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Table 2 Summary of reported enablers

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

Author (year) and country Study design and population TDF Domain Description of reported enablers
Brink et al. (2017) [41]
South Africa
Quasi-experimental (pre-post) Behavioural regulation Audit and feedback:
- Employment of pharmacists to implement an audit and feedback model in relation to adhering to guidelines; providing feedback in written and verbal form
- Benchmarking between hospitals and regions via comparative tables and graphs to compare and contrast results
Pharmacists
Surgeons
Anaesthetists
Theatre and surgical ward nurses
Hospital, pharmacy, nursing and theatre managers
Environmental context and resources Effective communication:
- Ensuring appropriate communication between multidisciplinary parties
Skills
Social/professional role and identity Role delegation:
- Anaesthetists taking responsibility for antibiotic administration
Bryson et al. (2015) [42]
UK
Quasi-experimental (pre-post) Knowledge Guideline dissemination:
- Dissemination of information through the use of advertising and educational programs such as announcements on the intranet, displaying posters in theatre, sending out information via email as well as verbally
Orthopaedic surgeons
Anaesthetists
Environmental context and resources
Cameron et al. (2015) [43]
UK
Quasi-experimental (pre-post), Quantitative descriptive Knowledge Guideline dissemination:
- Guideline availability in theatre to help with decision making
- Guidelines presented in a simple ‘traffic light system’ format
Consultant general surgeons
Anaesthetists
Environmental context and resources
Carlès et al. (2006) [44]
France
Quasi-experimental (pre-post) Behavioural regulation Support tools:
- Use of personalised SAP kits for patients undergoing surgery that are prepared by pharmacy in advance
Anaesthesiologists Environmental context and resources
Caruso et al. (2017) [45]
USA
Quasi-experimental (pre-post) Social influences Multidisciplinary collaboration:
- Teamwork between specialties to develop plans in order to increase SAP adherence
Paediatric anaesthesiologists
Surgeons
Infectious disease physicians
Pharmacists
Quality improvement specialists
Behavioural regulation Audit and feedback:
- Monitoring of adherence via compliance reports
Support tools:
- Incorporating antibiotic order set into pre-existing pre-surgical admission routine work
Guideline dissemination:
- Dissemination of dosage information via signs posted in theatre and visual aid pocket cards
Environmental context and resources
Knowledge
Collier et al. (1998) [46]
USA
Quasi-experimental (pre-post) Knowledge Educational services:
- Workshops to inform clinical staff of organisational changes that would be made to improve practice
Vascular surgeons
Anaesthetists
Theatre and ward nurses
Pharmacists
Environmental context and resources Other enablers:
- Rectifying issues as they are identified
Conaty et al. (2018) [47]
Ireland
Quasi-experimental (pre-post) Behavioural regulation Audit and feedback:
- Weekly audit and feedback sessions (regular surveillance)
Orthopaedic surgeons
Anaesthetists
Nurses
Pharmacists
Knowledge Educational services:
- Educational workshops and reminders on appropriate SAP
Guideline dissemination:
- Dissemination of guidelines electronically and through posters displayed in theatre
Environmental context and resources
De Almeida et al. (2012) [48]
Brazil
Quasi-experimental (pre-post) Social influences Multidisciplinary collaboration:
- Collaboration between an ICU pharmacist and infectious diseases physician when reviewing patients to ensure guidelines are adhered to
Infectious disease physician
Pharmacist
Intensivist
Environmental context and resources Audit and feedback:
- Continual surveillance through compliance reports disseminated electronically and verbally
Dimopoulou et al. (2016) [49]
Greece
Quasi-experimental (pre-post) Knowledge Educational services:
- Workshops regarding appropriate SAP and SSI prevention
Guideline dissemination:
- Distribution of guidelines to clinical team
Paediatric surgeons, nurses and anaesthetists Environmental context and resources
Social/professional role and identity Role delegation:
