Influences on surgical antimicrobial prophylaxis decision making by surgical craft groups, anaesthetists, pharmacists and nurses in public and private hospitals

Abstract

BackgroundSurgical antimicrobial prophylaxis (SAP) is a leading indication for antibiotic use in the hospital setting, with demonstrated high rates of inappropriateness. Decision-making for SAP is complex and multifactorial. A greater understanding of these factors is needed to inform the design of targeted antimicrobial stewardship interventions and strategies to support the optimization of SAP and its impacts on patient care.MethodsA qualitative case study exploring the phenomenon of SAP decision-making. Focus groups were conducted with surgeons, anaesthetists, theatre nurses and pharmacists across one private and two public hospitals in Australia. Thematic analysis was guided by the Theoretical Domains Framework (TDF) and the Capabilities, Opportunities, Motivators-Behaviour (COM-B) model.ResultsFourteen focus groups and one paired interview were completed. Ten of the fourteen TDF domains were identified as relevant. Thematic analysis revealed six significant themes mapped to the COM-B model, and subthemes mapped to the relevant TDF domains in a combined framework. Key themes identified were: 1) Low priority for surgical antimicrobial prophylaxis prescribing skills; 2) Prescriber autonomy takes precedence over guideline compliance; 3) Social codes of prescribing reinforce established practices; 4) Need for improved communication, documentation and collection of data for action; 5) Fears and perceptions of risk hinder appropriate SAP prescribing; and 6) Lack of clarity regarding roles and accountability.ConclusionsSAP prescribing is a complex process that involves multiple professions across the pre-, intra- and post-operative surgical settings. The utilisation of behaviour change frameworks to identify barriers and enablers to optimal SAP prescribing supports future development of theory-informed antimicrobial stewardship interventions. Interventions should aim to increase surgeon engagement, enhance the prioritisation of and accountability for SAP, and address the underlying social factors involved in SAP decision-making, such as professional hierarchy and varied perceptions or risks and fears.

Factors that influence adherence to surgical antimicrobial prophylaxis (SAP) guidelines: a systematic review

“…The TDF has been used to explore factors relating to guideline adherence in a recent qualitative study published by Ierano et al [85] Themes were mapped to ten domains of the TDF, including knowledge, environmental context and resources, behavioural regulation and emotion [85]. Ierano et al [85] noted that whilst guidelines were deemed to be of value, practice may differ to guideline recommendations due to a clinician's perception of gaps in the current evidence, thus resulting in deviations from guidelines. Furthermore, although participants in that study were acutely aware of both local and national guidelines, prescriber autonomy was considered to be of greater importance [85].…”

Identifying targets for improvement using a nationally standardized survey: Surgical antimicrobial prophylaxis in orthopedic surgery

“…The consequences of antibiotic overuse, such as prolonged SAP duration, have been well described in the literature and include lack of SSI reduction 30 and patient harms such as antibiotic side effects, 31 Clostridioides difficile infections, 30,31 acute kidney injury, 30 and contribution to antimicrobial resistance. 30 Qualitative research in Australia 32,33 and the United Kingdom 34 has highlighted potential influences on SAP prescribing culture. The fear of causing patient harm, such as surgical site infections, 32,33 and litigation claims for malpractice 32,33 have been identified as drivers for overuse of SAP.…”

“…30 Qualitative research in Australia 32,33 and the United Kingdom 34 has highlighted potential influences on SAP prescribing culture. The fear of causing patient harm, such as surgical site infections, 32,33 and litigation claims for malpractice 32,33 have been identified as drivers for overuse of SAP. Further education is required to communicate the evidence that antimicrobial overuse may also cause significant patient harm.…”

Research Article – BMC Health Service Research (IF -1.93) Barriers and Facilitators to Implementing Evidence Based Bleeding Management in Australian Cardiac Surgery Units: A Qualitative Interview Study Analysed With the Theoretical Domains Framework and COM-B Model

“…While there is currently little qualitative research on facilitators to implementing bleeding management in cardiac surgery in Australia, the studies reporting on facilitators to change, highlight the success of monitoring, audit and feedback of data on outcomes and performance to reduce variability in practice (25,26). This is also demonstrated in studies across other cohorts which suggest capitalising on the driven and competitive behaviour of surgeons through regular analysis and feedback of data on outcomes and performance can be utilised as enabler to improve practice (53)(54)(55)(56)(57).…”