Timing of preoperative antibiotics for knee arthroplasties: Improving the routines in Sweden

PRESS (Propofol, Remifentanil, Electricity/EEG, Setup and Setting) to Start: Introducing a Total Intravenous Anaesthesia Checklist at a Large Teaching Hospital

Total intravenous anaesthesia (TIVA) is becoming more widely used, and as of yet there are few safety checks for the use of TIVA when compared to inhaled anaesthesia. This study aims to assess the feasibility and utility of introducing a TIVA checklist at a large teaching hospital. Methods A survey was sent out to all consultant and trainee anaesthetists at our hospital regarding their use of TIVA and errors in practice related to its use. A checklist was created based on common errors reported in the survey, errors described in NAP5 and our hospital's standard operating procedure. The checklist was introduced, and another survey was distributed a month later to assess compliance and utility and to gain feedback. Results In the first survey, there were 39 responses. A total of 64% had seen an error with the use of TIVA. For those using TIVA 70% of the time or more, 31% had seen an error in the last three months. Twelve per cent of those who had seen errors found that the errors led to patient harm. Only 33% used a method to double-check for errors prior to commencing TIVA. In the follow-up survey, 80% of those who used the checklist had found it useful, and 30% had corrected an error while using the checklist. Eighty-seven per cent felt the checklist would prevent errors from being made. Eighty per cent of respondents said they would use the checklist in their future practice. The checklist was found to be more useful for trainees, and for those who use TIVA less often. Discussion The 'PRESS to start TIVA" checklist has been shown to be a useful tool to prevent errors and a majority of anaesthetists at our hospital plan to use it going forward. Our data suggests that anaesthetists who are less experienced with TIVA benefit more from having a checklist. There was a marked increase in the number of anaesthetists who would use a checklist in the future, compared to those who used one in the initial survey. This shows that introducing a checklist is feasible and is likely to reduce errors going forward.

Antibiotics for UTI Prevention After Intradetrusor OnabotulinumtoxinA Injections

IMPORTANCE

Urinary tract infections (UTIs) occur in 8.6% to 48.1% of patients after intradetrusor onabotulinumtoxinA injections.

OBJECTIVE

The objective of this study was to evaluate both choice and duration of antibiotic prophylaxis on the incidence of UTI within 30 days after in-office onabotulinumtoxinA injections.

STUDY DESIGN

We included a single-site, retrospective cohort of 305 patients with overactive bladder or bladder pain syndrome receiving postprocedure prophylactic antibiotics for in-office, 100-unit intradetrusor onabotulinumtoxinA injections from 2019 to 2023. Categories of antibiotic prophylaxis compared included (1) nitrofurantoin 100 mg twice daily for 3 days, (2) nitrofurantoin 100 mg twice daily for 5 days, (3) trimethoprim-sulfamethoxazole 160 mg/800 mg twice daily for 3 days, and (4) "other regimens." Primary outcome was incidence of UTI within 30 days. Variables were compared via χ2 test. Crude/adjusted odds were estimated using binary logistic regression.

RESULTS

Incidence of UTI was 10.4% for 3-day nitrofurantoin, 20.5% for 5-day nitrofurantoin, 7.4% for 3-day trimethoprim-sulfamethoxazole, and 25.7% among "other regimens" (P = 0.023). Differences among primary regimens were substantial but not statistically significant: 3-day trimethoprim-sulfamethoxazole had 31% lower odds of UTI versus 3-day nitrofurantoin (odds ratio [OR], 0.689; P = 0.518). Compared with 3-day nitrofurantoin regimen, the 5-day nitrofurantoin regimen had twice the odds of UTI (OR, 2.22; P = 0.088). Those receiving "other regimens" had nearly 3 times the odds of UTI (OR, 2.98; P = 0.018). Results were similar adjusting for age and race. Overall urinary retention rate was 1.97%.

CONCLUSIONS

Prophylactic antibiotic choice and duration of treatment potentially affect UTI incidence after in-office, intradetrusor onabotulinumtoxinA injections. Nitrofurantoin and trimethoprim-sulfamethoxazole for 3 days have the lowest UTI incidence.

