxis may be a reasonable choice for most orthopedic trauma patients with closed fractures.
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Affiliation(s)
- Kristopher M Lundine
- Division of Orthopaedics, Health Sciences Centre, 3330 Hospital Dr. NW, Calgary, Alberta.
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Perioperative antibiotic prophylaxis: improved compliance and impact on infection rates. Epidemiol Infect 2010; 139:1326-31. [DOI: 10.1017/s0950268810002505] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
SUMMARYThe aims of this study were to determine adherence to the perioperative antibiotic prophylaxis (PAP) protocol used at a large Italian teaching hospital during a 6-year period, to assess the variables associated with inappropriate administration, and to measure the impact on surgical site infection (SSI) rates. There were 28 621 patients surveyed of which 74·6% received PAP. An improvement in adherence to the PAP protocol was registered for 58·8% of patients. Significant risk factors were an American Society of Anesthesiologists (ASA) score ⩾2 [odds ratios (OR) from 1·28 (95% confidence interval (CI) 1·19–1·37) to 1·87 (95% CI 1·43–2·44)], prolonged duration of surgery (OR 1·68, 95% CI 1·56–1·82) and urgent surgery (OR 2·16, 95% CI 1·96–2·37). During the study period, a significant reduction in SSIs rates was detected. We concluded that the global reduction of inadequate PAP administration signifies the efficacy of a multidisciplinary quality improvement initiative on antimicrobial utilization, and this is supported by the observed reduction of the SSI rate.
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Nair BG, Newman SF, Peterson GN, Wu WY, Schwid HA. Feedback Mechanisms Including Real-Time Electronic Alerts to Achieve Near 100% Timely Prophylactic Antibiotic Administration in Surgical Cases. Anesth Analg 2010; 111:1293-300. [PMID: 20841414 DOI: 10.1213/ane.0b013e3181f46d89] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Fahy BG, Bowe EA, Conigliaro J. Perioperative Antibiotic Process Improvement Reaps Rewards. Am J Med Qual 2010; 26:185-92. [DOI: 10.1177/1062860610382133] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | - Joseph Conigliaro
- University of Kentucky, Lexington, KY, Lexington VA Medical Center, Lexington, KY
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Bion JF, Abrusci T, Hibbert P. Human factors in the management of the critically ill patient. Br J Anaesth 2010; 105:26-33. [PMID: 20511333 DOI: 10.1093/bja/aeq126] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Unreliable delivery of best practice care is a major component of medical error. Critically ill patients are particularly susceptible to error and unreliable care. Human factors analysis, widely used in industry, provides insights into how interactions between organizations, tasks, and the individual worker impact on human behaviour and affect systems reliability. We adopt a human factors approach to examine determinants of clinical reliability in the management of critically ill patients. We conducted a narrative review based on a Medline search (1950-March 2010) combining intensive/critical care (units) with medical errors, patient safety, or delivery of healthcare; keyword and Internet search 'human factors' or 'ergonomics'. Critical illness represents a high-risk, complex system spanning speciality and geographical boundaries. Substantial opportunities exist for improving the safety and reliability of care of critically ill patients at the level of the task, the individual healthcare provider, and the organization or system. Task standardization (best practice guidelines) and simplification (bundling or checklists) should be implemented where scientific evidence is strong, or adopted subject to further research ('dynamic standardization'). Technical interventions should be embedded in everyday practice by the adjunctive use of non-technical (behavioural) interventions. These include executive 'adoption' of clinical areas, systematic methods for identifying hazards and reflective learning from error, and a range of techniques for improving teamworking and communication. Human factors analysis provides a useful framework for understanding and rectifying the causes of error and unreliability, particularly in complex systems such as critical care.
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Affiliation(s)
- J F Bion
- University Department of Anaesthesia and ICM, N5, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK.
