The impact of a quality improvement complex intervention on the incidence of surgical site infection and the knowledge and attitudes of healthcare professionals

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Horgan, Sinéad
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University College Cork
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Background Surgical site infection (SSI) is a serious post-operative complication that depletes hospital resources and has a detrimental impact on patient outcomes. There is published evidence to help healthcare professionals prevent SSIs, yet SSI prevention remains suboptimum and a complex problem to address. Implementing evidence-based prevention strategies to reduce SSIs in acute hospital settings is one example of this complexity. Therefore, it is critical that healthcare professionals have sufficient knowledge on SSI and an understanding of their role in SSI prevention, and are aware of and implement prevention strategies to reduce the incidence of SSIs. Aim The aim of this study was to develop and examine the effect of a quality improvement complex intervention on the incidence of SSI and the knowledge and attitudes of healthcare professionals regarding SSI prevention and surveillance in a university hospital setting. Methods Two systematic reviews of the literature were conducted. The first systematic review aimed to identify, describe, and review the evidence from the literature on the knowledge and attitudes of healthcare professionals towards SSI and SSI surveillance and to examine the effects of interventions that aimed to enhance healthcare professionals’ knowledge and attitudes. The second systematic review examined interventions conducted in acute health care on the incidence of SSIs as well as patient outcomes including length of stay, intensive care unit admission, and mortality rate. Two quantitative studies were conducted to evaluate the impact of a locally designed complex intervention named after the process - Initiation, Surveillance, Sharing, Improvements and Plan for future (ISSIP) using pre-post-test design. Normalisation Process Theory guided healthcare professionals in the design, development, understanding and implementation of the ISSIP intervention in a complex acute health care setting. A quasi-experimental study was conducted in a paired sample of 74 healthcare professionals to examine their knowledge and attitudes towards SSI prevention and surveillance using a questionnaire before and after the intervention. Records from a cohort of patients were retrospectively reviewed to ascertain the baseline SSI incidence rate in the first six months of 2018 (n=95). Consecutive patients (n=216) undergoing colorectal surgery were subsequently followed up postoperatively to measure the impact of the complex quality improvement intervention (ISSIP) on the incidence of SSI. Results Findings from the literature in the first systematic review showed that healthcare professionals’ overall knowledge of SSI and its prevention was poor, while their attitude towards SSI prevention was positive. In the second systematic review, literature revealed that interventions that were effective in reducing the incidence of SSIs had multiple components including bundles, stakeholder engagement, targeted surveillance, and education. Over the course of the current study, there was a statistically significant improvement in healthcare professionals’ understanding of SSI and its prevention after the ISSIP intervention. Pre-test and post-test, attitudes towards SSI prevention and surveillance were positive, with a noticeable positive shift in participants' attitudes in relation to the organisational role in implementing prevention strategies. The ISSIP intervention resulted in a 2.5-fold decrease in the incidence of SSIs and brought about improvements in practice, engagement of multidisciplinary healthcare professionals, and a collaborative approach to reducing SSIs. Other critical elements that supported the ISSIP intervention and were pivotal to its success were: leadership engagement, an implementation group, a dedicated facilitator, ongoing education, a surgeon champion, and the expertise of a surveillance scientist. Conclusion ISSIP is a theory-based multicomponent multidisciplinary complex intervention that was successful in reducing the incidence rates of SSIs in patients undergoing elective colorectal surgery. ISSIP also had a positive effect on healthcare professionals' knowledge and attitudes regarding SSI prevention and surveillance. The use of ISSIP provided a novel framework for the study which is transferable to other hospitals developing a programme for preventing SSIs. Numerous recommendations originate from this research including the recommendation that hospital leadership and staff engage in SSI surveillance supported through the utilisation of a quality improvement approach, underpinned by a national clinical guideline.
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Quality impovement , Surgical site infection , Surveillance , Knowledge and attitudes , Prevention , Colorectal surgery , Complex Intervention
Horgan, S. 2023. The impact of a quality improvement complex intervention on the incidence of surgical site infection and the knowledge and attitudes of healthcare professionals. PhD Thesis, University College Cork.
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