Significance and current approaches to vascular graft infection

Vascular graft/endograft infection (VGEI) is a constant in cardiovascular surgery with published rates between 1 and 5%. Every graft type and anatomical location is a potential target for infectious complications. These patients are sick patients with high frailty burden. Management of VGEI entails a multidisciplinary and multimodality approach. Here we review some aspects of the problem of VGEI including prevention, diagnosis, and surgical therapy with focus on recent developments in the field.

Intra-operative drug level monitoring of pre-operative antibiotic for surgical prophylaxis in the patients of elective spinal surgery

OBJECTIVES

Single dose prophylaxis is good enough for general surgery with low risk patients. However, the evidence for the effectiveness of single dose anti-microbial prophylaxis (AMP) is not conclusive in high risk patients and spinal surgeries requiring instrumentation or the use of implants in particular. No studies have explored the various concentration of ceftriaxone in plasma and tissue as well during an ongoing spinal surgery. Therefore, the objective of study was to correlate the serum and tissue concentrations of ceftriaxone with the SSI and identify patients with increased risk of SSI.

METHODS

It was an open label prospective study in 50 consecutive patients who underwent elective spine surgery under prophylactic cover of ceftriaxone. Serum and tissue concentration were estimated by high pressure liquid chromatography during the ongoing surgery.

RESULTS

Subjects were observed for any post-operative complications including SSI. Serum (p=0.002) and tissue (p=0.012) concentrations of ceftriaxone at the closure of spinal surgery were associated with SSI. Duration of the surgery (p=0.04) and use of implants (p=0.02) were also important surgery related risk factors.

CONCLUSIONS

Serum and tissue concentrations of ceftriaxone at the closure and duration of surgery and instrumentation or use of implants in the spinal surgery are good predictors of SSI.

Dual Antibiotic Prophylaxis in Primary Total Knee Arthroplasty-No Benefit for Extremely Obese Patients

We performed this study to assess the effectiveness of multimodal total knee arthroplasty prosthetic joint infection (TKA-PJI) prophylaxis including "on-time" dual-antibiotic prophylaxis, and the influence of body mass index (BMI) on prophylaxis effectiveness. After obtaining Institutional Review Board approval, we assessed 1,802 primary TKAs (1,496 patients) who received cefazolin alone or cefazolin combined with vancomycin for TKA-PJI prophylaxis. A detailed chart review was performed to determine patient demographic features (age, gender, BMI, American Society of Anesthesiologists Score), antibiotic selection, vancomycin administration timing, and 1-year PJI rates. Statistical assessment was accomplished using a two-sided Student's t-test or Fisher's exact test. Patients who received dual-antibiotic prophylaxis with "on time" vancomycin infusion (Group CVt) had significantly lower infection rates than other TKA patients (0.8 vs. 2.7%, p < 0.01). "On Time" vancomycin administration was associated with a lower TKA-PJI rate for patients with a BMI < 45 kg/m² (0.5 vs. 2.6%, p < 0.01) with no infections in 120 TKA patients with a BMI between 40 and 44.9 kg/m² (p < 0.01). No difference was noted for patients with a BMI ≥ 45 kg/m² (3.3 vs. 2.6%, p = 0.71). There were no infections in 150 TKA patients with a normal BMI (18-25 kg/m²) in any PJI-prophylaxis treatment group. Adoption of a dual-antibiotic prophylaxis approach can successfully reduce TKA-PJI rates among overweight and moderately obese patients. The approach does not appear to influence outcomes for low risk patients with a normal BMI (18-25 kg/m²) or for higher risk patients with a BMI > 45 kg/m².

The Use of Antibiotics for the Prevention of Surgical Site Infections in Two Government Hospitals in Taif, Saudi Arabia: A Retrospective Study

Background

Surgical site infections (SSIs) are among the most common postoperative complications. To reduce the occurrence of surgical wound infections, suitable antimicrobials should be administered.

Aim of the work

This study investigated the prophylactic use of antibiotics to prevent SSIs, in terms of agents and/or combination preferences, and the adherence of surgeons to both national and international guidelines of surgical antibiotic prophylaxis in Taif city government hospitals.

Methods

This is a retrospective study using a chart review of patients' medical records in two government hospitals in Taif city, Saudi Arabia, from July 2016 to July 2018. While maintaining the confidentiality of the patient’s data, it was collected and analyzed using the chi-squared and Fisher’s exact tests, and the difference between means was tested using the student’s t-test.