- Transferring the responsibility of SAP prescribing to the surgeon, whilst administration of antibiotics is to be carried out by the ward nurse or anaesthetist
Reinforcement Local opinion leader:
- Use of a champion or a leader to assist with adhering to guidelines (to reinforce guideline use)
Social influences
Garcell et al. (2017) [50]
Qatar
Quasi-experimental (pre-post) Behavioural regulation Audit and feedback:
- Regular audit and feedback sessions
Surgical staff Knowledge Educational services:
- Discussions around local SAP policy
Environmental context and resources
Haynes et al. (2011) [51]
USA
Quasi-experimental (pre-post) Behavioural regulation Support tools:
- Use of a special antibiotic order set with an automated time system to force cessation of antibiotic use once time was exceeded. Removing the prescribing duration from the prescriber
Physicians Environmental context and resources
Hermsen et al. (2008) [52]
USA
Quasi-experimental (pre-post) Behavioural regulation Support tools:
- Development and use of a standardised antibiotic order form to provide guidance on antibiotic choice, duration and dose
Educational services:
- Educational sessions to doctors, pharmacists and nurses in regards to the form and the Surgical Infection Prevention Program
Physicians
Pharmacists
Nurses
Environmental context and resources
Knowledge
Hincker et al. (2017) [53]
USA
Quasi-experimental (pre-post) Behavioural regulation Support tools:
- Modification of EMR system to include decision support tool to guide antibiotic choice and re-dosing interval
Real-time reminders:
- Electronic reminder (on EMR) to indicate when patient should be re-dosed; real-time information
Anaesthesia staff Environmental context and resources
Reinforcement
Kao et al. (2010) [54]
USA
Staggered cohort Knowledge Educational sessions:
- Lectures to clinical staff
- Drawing attention to importance of compliance
Support tools:
- Use of a preoperative checklist and standardised forms to order antibiotics
Other enablers:
- Staggering introduction of interventions to give staff an opportunity to implement change
Anaesthesia and surgical staff Environmental context and resources
Behavioural regulation
Kim et al. (2012) [55]
Korea
Quasi-experimental (pre-post) Behavioural regulation Audit and feedback:
- Reporting of results to the public as well as to hospitals
Not specified
Kritchevsky et al. (2008) [56]
USA
Cluster randomised trial Behavioural regulation Support tools:
-Development of prewritten order set for antibiotics
-Guidelines, forms and literature reviews shared amongst intervention hospitals
-Monthly conferences
Audit and feedback:
-Comparative feedback reports sent to all participating hospitals
Educational services:
- Monthly conferences held to discuss issues and successes experienced by participating intervention hospitals
-Meetings held to discuss strategies on how to overcome obstacles related to practice
Physician assistants
Nurse practitioners
Pharmacists
Surgeons
Anaesthesiologists
Environmental context and resources
Knowledge
Lingard et al. (2011) [57]
Canada
Quasi-experimental (pre-post) Behavioural regulation Support tools:
- Use of a checklist to prompt antibiotic use and documentation
Effective communication:
- Comprehensive preoperative team briefings: enhanced communication between multidisciplinary staff members
General surgeons
Anaesthesiologists
Theatre nurses
Technical assistants
Environmental context and resources
Skills
Nair et al. (2010) [58]
USA
Quasi-experimental (pre-post) Environmental context and resources Support tools:
- Implementation of AIMS: electronic anaesthesia documentation system
Audit and feedback:
- Regular performance reports indicating success rates
- Electronic reminders (via email) to document antibiotic information if missing in AIMS
Real-time reminders:
- Real-time electronic feedback and reminders via a decision support system known as SAMs which is linked to AIMS; reminders to carry out specific action
Anaesthesiologists
Nurse anaesthetists
Behavioural regulation
Reinforcement
Nair et al. (2011) [59]
USA
Quasi-experimental (pre-post) Environmental context and resources Real-time reminders:
- Use of SAMs: real time alerts to prompt antibiotic administration in a timely fashion. Frequent messages until action taken
Anaesthesia staff Behavioural regulation
Reinforcement