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de Vries EN, Dijkstra L, Smorenburg SM, Meijer RP, Boermeester MA. The SURgical PAtient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis. Patient Saf Surg 2010; 4:6. [PMID: 20388204 PMCID: PMC2867812 DOI: 10.1186/1754-9493-4-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 04/13/2010] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Surgical site infection (SSI) is an adverse event in which a close relation between process of care and outcome has been demonstrated: administration of antibiotic prophylaxis decreases the risk of SSI. In our tertiary referral centre, a SURgical PAtient Safety System (SURPASS) checklist was developed and implemented. This multidisciplinary checklist covers the entire surgical pathway and includes, among other items, administration of antibiotic prophylaxis before induction of anaesthesia. The aim of this study was to determine the effect of SURPASS implementation on timing of antibiotic prophylaxis. METHODS A retrospective analysis was performed on two cohorts of patients: one cohort of surgical patients that underwent surgery before implementation of the checklist and a comparable cohort after implementation. The interval between administration of antibiotic prophylaxis and incision was compared between the two cohorts. RESULTS A total of 772 surgical procedures were included. More than half of procedures were gastro-intestinal; others were vascular, trauma and hernia repair procedures. After implementation, the checklist was used in 81.4% of procedures. The interval between administration of antibiotic prophylaxis and incision increased from 23.9 minutes before implementation of SURPASS to 29.9 minutes after implementation (p = 0.047). In procedures where the checklist was used, the interval increased to 32.9 minutes (p = 0.004). The proportion of patients that did not receive antibiotics until after the incision decreased significantly. CONCLUSION The use of the SURPASS checklist leads to better compliance with regard to the timing of antibiotic prophylaxis administration.
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Affiliation(s)
- Eefje N de Vries
- Department of Surgery, Academic Medical Centre, Amsterdam, the Netherlands
- Department of Quality and Process Innovation, Academic Medical Centre, Amsterdam, the Netherlands
| | - Lucia Dijkstra
- Department of Surgery, Academic Medical Centre, Amsterdam, the Netherlands
- Department of Quality and Process Innovation, Academic Medical Centre, Amsterdam, the Netherlands
| | - Susanne M Smorenburg
- Department of Quality and Process Innovation, Academic Medical Centre, Amsterdam, the Netherlands
| | - R Peter Meijer
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, the Netherlands
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Staggered Sensitivity Results. AORN J 2010; 91:312, 265. [DOI: 10.1016/j.aorn.2009.11.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 11/12/2009] [Indexed: 11/24/2022]
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Gagliardi AR, Fenech D, Eskicioglu C, Nathens AB, McLeod R. Factors influencing antibiotic prophylaxis for surgical site infection prevention in general surgery: a review of the literature. Can J Surg 2009; 52:481-9. [PMID: 20011184 PMCID: PMC2792388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2008] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are common surgical complications that can be prevented with antibiotic prophylaxis. Research shows poor adherence to guidelines for this practice. We conducted a scoping review to identify factors or interventions that influence antibiotic prophylaxis administration. METHODS An investigator with informatics training searched indexed (MEDLINE, Cochrane Library) and nonindexed (Internet) sources from January 1996 to February 2007. Selected studies were English-language, peer-reviewed, quantitative or qualitative studies describing factors or interventions influencing adherence to SSI-prevention guidelines or SSI rates in general surgery. Two investigators independently reviewed citations and full-text articles and extracted data, and met to compare selections or data and resolve differences through discussion. We extracted data on type of surgery, study design, intervention or factors examined and key findings. We then examined the quantity and type of studies and their findings. RESULTS Nineteen of 192 studies met the eligibility criteria. Seven studies investigated predictors of appropriate antibiotic use through descriptive or exploratory means. Twelve evaluated adherence to antibiotic prophylaxis recommendations by comparing patient cohorts before and after the introduction of quality-improvement strategies. Individual knowledge, attitudes, beliefs and practice; team communication and allocation of responsibilities; and institutional support for promoting and monitoring practice appear to influence practice. CONCLUSION Larger and multisite studies included in our review favour implementation of multidisciplinary pathways, individualized performance data and written or computerized order sets as quality-improvement strategies, but further research is warranted to more rigorously evaluate the effectiveness of these strategies on antibiotic prophylaxis practice.
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Affiliation(s)
- Anna R Gagliardi
- Toronto General Research Institute, University Health Network, University of Toronto, Toronto ON M5G 2C4.
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Pan SC, Kung HC, Lin JW, Hsieh SM, Chang SC. Effectiveness of Workflow Change for Improving the Timing of Prophylactic Antibiotics. Tzu Chi Med J 2009. [DOI: 10.1016/s1016-3190(09)60061-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abstract
The advancement of surgical technology has made surgery an increasingly suitable management option for an increasing number of medical conditions. Yet there is also a growing concern about the number of patients coming to harm as a result of surgery. Studies show that this harm can be prevented by better teamwork and communication in operating theatres. This article discusses the extent of adverse events in surgery and how effective teamwork and communication can improve patient safety. It also highlights the role checklists and briefing in improving teamwork and reducing human error in surgery.