Results

Prophylactic antibiotics were used in 157 patients who had surgery (Group 1) while 52 patients did not receive preoperative antibiotics (Group 2). The most commonly used prophylactic antibiotics were metronidazole, cefuroxime, cefazolin, and ceftriaxone. Other antimicrobials used included cefotaxime, amoxicillin/clavulanic acid, cephalexin, and amoxicillin. Surgical site infections developed in one patient of those who received antibiotics preoperatively and in three Group 2 patients. The mean hospital length of stay in Group 1 was 38.5±9.2 hours, and 57.3±12.1 hours in Group 2 patients. The types of antibiotics used were generally within the scope of national and international recommended guidelines.

Conclusion

The use of preoperative prophylactic antibiotics significantly reduces the development of surgical site infections and the mean length of hospital stay. Various antimicrobial drugs that were used prophylactically in surgical practice are within the recommendations of both national and international guidelines.

Causes and Effects of Introducing Surgery Safety Checklist: A Review

The medical treatment process, particularly surgery, is inescapably bound to potential complications or undesirable adverse events. This narrative review aims to present the causes and effects of the introduction of the WHO Surgery Safety Checklist (SSC), the use of which is expected to reduce the number of perioperative errors, complications, and mortality. To achieve this objective, we performed a bibliometric analysis of medical citations indexed in the PubMed database using the SSC subject heading. Findings revealed a total of 1441 articles meeting inclusion status, with 1171 published during the last decade. After the screening of titles and abstracts, the members of the research team selected 75 articles, deemed most relevant for inclusion in the review, which were then thoroughly analyzed. All in all, the findings were that the use of SSC appreciably reduced the number of simple logistic errors in the perioperative period decreasing the frequency of resulting complications and mortality.

Vancomycin-soaked wrapping of harvested hamstring tendons during anterior cruciate ligament reconstruction. A review of the 'vancomycin wrap'

The practice of 'vancomycin wrapping' of harvested hamstring autografts during Anterior Cruciate Ligament Reconstruction (ACLR) surgery has gathered recent interest. This practice involves the wrapping of harvested grafts in a vancomycin-soaked swab during the preparatory phase. Different techniques are observed, and a small number of studies have shown that pre-soaking hamstring ACLR grafts in this manner dramatically reduces the post-surgical infection rate compared with standard intravenous antibiotic prophylaxis alone. However, the literature surrounding this practice is surprisingly limited and thus the basis and rationale of the 'vancomycin wrap' has established itself largely without question. The exact popularity of this practice is difficult to establish but there has been increasing disclosure of its efficacy in reducing post-operative infection in ACLR since 2012. We provide a synopsis of the current literature surrounding vancomycin and its use in 'wraps' in ACLR to help apprise the surgeon of the nature of infection in ACLR, the rationale for vancomycin, whilst considering evidence to support alternatives and discussing potential ramifications for future practice.

Dual-Agent Antibiotic Prophylaxis Using a Single Preoperative Vancomycin Dose Effectively Reduces Prosthetic Joint Infection Rates With Minimal Renal Toxicity Risk

BACKGROUND

We performed this study to compare prosthetic joint infection (PJI) and renal toxicity rates following hip and knee total joint arthroplasty (TJA) when a first-generation cephalosporin was administered either alone or in combination with a single preoperative vancomycin dose, whether vancomycin administration timing potentially influenced dual-antibiotic PJI prophylaxis approach effectiveness, and whether single-dose vancomycin use increased risk of renal impairment.

METHODS

This was a retrospective study of 1997 consecutive primary TJAs (1871 patients) treated with cefazolin alone (1044 TJAs) or cefazolin with single-dose vancomycin (953 TJAs). The vancomycin group included 476 TJAs (450 patients) with infusion started at least 45 minutes before the skin incision and 477 TJAs (464 patients) with infusion started less than 45 minutes before the skin incision.

RESULTS

The addition of a single dose of vancomycin did not significantly reduce PJI rates when compared with cefazolin alone (1.6% vs 2.1%, P = .32). However, the PJI rate was significantly lower following primary TJA when vancomycin administration was initiated at least 45 minutes before incision (0.2%) when compared with other TJA procedures performed using cefazolin and vancomycin (2.9%, P < .01) or cefazolin alone (2.1%, P < .01). We observed no difference in renal toxicity between treatment groups.