O’Reilly et al. (2006) [60]
USA
Quasi-experimental (pre-post) Environmental context and resources Support tools:
- Modification of electronic perioperative systems to allow documentation of antibiotic particulars
Audit and feedback:
- Regular performance feedback to individual staff members (electronic). Verbal feedback given to staff who are constantly non-compliant
- Publication of performance results to serve as a reminder as well as verbal reminders during staff meetings
Surgeons
Nurses
Anaesthesia staff
Behavioural regulation
Social/professional role and identity Role delegation:
- Anaesthetists responsible for administering antibiotics
Ozgun et al. (2010) [61]
Turkey
Quasi-experimental (pre-post) Knowledge Educational services:
- Educational sessions held regarding SAP principles as well as what is considered inappropriate use
- Data on current practice presented to staff
- Discussion of specialty specific issues discussed with surgical team
Guideline dissemination:
- SAP guidelines distributed during staff meetings and displayed throughout hospital
Surgeons
Anaesthetists
Nurses
Environmental
context and resources
Parker et al. (2007) [62]
USA
Quasi-experimental (pre-post) Behavioural regulation Support tools:
-Use of standardised preoperative antibiotic order forms
Real time reminders:
-Use of an anaesthesia record keeping system to remind anaesthesia provider of appropriate time to administer antibiotics
Non-cardiac surgeons
Anaesthesiologists and anaesthesia care providers
Preoperative nursing staff
Environmental context and resources
Reinforcement
Social/professional role and identity Role delegation:
-Delegating role of confirming and administering antibiotic prophylaxis to anaesthesia personnel
-Antibiotics sent with patients to theatre in order to assist with its administration before incision
Knowledge Educational sessions:
-Educating staff on antibiotic prophylaxis in order to change attitudes towards use
Environmental context and resources
Ribed et al. (2018) [63]
Spain
Quasi-experimental (pre-post) Environmental context and resources Support tools:
- Prepopulating SAP information onto the CPOE to assist with correct antibiotic prescribing
Real-time reminders:
- Integrating reminders into clinician’s workflow to modify patient’s prescription based on lab results
Educational services:
- Educational sessions to increase SAP awareness
- Pharmacy led training sessions on how to use the CPOE
Orthopaedic surgeons
Nurses
Pharmacists
Behavioural regulation
Reinforcement
Knowledge
Riggi et al. (2014) [64]
USA
Quasi-experimental (pre-post) Environmental context and resources Real-time reminders:
- Use of an automated intraoperative paging system to ensure antibiotics are re-dosed at the appropriate time during lengthy procedures
Educational services:
- Education sessions to anaesthesiology and surgical staff
Audit and feedback:
- Feedback to staff when non-compliance occurred (to individual staff member and chairman of anaesthesiology)
Other enablers:
- Standardisation of SAP protocol (hospital wide)
Surgical staff
Anaesthesia staff
Knowledge
Behavioural regulation
Reinforcement
Ritchie et al. (2004) [65]
New Zealand
Quasi-experimental (pre-post) Behavioural regulation Real-time reminders:
- Use of a pre-printed sticker on medication chart that included antibiotic particulars (dose, duration and dosing interval) to assist with correct prescribing: information present at point of care – immediate reminder of antibiotic policy
Anaesthetists
Pharmacists
 
Reinforcement
Environmental context and resources
Social/professional role and identity Role delegation:
- Anaesthetists responsible for applying sticker as they administer first dose
Rosenberg et al. (2008) [66]
USA
Quasi-experimental (pre-post) Behavioural regulation Support tools:
- “Piggybacking” antibiotic administration verification to surgical time out sheet (preoperative checklist). Acts as a prompt to ensure antibiotics are administered prior to incision
Anaesthesiologists
Theatre nurses
Environmental context and resources
Schwann et al. (2011) [67]
USA
Quasi-experimental (pre-post) Behavioural regulation Real-time reminders:
- Use of a POCEP to provide real-time notifications during a procedure to administer antibiotics: reminder system
Anaesthesiologists
Certified registered nurse anaesthetists
