Infection Control & Hospital Epidemiology


feedback alone resulted in a decrease in SSIs among orthopedic patients.76


Application of EPOC criteria


Only 8 studies met EPOC criteria for inclusion in our analysis (Fig. 1). Overall, we observed no clear differences in implemen- tation strategies between studies that met the EPOC criteria and those that did not. Most of these studies described a multifaceted approach that included efforts to define a common goal for improvement, to engage and educate multidisciplinary teams and senior leaders, to simplify and standardize care (bundles, protocols, policies, and briefings), to collect data and offer performance feedback, and to provide opportunities for shared learning.31,45,59,91,121 Many studies specifically commented on the importance of several important factors when implementing best practices (1) senior leadership support, (2) engaging and educating multidisciplinary teams, (3) locally relevant education materials, and (4) an “enabling infrastructure” to collect data, analyze, and provide feedback.59,91,121 The remaining 3 studies described efforts to standardize care (ie, bundles, protocols, and policies) but pro- vided little to no information about additional implementation strategies (Table 3).78,79,96


Discussion


In this systematic review, we identified 125 studies that described implementation strategies to increase the adoption of evidence- based SSI prevention measures and categorized the strategies according to the Four E framework.19,20,22,23,159 Most of the studies used a multifaceted approach and addressed change at multiple levels within their healthcare organization. These strategies aimed (1) to build and encourage multidisciplinary teamwork, (2) to obtain leadership buy-in, (3) to increase staff and patient aware- ness and knowledge about SSIs and prevention practices, (4) to standardize and simplify clinical processes, (5) to create verifica- tion procedures, and (6) to provide timely feedback to stakehold- ers to support improvement efforts. Although strategies varied among studies and we were not able to identify the best approach, lessons learned from successful HAI prevention efforts highlighted the importance of employing multifaceted strategies, including engagement, education, execution, and evaluation.160 Globally, SSI prevention is a priority.3,4,8,9,12 Unfortunately,


effective and reliable SSI prevention measures are not consistently implemented in practice, leading to variable success in reducing these infections.161–163 Several themes emerged from our system- atic review. First, successful strategies often engaged multidisciplinary


perioperative staff in leading SSI improvement efforts, highlighting the influential role different specialties have in improving care. Second, leadership participation to champion and support improvement efforts were invaluable and contributed to success. Leadership included senior executives and hospital administrators and sometimes extended to government officials, especially in LMICs.160,164,165 Although specific leadership actions were poorly described, successful HAI prevention efforts require leadership support to identify and remove implementation barriers, including the adaptive challenges of changing people’s priorities, beliefs, habits, and loyalties.166 Third, most studies included education to increase knowledge


of best practices. Insufficient knowledge of evidence-based recom- mendations is a significant barrier to adoption of clinical practice guidelines.167 In addition to traditional learning-based teaching


295


methods, some studies reinforced education by using real-life simulations, 64 monthly coaching calls,45,111 and yearly training courses.152 The role of the surgical patient as an important stake- holder in SSI prevention was highlighted in a few studies and is gaining increasing recognition. An expert panel recently published practical ways to engage and educate patients, including educa- tional leaflets translated into multiple languages.168 Fourth, most studies used protocols, care bundles, and checkl-


ists to simplify and standardize evidence-based interventions as part of their multifaceted approach. Several studies, for example, used checklists to summarize recommended practices. In LMICs, the most common method was to adapt the 2009 WHO surgical safety checklist based on local resources and culture.30,123,126,132,134 Local ownership of interventions and implementation strategies were especially important in these settings. Nevertheless, protocols and checklists are tools that only work if staff think they add value. Successful implementation requires significant staff engagement that taps into the intrinsic motivation of professionals and uses peer learning to change behaviors and shift social norms.169 Finally, almost all studies incorporated an evaluation strategy


to monitor performance and provide feedback to frontline staff. Monitoring and feedback can heighten the sense of urgency, pro- mote accountability, and show clinicians how they are performing. For example, in 1 study, patients were surveyed post discharge for SSI, direct feedback was given to the responsible surgeon, and a 31% decrease in the odds of an SSI was achieved.32 In addi- tion to monitoring outcomes, monitoring process measures and providing feedback may identify additional opportunities to improve.113 Feedback can also be used to reframe SSI as a social problem,


to foster ownership among staff, and to generate friendly compe- tition.67 Two studies provided peer-to-peer performance compar- isons, 65,139 whereas others made team-to-team and interhospital comparisons within hospital networks.43,128,147 An important lesson, however, was that monitoring and feedback of outcomes alone may not be sufficient to change behaviors or practices.18 Several studies did not reduce SSI rates (Appendix 2). Though it


was challenging to understand causality, most of these studies did not describe strategies to address 1 or more of the Four Es (ie, engage, educate, execute, and evaluate). For example, some studies implemented the 2009WHOsurgical safety checklist with- out describing strategies to engage, educate, evaluate, or provide feedback to staff.77,120 In the study by Reames et al111 the investi- gators implemented a checklist-based initiative to decrease SSI; however, participating organizations lacked the infrastructure to collect data. As a result, improvement teams did not receive feed- back on performance or SSI rates. Finally, in the RCT by Anthony et al96 the authors expressed concerns about the validity of the intervention bundle, as did other commentaries.96,170 Weacknowledge several limitations of this review. First, most of


the studies implemented multifaceted strategies, making it impos- sible to identify the relative importance of individual strategies or the most effective implementation strategies. Furthermore, our approach to summarizing strategies may be at risk for observer bias. Nevertheless, we identified a broad range of implementation strategies that can be adapted based on local culture and resources and we provide an extensive list of references that hospitals can access for more detailed information. Second, it was sometimes challenging to differentiate between studies designed to evaluate the effectiveness of a clinical intervention (eg, does decolonization improve outcomes?) and studies designed to increase compliance with evidence-based interventions. In addition, our analysis


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