CONCLUSION

In our institution, the addition of vancomycin to cefazolin at least 45 minutes before incision reduced PJI infection rates in primary hip and knee TJA with a low risk of renal impairment.

Effects of an intervention (SÄKLÄK) on prescription of potentially inappropriate medication in elderly patients

BACKGROUND

Polypharmacy is known to increase the risk for drug-related problems, and some drugs, potentially inappropriate medications (PIMs), are especially troublesome.

OBJECTIVE

To analyse the effects on prescription of PIMs of the SÄKLÄK project, an intervention model created to improve medication safety for elderly patients in primary care.

METHOD

The SÄKLÄK project was a multiprofessional intervention in primary care consisting of self-assessment, peer review, feedback and written agreements for change. Five Swedish primary care centres participated in the intervention and five served as comparison group. Data were collected from the Swedish Prescribed Drug Register on PIMs (long-acting benzodiazepines, anticholinergics, tramadol, propiomazine, antipsychotics and non-steroidal anti-inflammatory drugs) prescribed to patients aged 65 years and older. Total number of patients and change in patients using PIMs before and after intervention with-in groups was analysed as well as differences between intervention and comparison group.

RESULTS

A total of 32566 prescriptions of PIMs were dispensed before the intervention, 19796 in the intervention group and 12770 in the comparison group. After intervention a decrease was seen in both groups, intervention-22.2% and comparison-8.8%. All groups of PIMs decreased, except for antipsychotics in the comparison group. For the intervention group, a significant decrease in mean dose/patient was seen after the intervention but not in the comparison group.

CONCLUSION

Our study shows this method has some effects on prescription of PIMs. The evaluation indicates this is a feasible method for improvement of medication use in primary care and the method should be tested on a larger scale.

Timing of Antibiotic Prophylaxis for Preventing Surgical Site Infections in Foot and Ankle Surgery

BACKGROUND

Surgical site infections (SSIs) are one of the most troublesome complications after foot and ankle surgery. Previous literature has emphasized the significance of appropriate timing of antibiotic prophylaxis. However, the optimal timing of antibiotic prophylaxis for SSI prevention is still inconclusive. Our study aimed to investigate the optimal timing of antibiotic administration and to elucidate the risk factors for SSIs in foot and ankle surgery.

METHODS

A retrospective review of 1933 foot and ankle procedures in 1632 patients from January 1, 2011, through August 31, 2015, was performed. Demographic data; type, amount, and timing of antibiotic administration; incision; and closure time were recorded. Subsequent wound infection and incision and drainage procedure (I&D) within 30 days and 90 days were documented. Outcomes and demographic variables were compared between procedures in which antibiotics were administered less than 15 minutes and between 15 to 60 minutes prior to incision. A total of 1569 procedures met inclusion criteria.

RESULTS

There were 17 cases (1.1%) of subsequent wound infection, of which 6 required a subsequent I&D within 30 days. There were 63 additional cases (4%) of wound complications, which did not meet SSI criteria. When comparing SSI and non-SSI groups, the only significant independent predictors were longer surgeries and nonambulatory surgeries (both P < .05). Stepwise multivariate logistic regression analysis demonstrated that 91.8% of the risk of an SSI could be predicted by ASA score and length of surgery alone.

CONCLUSION

In foot and ankle surgeries, the timing of intravenous antibiotic prophylaxis did not appear to play a significant role in the risk of SSI. Host factors and duration of surgery appear to have played a much larger role in SSI than the timing of antibiotic prophylaxis.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Safer drug use in primary care - a pilot intervention study to identify improvement needs and make agreements for change in five Swedish primary care units

Background

There is an urgent need to improve patient safety in the area of medication treatment among the elderly. The aim of this study was to explore which improvement needs and strengths, relating to medication safety, arise from a multi-professional intervention in primary care and further to describe and follow up on the agreements for change that were established within the intervention.

