Developing Surgical Antimicrobial Prophylaxis Interventions Using Theoretical Domains Framework

BACKGROUND: Surgical site infections are common causes of healthcare-associated infections. Using surgical antimicrobial prophylaxis (SAP) is a complex process that can reduce these rates if performed correctly. While antimicrobial stewardship programs have developed guidelines for SAP, there has been less focus on understanding and modifying the behavioral and contextual factors required to optimize prophylaxis use. We performed chart reviews and workflow analyses to develop interventions based on a theoretical framework to improve SAP use in two academic hospitals. METHODS: SAP use during a one month period (October 2016) was analyzed for orthopedic and general surgery procedures by chart review. The primary outcomes of interest included SAP choice, preoperative timing, intraoperative re-dosing, and postoperative continuation. Structured workflow analyses were performed to understand the processes involved in SAP ordering and administration. These findings were applied to the Theoretical Domains Framework (TDF) to develop theory-based interventions. RESULTS: We reviewed 88 orthopedic and 63 general surgery procedures. Adherence to institutional guidelines for prophylaxis choice was low in both orthopedic (55%) and general surgery (70%). For general surgery, preoperative timing was incorrect in 25% of cases, re-dosing for procedure duration was incorrect in 59% of cases, and re-dosing for blood loss was not routinely performed. Alternatively, for orthopedic surgery cefazolin was re-dosed too early, at a median of 93 minutes (n = 42), and postop antibiotic use was continued for 10 days in all 14 aseptic hip revisions. There was variation in practice patterns among orthopedic surgeons. Using TDF, we identified barriers among numerous theoretical domains for re-dosing (knowledge; memory, attention, and decision processes; environmental context and resources), choice of antibiotic and postoperative duration (knowledge; beliefs about consequences; emotion; social influences). CONCLUSION: We identified suboptimal SAP use in two surgical services, each with distinct deficiencies. Performing in-depth chart reviews and workflow analyses characterized the specific behavioural and contextual barriers that require intervention. DISCLOSURES: All authors: No reported disclosures.