290


Table 1. Common Infection Prevention Measures IPC Measure


All Studies


Surgical antimicrobial prophylaxis


Skin-prep techniques Hair removal techniques Temperature control Glucose control


Wound care/sterile dressing Preoperative bathing


OR discipline/traffic/cleaning Instrument sterilization Hand hygiene


Preoperative mupirocin/ chlorhexidine


Gloving technique


Staphylococcus aureus screening and decolonization


Method of wound closure Hyperoxia


Bowel preparation practices Nutritional support


Goal-directed intravenous fluid Surgical drain placement


Isolation protocol/contact precautions


OR ventilation control


(n=125), No. 84


37 29 24 22 20 19 17 15 13 17


10 12


5 4 7 4 4 3


3 Note. IPC, infection prevention and control; OR, operating room.


Promise T. Ariyo et al


Low and Middle Income Countries (n=20), No.


14


4 3 1 1 3 2 1 4 4 0


0 0


0 0 2 0 0 0


31 0


simplifying and standardizing the care delivery process and creat- ing verification checks. Furthermore, 57 studies (46%) imple- mented protocols, pathways, and policies to improve adoption


of prevention measures.31,34,39–41,43,46,53,55–58,61,65,69,74,75,78,79,81,83,85,87, 89,94,95,100,102–104,107,109,113,121–123,127,130,131,136,143–145,150–152,154 In addi- tion, 43 studies combined measures into a “bundle” of care


practices.33,40,42,43,46,47,53,54,59,61,66,68,69,75,78,79,83–87,96,98–100,105,107,108,110,112, 113,115,116,118,121,135,137,139,140,146,155 In 1 study, SSI were reduced rates by serially introducing a care bundle for cesarean section at a large community hospital.86 A study involving 24 hospitals in Michigan showed a dose response in which increased bundle compliance resulted in decreased SSIs, suggesting synergy among prevention measures in the bundle.112 Among the 125 studies, 26 (21%) used checklists to improve the


adoption of evidence-based interventions.30,36,52,64,66,69,71,75,77,86,97, 111,113,120,123,126,132,134,140,143,145,146,157 Other studies used order sets,75, 103,149 electronic reminders,101,115 and automatic stops for anti-


biotics129 to create verification checks and to improve adherence. Many of the LMIC studies adapted the 2009 WHO Surgical


Safety Checklist to local needs, 36,123,126,132,134 protocols,94,95,122 and policies81,121 to simplify and standardize care. In a study con- ducted in Moldova, local ownership and buy-in were promoted by developing an anesthesia preoperative evaluation template that included several SSI prevention interventions to improve work- flow.132 An Argentinean study described an automatic-stop pro- phylaxis form that empowered pharmacists to stop prolonged postoperative antimicrobials.129 Both studies showed significantly decreased SSI rates.


Evaluation Of 125 studies, 15 (11%) focused on patient education and


their shared responsibility for infection prevention.44,69,71,75, 78,80,82,85,86,88,101,113,115,117,146 Riley et al88 gave patients reading


material on skin preparation with presurgery instructions. Aiken et al121 used posters to educate patients about the importance of receiving antibiotics before incision and prompt discontinua- tion after surgery. Also, 2 studies used a preoperative checklist to educate and prepare patients for surgery.69,71 Of 20 studies with LMIC programs, 12 (60%) used staff edu-


cation to reduce SSI rates.37,44,56,91,106,121–123,129,132,142,152 Aproject in Kenya took ∼600 hours of staff meeting time to develop and implement antibiotic best practices.121 Jenkins et al37 delivered monthlywebinarsovera2-year period in 17 LMICstodecrease SSIs among pediatric congenital heart surgery patients. Day-long seminars, 95 one-on-one physician training,129 and online mod- ules designed for both existing and new staff were also described,56 all leading to decreases in SSIs. In 1 LMIC study, 44 educating patients on wound care by providing illustrated discharge instructions reduced SSIs among patients undergoing cleft lip and palate repair in India.


Execution


Execution strategies were described by 108 of the 125 studies (86%). Execution often focused on streamlining interventions by


Of 125 studies, 74 studies (59%) described evaluation activities, with a general focus on giving feedback to key stakeholders to support improvement efforts. Some studies used a benchmark approach to compare performance among peers.32,58,107,121 Another strategy reported feedback to the frontline providers and hospital leadership.113 In that study, providing feedback using a dashboard to compare local data to national benchmarks was associated with a significant decrease in SSI rates and improvement in patient outcomes, including SSI, length of stay, and patient satisfaction. One study posted hospital-based newsletters in public places, such as waiting rooms and elevators, to celebrate staff contributions to decreasing SSIs, 147 and another displayed score- cards of infection rates in patient care areas.139 In addition, 5 studies implemented prospective SSI surveillance


and performance feedback to surgeons as an unimodal implemen- tation strategy.32,76,124,148,153 In 1 multicenter study, 34 hospitals participating in a Dutch surveillance network collected SSI data and provided feedback exhibited significant decreases in SSI rates over 5 years.128 Other studies similarly showed that raising aware- ness among surgeons about infection rates could lead to practice change and improvements in outcomes.32,158 Of 20 LMIC studies, 11 (55%) emphasized evaluation and


feedback as an implementation strategy.37,76,91,94,121,122,126,132,134, 138,152 In Brazil, the National Nosocomial Infection Surveillance


System was used to evaluate performance and provide feedback to providers.152 Other evaluation methods included direct observa- tion and immediate feedback of clinical performance to create a sense of accountability and motivation for improvement.134,152 For instance, a tool called the “infectometer” was used in clinical areas to report weekly and monthly HAI rates compared to the expected incidence of infection.152 In Belgrade, active surveillance with


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