Methods

The SÄKLÄK project was a multi-professional intervention in primary care consisting of self-assessment, peer-review, feedback and written agreements for change. Data were obtained from five primary care units randomised to the intervention group. Reviewer feedback reports and agreements for change were analysed using content analysis.

Results

Strengths that were identified included a committed leadership, work methods to enhance medication safety and access to consultants. Methods for securing an accurate medication list, knowledge and methods of working of the prescriber and patient’s ability to contribute to medication safety were areas that gave rise to three predesigned categories for improvement needs on a local level. Another category became apparent during the analysis; namely learning from mistakes and from results. In all categories, apparent shortcomings were identified. These included inaccurate medication lists, lack of medication reconciliation, lack of time for follow-up of elderly patients, need for further education in geriatrics and pharmacotherapy and lack of information on indication and maximum dosage. An increased number of medication reviews were among the most common agreements for change seen.

Conclusions

This study identified substantial shortcomings, like poorly updated medication lists, which affected medication safety in the participating Swedish primary care units. Similar shortcomings are most likely present in other primary care units in the country. Working together multi-professionally, including performing medication reviews, could be one way of improving medication safety. On the other hand, the individual physician must possess enough pharmaceutical knowledge and the working conditions must allow time for follow-up of prescriptions. Strengths of the primary care unit, such as successful methods of working, must be taken advantage of. The culture in primary care may affect the ability to successfully implement routines that improve patient safety and reduce risk of medication errors.

Working towards safer surgery in Africa; a survey of utilization of the WHO safe surgical checklist at the main referral hospitals in East Africa

Background

Mortality from anaesthesia and surgery in many countries in Sub-Saharan Africa remain at levels last seen in high-income countries 70 years ago. With many factors contributing to these poor outcomes, the World Health Organization (WHO) launched the “Safe Surgery Saves Lives” campaign in 2007. This program included the design and implementation of the “Surgical Safety Checklist”, incorporating ten essential objectives for safe surgery. We set out to determine the knowledge of and attitudes towards the use of the WHO checklist for surgical patients in national referral hospitals in East Africa.

Methods

A cross-sectional survey was conducted at the main referral hospitals in Mulago (Uganda), Kenyatta (Kenya), Muhimbili (Tanzania), Centre Hospitalier Universitaire de Kigali (Rwanda) and Centre Hospitalo-Universitaire de Kamenge (Burundi). Using a pre-set questionnaire, we interviewed anaesthetists on their knowledge and attitudes towards use of the WHO surgical checklist.

Results

Of the 85 anaesthetists interviewed, only 25 % regularly used the WHO surgical checklist. None of the anaesthetists in Mulago (Uganda) or Centre Hospitalo-Universitaire de Kamenge (Burundi) used the checklist, mainly because it was not available, in contrast with Muhimbili (Tanzania), Kenyatta (Kenya), and Centre Hospitalier Universitaire de Kigali (Rwanda), where 65 %, 19 % and 36 %, respectively, used the checklist.

Conclusion

Adherence to aspects of care embedded in the checklist is associated with a reduction in postoperative complications. It is therefore necessary to make the surgical checklist available, to train the surgical team on its importance and to identify local anaesthetists to champion its implementation in East Africa. The Ministries of Health in the participating countries need to issue directives for the implementation of the WHO checklist in all hospitals that conduct surgery in order to improve surgical outcomes.

Surgical Site Infection After Total Knee Arthroplasty: Risk Factors in Patients With Timely Administration of Systemic Prophylactic Antibiotics

BACKGROUND

Surgical site infection (SSI) after total knee arthroplasty (TKA) is a catastrophic complication. Administration of prophylactic antibiotics within 60 minutes before surgery is a well-established strategy to prevent SSI. The study is aimed to identify the risk factors for SSI regarding primary TKA in patients with timely administration of systemic prophylactic antibiotics.

METHODS

A retrospective review of patients with primary TKA between 2009 and 2013 was conducted. Patients who had prophylactic antibiotics administered after skin incision or >60 minutes before skin incision were excluded.

