Barriers-enablers-ownership approach: a mixed methods analysis of a social intervention to improve surgical antibiotic prescribing in hospitals

Abstract

ObjectivesTo assess an intervention for surgical antibiotic prophylaxis (SAP) improvement within surgical teams focused on addressing barriers and fostering enablers and ownership of guideline compliance.DesignThe Queensland Surgical Antibiotic Prophylaxis (QSAP) study was a multicentre, mixed methods study designed to address barriers and enablers to SAP compliance and facilitate engagement in self-directed audit/feedback and assess the efficacy of the intervention in improving compliance with SAP guidelines. The implementation was assessed using a 24-month interrupted time series design coupled with a qualitative evaluation.SettingThe study was undertaken at three hospitals (one regional, two metropolitan) in Australia.ParticipantsSAP-prescribing decisions for 1757 patients undergoing general surgical procedures from three health services were included. Six bimonthly time points, pre-implementation and post implementation of the intervention, were measured. Qualitative interviews were performed with 29 clinical team members. SAP improvements varied across site and time periods.InterventionQSAP embedded ownership of quality improvement in SAP within surgical teams and used known social influences to address barriers to and enablers of optimal SAP prescribing.ResultsThe site that reported senior surgeon engagement showed steady and consistent improvement in prescribing over 24 months (prestudy and poststudy). Multiple factors, including resource issues, influenced engagement and sites/time points where these were present had no improvement in guideline compliance.ConclusionsThe barriers-enablers-ownership model shows promise in its ability to facilitate prescribing improvements and could be expanded into other areas of antimicrobial stewardship. Senior ownership was a predictor of success (or failure) of the intervention across sites and time periods. The key role of senior leaders in change leadership indicates the critical need to engage other specialties in the stewardship agenda. The influence of contextual factors in limiting engagement clearly identifies issues of resource distributions/inequalities within health systems as limiting antimicrobial optimisation potential.

Tipping the balance: A systematic review and meta-ethnography to unfold the complexity of surgical antimicrobial prescribing behavior in hospital settings

“…The remainder were classified as satisfactory [ 56 ] as they were perceived to be less valuable than key papers–e.g. less conceptually rich but likely still relevant; or questionable [ 62 , 63 , 65 , 66 ] as their likely contribution, to answering the research question in this meta-ethnography, was uncertain.…”

“…This is because the ownership of the change process by the surgical service, and leadership by senior surgical members, increases the profile and efficacy of interventions [ 58 ]. Moreover, senior ownership of and engagement with an intervention are indicators for its likely success [ 65 ].…”

“…The conceptual model makes visible the important influence of social and structural/environmental mediators on surgical APB in hospital settings, indicating that APB needs to be reconceptualized as a multi-dimensional problem, consistent with previous research [ 68 ]. Interventions to improve surgical APB will need to take a systems approach rather than just targeting individuals [ 77 ]; and co-creation, with surgical teams, is likely to be important to ensure engagement, ownership [ 65 ] and ultimately sustainability, for example through the application of Participatory Action Research [ 78 ]; or a Change Laboratory [ 79 ].…”

Long-Term Impact of a Smartphone App on Prescriber Adherence to Antibiotic Guidelines for Adult Patients With Community-Acquired Pneumonia: Interrupted Time-Series Study

“…Causes of failure to achieve large changes in antibiotic guideline adherence include within-team dynamics that may contribute to lack of support for changes in prescriber behavior. Junior clinicians, who write almost all prescriptions, may be more influenced by the entrenched opinions of their senior colleagues than by the advice contained in a guideline [ 20 , 21 ]. Other causes of low adherence may pertain to app-related factors like usability, acceptability, and app fatigue, although SCRIPT was designed using state-of-the-art co-design approaches through interactions between designers and end-user stakeholders [ 22 , 23 ].…”

Six Long-Standing Questions about Antibiotic Prophylaxis in Surgery

“…Limiting the duration of SAP to a single preoperative dose can reduce the risk of CDI [28] but cannot eliminate it entirely. Although the misuse and overuse of antibiotics are the main drivers of AMR [29] and are a result of the large numbers of surgical procedures, SAP is among the highest-volume categories of antibiotic use within health systems globally [30], and the effects of incorrect SAP on the spread of AMR have been studied insufficiently. A prolonged course of SAP resulted in a greater risk of acquiring resistant bacteria after cardiovascular surgery in an observational 4-year cohort study at a tertiary care center [24].…”