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Affiliation(s)
- Amit Vats
- Centre for Patient Safety and Service Quality, Department of Biosurgery and Surgical Technology, Imperial College, London.
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Gagliardi AR, Eskicioglu C, McKenzie M, Fenech D, Nathens A, McLeod R. Identifying opportunities for quality improvement in surgical site infection prevention. Am J Infect Control 2009; 37:398-402. [PMID: 19201509 DOI: 10.1016/j.ajic.2008.10.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Revised: 10/15/2008] [Accepted: 10/19/2008] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study evaluated surgical site infection (SSI) prevention strategies at a network of university hospitals to identify interventions that may be required to improve compliance with guidelines. METHODS Qualitative methods were used for thematic analysis of institutional tools and protocols, and transcripts of interviews with 7 surgical division heads and 11 professional managers of quality improvement or infection prevention and control at 7 hospitals. They were asked about awareness of, and accountability for, SSI prevention, and current and recommended strategies to promote compliance. RESULTS Despite awareness of SSI prevention guidelines and the presence of organizational factors thought necessary for quality improvement (coordinators, champions), most sites had not reviewed their own practice and implemented corrective strategies. Barriers included use of passive educational strategies, lack of clinician accountability, limited implementation of point-of-care tools, and an absence of performance data. CONCLUSION The sites involved in this evaluation and others interested in increasing compliance with SSI prevention guidelines might implement education and performance data in tandem with accountabilities that trigger action, more actively engage champions to promote SSI prevention, create or update and incentivize use of tools such as standard orders, and encourage greater teamwork through organizational support of quality improvement.
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Adherence to Surgical Site Infection Guidelines in Italian Cardiac Surgery Units. Infection 2009; 37:148-52. [DOI: 10.1007/s15010-008-7474-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Accepted: 04/06/2008] [Indexed: 11/26/2022]
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Affiliation(s)
- George C Velmahos
- John F. Burke Professor of Surgery, Harvard Medical School, Chief, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
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46
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Garey KW, Amrutkar P, Dao-Tran TK, Frost CP, Chen H, Essien EJ, Gentry LO. Economic Benefit of Appropriate Timing of Vancomycin Prophylaxis in Patients Undergoing Cardiovascular Surgery. Pharmacotherapy 2008; 28:699-706. [DOI: 10.1592/phco.28.6.699] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Barie PS. Current Issues in the Prevention and Management of Surgical Site Infection. Surg Infect (Larchmt) 2006. [DOI: 10.1089/sur.2006.7.s3-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Philip S. Barie
- Departments of Surgery and Public Health, Division of Critical Care and Trauma, Weill Medical College of Cornell University, and Anne and Max A. Cohen Surgical Intensive Care Unit, NewYork-Presbyterian Hospital, Weill Cornell Center, New York, New York
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Espin S, Lingard L, Baker GR, Regehr G. Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room. Qual Saf Health Care 2006; 15:165-70. [PMID: 16751464 PMCID: PMC2464856 DOI: 10.1136/qshc.2005.017475] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This paper explores the factors that influence the persistence of unsafe practice in an interprofessional team setting in health care, towards the development of a descriptive theoretical model for analyzing problematic practice routines. Using data collected during a mixed method interview study of 28 members of an operating room team, participants' approaches to unsafe practice were analyzed using the following three theoretical models from organizational and cognitive psychology: Reason's theory of "vulnerable system syndrome", Tucker and Edmondson's concept of first and second order problem solving, and Amalberti's model of practice migration. These three theoretical approaches provide a critical insight into key trends in the interview data, including team members' definition of error as the breaching of standards of practice, nurses' sense of scope of practice as a constraint on their reporting behaviours, and participants' reports of the forces influencing tacit agreements to work around safety regulations. However, the relational factors underlying unsafe practice routines are poorly accounted for in these theoretical approaches. Incorporating an additional theoretical construct such as "relational coordination" to account for the emotional human features of team practice would provide a more comprehensive theoretical approach for use in exploring unsafe practice routines and the forces that sustain them in healthcare team settings.
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Affiliation(s)
- S Espin
- Faculty of Community Services, Ryerson University, 350 Victoria Street, Toronto, Canada.
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