RESULTS

Of the 3152 patients enrolled, the incidence of SSI and deep-implant SSI was 1.52% and 0.79%, respectively. Charlson Comorbidity Index ≥3 was an independent risk factor for both SSI (odds ratio [OR], 2.34; 95% confidence interval [CI], 1.24-4.44, P = .01) and deep-implant SSI (OR, 3.46; 95% CI, 1.52-7.91, P < .01). Optimal dose of systemic antibiotics adjusted by patients' body weight for prophylaxis (OR, 0.29; 95% CI, 0.17-0.62, P < .01) and using antibiotic-laden bone cement (OR, 0.33; 95% CI, 0.17-0.64, P < .01) were significant protective factors for SSI. Meanwhile, using antibiotic-laden bone cement (OR, 0.31; 95% CI, 0.13-0.76, P = .01) also significantly decreased the risk of deep-implant SSI.

CONCLUSION

Our findings highlight the importance of appropriate dosage of prophylactic antibiotics and use of antibiotic-laden cement in preventing SSI after primary TKA. For prevention of deep-implant SSI, using antibiotic-laden bone cement seems to be an advisable strategy.

Etiology of bone and joint infections: a case series of 363 consecutive patients from an orthopaedic infection unit

BACKGROUND

Bone and joint infections remain a clinical challenge with potentially serious consequences. Nevertheless there is a lack of studies with strict criteria for diagnosis and etiology. The primary aim of this study was to determine the causative agents in orthopaedic infections using strict diagnostic criteria for infection and etiology. The secondary aim was to assess the timing of post-operative infections in relation to pathogens and to compare causative bacteria in different parts of the body.

METHODS

A retrospective registry study of 363 consecutive cases of bone and joint infections was performed. Microbiological data on sampling and culture results were registered.

RESULTS

Staphylococcus aureus dominated in both operated (45%) and non-operated (44%) patients, followed in frequency by coagulase-negative staphylococci (CoNS) in operated patients (11%) and beta-haemolytic streptococci in non-operated patients (16%) (p < 0.001). There were no polymicrobial infections in non-surgical cases (p < 0.001). For operated patients, Gram-negative bacilli were observed in 6%, almost exclusively isolated from the lower extremity. Propionibacterium spp. was the most common finding after spinal surgery. In 90/363 (25%), the agent responsible for the infection could not be defined according to the strict criteria used.

CONCLUSION

S. aureus dominated as etiological agent in all bone and joint infections, including operated patient given peri-operative prophylaxis. Improved timing of antibiotic prophylaxis seen after the introduction of the Swedish national project PRISS may have changed this. The number of infections with uncertain etiology was high, stressing the importance of more studies on diagnostics, as well as strict diagnostic algorithms.

Healthcare system intervention for safer use of medicines in elderly patients in primary care-a qualitative study of the participants' perceptions of self-assessment, peer review, feedback and agreement for change

Background

The elderly population is increasing and with advanced age comes a higher risk for contracting diseases and excessive medicine use. Polypharmacy can lead to drug-related problems and an increased need of health care. More needs to be done to help overcome these problems. In order for new models to be successful and possible to implement in health care they have to be accepted by caregivers. The aim of this study was to evaluate participants’ perceptions of the SÄKLÄK project, which aims to enhance medication safety, especially for elderly patients, in primary care.

Methods

This is a qualitative study within the SÄKLÄK project. The SÄKLÄK project is a multi-professional intervention in primary care consisting of self-assessment, peer review, feedback and written agreements for change. A total of 17 participants from the intervention’s primary care units were interviewed. Most of the interviews were done on a one-to-one basis. The interviews were recorded and transcribed verbatim. A survey was also sent to the primary care unit heads. Qualitative content analysis was used to explore the participants’ perceptions.

Results

The analysis of the interviews yielded six categories: multi-professional co-operation, a focus on areas of improvement, the joy of sharing knowledge, disappointment with the focus of the feedback, spend time to save time and impact on work. From these categories a theme developed: “Medication safety is a large area. In order to make improvements time needs to be invested and different professions must contribute.”

Conclusions

This study shows that our studied intervention method is feasible to use in primary care and that the multi-professional approach was perceived as being very positive by the participants. Multi-professional co-operation was time consuming, but was also deemed as an investment and an opportunity to share knowledge. Some points of improvement of the method were identified such as simplification of the self-assessment form and clearer instructions for reviewers. In addition, to have an impact on work the focus must lie in areas within the primary care units’ scope.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0334-6) contains supplementary material, which is available to authorized users.

