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the Four-E framework and highlight the adaptation of these strategies in LMICs.
Methods Data sources and search strategy
We searched the following databases: PubMed, EMBASE, CINAHL, Cochrane Library, and WHO Regional databases, including AFROLIB and Africa-wide information on EBSCO for articles published from January 1, 1990, through December 31, 2015. We used a comprehensive database-specific combination of terms, including medical subject headings (MeSH) related to SSI and prevention measures (Appendix 1).
Inclusion and exclusion criteria
Eligible studies described strategies to increase adherence with evidence-based interventions known to reduce SSI during the study period and reported SSI outcomes. For the purpose of our analysis, we used the 1988–2009 CDC guidelines for the pre- vention of SSI and the 2009WHO guidelines for safe surgery.12,27 We included experimental, observational studies, randomized controlled trials (RCT), controlled before-and-after (CBA) stud- ies, interrupted time series (ITS) studies, and quality improve- ment (QI) initiatives. All surgical patient populations and settings (inpatient or outpatient), and patients of all age groups were included. We excluded systematic reviews, meta-analyses, case reports, editorials or commentaries, and conference pro- ceedings. In addition, we restricted the search to studies written in English, French, and Spanish.
Study selection and data extraction
Articles were selected in several phases (Fig. 1). First, 6 reviewers independently screened titles and generated a list of potential abstracts for inclusion. Second, 4 authors (P.A., V.R., B.A., and B.Z.) independently reviewed the abstracts, identified articles for full-text review, and read the articles for eligibility. Data extracted from each study included author, study year and country, income level of country (low-middle or high, as defined by the World Bank28), setting, patient population (pediatric or adult, inpatient or outpatient), surgical specialty, infection prevention measures, compliance data, and SSI outcomes. Study quality was appraised with the Effective Practice and Organization of Care (EPOC) criteria, which considers RCTs, non-RCTs, CBA, and ITS as acceptable quality.29
Analysis of implementation strategies
We summarized implementation strategies according to 1 of the Four Es framework categories (ie, engage, educate, execute, or evaluate). These categories were not always mutually exclusive; reviewers decided on the best fit through group consensus. We extracted key stakeholders and compared studies that did and did not demonstrate a decrease in SSI to highlight some differences in implementation approaches.30–32
Results
We identified 13,798 records in our initial search and 2 articles from reference lists of the identified studies (Fig. 1). After removing duplicates, 9,823 unique titles remained, of which 7,342 were excluded because inclusion criteria were not met. Of the remaining 2,481 records, 2,106 were excluded because our
Promise T. Ariyo et al
study objective was not met or an abstract was not provided. The remaining 375 studies underwent full-text review. Of those, 255 were excluded because SSI rates were not reported, leaving 120 studies in our final analysis. An additional 5 studies were identified from another search of systematic reviews, providing 125 studies in our final analysis. The analysis included 124 cohort studies and 1 RCT.
Demographic characteristics
Overall, 105 studies (84%) were conducted in high-income countries and 20 (16%) in LMICs (Appendix 2). Also, 14 studies (12%) evaluated a pediatric population, 33–46 and 111 (88%) evaluated an adult, mixed (adult and pediatric), or undefined population. We quantified the studies by surgical specialty: 21 car- diothoracic,33,36,37,39,40,46–61 22 orthopedic,34,41,42,62–80 13 obstetrics and gynecology,81–93 23 gastrointestinal,94–116 3 neurosurgery,117–119 2 plastic surgery,44,120 28 multiple specialities,30–32,45,59,121–143 and 13 undefined speciality.38,43,144–154
Adherence to SSI prevention measures
Of the 70 studies (56%) that provided data on adherence with SSI preventive measures, 95% reported an increase in compliance with prevention measures. However, 37 studies (28%) did not sta- tistically evaluate the impact of interventions on SSI rates. Of the remaining 88 studies, 61 (69%) reported significant decreases
in SSIs,30,32,33,36,37,41,47–50,54,56,57,59–62,66,68–70,74,75,78,80,83–85,87–91,94,95,97, 102,105,108,110,112,113,115,117,118,121,124,126,127,129,132,134,135,138,139,144,145,148,150, 152,154 and 21 (24%) reported no change or no statistical decrease in SSIs.31,34,39,46,55,58,59,77,79,81,99,100,102,107,109,120,123,125,136,140,142 However, 2 studies (2%), including 1 RCT, reported increased SSIs.96,133 Overall, 103 studies (82%) used multifaceted strategies to
promote adherence to prevention measures. The most common measure was appropriate use of surgical antibiotic prophylaxis, which was reported in 86 of the 125 studies (68%) and in 14 of
the 20 (70%) studies conducted in LMICs.30,37,91,106,121–123,126,129, 132,134,138,142,152 Other common prevention measures were surgical site preparation (31%), hair removal techniques (25%), normo- thermia (20%), glycemic control (18%), wound care (17%), preop- erative bathing (16%), operating room discipline/traffic (14%), instrument sterilization (13%), hand hygiene (11%), preoperative cleansing (14%), and gloving techniques (8%) (Table 1).
Implementation of SSI prevention strategies using the Four Es framework
Most studies used multifaceted strategies to improve adherence with evidence-based SSI prevention measures. Moreover, 76 stud- ies (63%) described efforts to engage frontline staff as an important strategy to improve adherence with prevention measures. Also, 65 studies (54%) used some form of education to introduce the measures to frontline staff, compared to only 11% of studies that focused on patient education. Execution strategies to improve adherence were described by 108 studies (86%). In addition, 74 studies (59%) described evaluation activities. Overall, only 8 studies (6%) met the EPOC criteria, which limited our ability to identify best practices in the remaining 117 studies.
Engagement
Among all of the studies, 76 (63%) described efforts to engage frontline staff as an implementation strategy, largely by forming multidisciplinary teams. The range of disciplines included
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