Surgeons
Reinforcement
Environmental context and resources
Social/professional role and identity Role delegation:
- Anaesthesiologist or certified registered nurse anaesthetist responsible for validating the POCEP
Shapiro et al. (2018) [68]
USA
Quasi-experimental (pre-post) Environmental context and resources Educational services:
- Educational sessions highlighting current recommendations: presentation of current practice highlighting antibiotic usage (transparency of practice)
Gynaecological surgeons Knowledge
Sutherland et al. (2014) [69]
USA
Quasi-experimental (pre-post) Behavioural regulation Audit and feedback and multidisciplinary collaboration:
- Multidisciplinary involvement in feedback committee
- Discussions/contact made with staff who are constantly non-compliant to review practice
Anaesthesiologists
Surgeons
Social influences
Telfah et al. (2015) [70]
Jordan
Quasi-experimental (pre-post) Knowledge Educational services:
-Revising guidelines to ensure it is comprehensive then providing education to clinical staff to increase awareness
-One to one educational sessions and email reminders also provided
Medical, nursing and pharmacy staff
Surgical residents
Environmental context and resources
Social/professional role and identity Role delegation:
- Assigning a clinical pharmacist to review and evaluate prescribed medications to ensure compliance
Environmental context and resources Other enablers:
-Creation of a theatre satellite pharmacy to allow pharmacists to review and process all orders prior to supply, whilst also restricting access to antibiotics
Wax et al. (2007) [71]
USA
Quasi-experimental (pre-post) Reinforcement Real-time reminders:
-Activation of a visual reminder on the AIMS to ensure antibiotics are given before incision
Anaesthesia care team (certified registered nurse anaesthetist, anaesthesia house staff and attending anaesthesiologist) Behavioural regulation
Environmental context and resources
Whitman et al. (2008) [72]
USA
Quasi-experimental (pre-post) Social/professional role and identity Role delegation:
- Anaesthetists assumed responsibility of antibiotic administration in theatre
Anaesthetists Behavioural regulation Support tools:
- Use of a preoperative order form in preadmission clinic to ensure antibiotics are charted early
Other enablers:
- Ensuring patients don’t leave hold area until antibiotics are administered
Environmental context and resources
Willems et al. (2005) [73]
Belgium
Quasi-experimental (pre-post) Behavioural regulation Audit and feedback:
- Highlighting cost to hospital when SAP not adhered to (use of a follow up form to highlight cost of antibiotics when following SAP guidelines vs the antibiotic regimen used by the doctor)
Physicians
Zanetti et al. (2003) [74]
USA
Randomised control trial Environmental context and resources Real-time reminders:
- Use of an audible alarm (computer generated) to notify staff when antibiotic needs to be re-dosed as well as pop-up notification displaying re-dosing guidelines
Surgical staff Behavioural regulation
Reinforcement
Zanotto et al. (2006) [75]
Brazil
Quasi-experimental (pre-post) Behavioural regulation Support tools:
- Placing software restrictions on certain antibiotics to limit inappropriate prescribing
- Interruption of dispensing if no reason documented electronically to justify extended antibiotic use
Not specified Environmental context and resources
Zhou et al. (2016) [76]
China
Quasi-experimental (pre-post) Social/professional role and identity Role delegation:
- Delegating task of reviewing antimicrobial prescribing to clinical pharmacist
Pharmacists
Surgeons
Nurses
Knowledge Educational services:
- Educational sessions to medical, surgical and nursing staff regarding appropriate SAP
Environmental context
Behavioural regulation Audit and feedback:
- Weekly performance reports regarding SAP adherence and irrational antibiotic use
- Communication between staff when inappropriate prescribing detected
  1. Abbreviations: AIMS Anaesthesia Information Management System, CPOE computerised physician order entry, EMR electronic medical record, POCEP point-of-care electronic prompt, SAM Smart Anaesthesia Manager, SAP surgical antimicrobial prophylaxis, SSI surgical site infection
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