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Background

Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.

Objectives

This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.

Design

We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.

Setting

Welsh Government and NHS Wales.

Participants

Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.

Main outcome measures

Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.

Results

An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.

Conclusions

Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled study

The implementation of a surgical safety checklist is said to minimize postoperative surgical complications. However, to our knowledge, no randomized controlled study has been done on the influence of checklists on postoperative outcomes in a developing country. We conducted a prospective randomized controlled study with parallel group study design of the implementation of WHO surgical safety checklist involving 700 consecutive patients undergoing operations in our hospital between February 2012 and April 2013. In 350 patients, the checklist was implemented with modifications-the Rc arm. The control group of 350 patients was termed the Rn arm. The checklist was filled in by a surgery resident, and only the participants in the study were blinded. Postoperative wound-related (p = 0.04), abdominal (p = 0.01), and bleeding (p = 0.03) complications were significantly lower in the Rc compared to the Rn group. The number of overall and higher-grade complications (Clavien-Dindo grades 3 and 4) per patient reduced from 0.97 and 0.33 in the Rn arm to 0.80 and 0.23 in the Rc arm, respectively. A significant reduction in mortality was noted in the Rc arm as compared to the Rn arm (p = 0.04). In a subgroup analysis, the number of overall and higher-grade complications per patient with incomplete checklists was higher than that with fully completed checklist group. Implementation of WHO surgical safety checklist results in a reduction in mortality as well as improved postoperative outcomes in a tertiary care hospital in a developing country.

The economics and timing of preoperative antibiotics for orthopaedic procedures

BACKGROUND

The efficacy of antibiotics in preventing surgical site infections (SSIs) depends on the timing of administration relative to the start of surgery. However, currently, both the timing of and recommendations for administration vary substantially.

AIM

To determine how the economic value from the hospital perspective of preoperative antibiotics varies with the timing of administration for orthopaedic procedures.

METHODS

Computational decision and operational models were developed from the hospital perspective. Baseline analyses looked at current timing of administration, while additional analyses varied the timing of administration, compliance with recommended guidelines, and the goal time-interval.

FINDINGS

Beginning antibiotic administration within 0-30 min prior to surgery resulted in the lowest costs and SSIs. Operationally, linking to a pre-surgical activity, administering antibiotics prior to incision but after anaesthesia-ready time was optimal, as 92.1% of the time, antibiotics were administered in the optimal time-interval (0-30 min prior to incision). Improving administration compliance from 80% to 90% for this pre-surgical activity results in cost savings of $447 per year for a hospital performing 100 orthopaedic operations a year.

CONCLUSION

This study quantifies the potential cost-savings when antibiotic administration timing is improved, which in turn can guide the amount hospitals should invest to address this issue.

Patterns in neurosurgical adverse events and proposed strategies for reduction

Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to reducing risk and to measuring and improving outcomes. The authors performed a review of patterns and frequencies of adverse events in neurosurgery as background for future efforts directed at the improvement of quality and safety in neurosurgery.

They found 6 categories of contributory factors in neurosurgical adverse events, categorizing the events as influenced by issues in surgical technique, perioperative medical management, use of and adherence to protocols, preoperative optimization, technology, and communication. There was a wide distribution of reported occurrence rates for many of the adverse events, in part due to the absence of definitive literature in this area and to the lack of standardized reporting systems.

On the basis of their analysis, the authors identified 5 priority recommendations for improving outcomes for neurosurgical patients at a population level: 1) development and implementation of a national registry for outcome data and monitoring; 2) full integration of the WHO Surgical Safety Checklist into the operating room workflow, which improves fundamental aspects of surgical care such as adherence to antibiotic protocols and communication within surgical teams; and 3–5) activity by neurosurgical societies to drive increased standardization for the safety of specialized equipment used by neurosurgeons (3), more widespread regionalization and/or subspecialization (4), and establishment of data-driven guidelines and protocols (5). The fraction of adverse events that might be avoided if proposed strategies to improve practice and decrease variability are fully adopted remains to be determined. The authors hope that this consolidation of what is currently known and practiced in neurosurgery, the application of relevant advances in other fields, and attention to proposed strategies will serve as a basis for informed and concerted efforts to improve outcomes and patient safety in neurosurgery.